Skip to main content
SpringerLink
Log in

Upper gastrointestinal bleeding: Etiology and management

  • Symposium on Hepatology-II
  • Published:
The Indian Journal of Pediatrics Aims and scope Submit manuscript

Abstract

Upper gastrointestinal bleeding is a potentially fatal condition at times due to loss of large volumes of blood. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage (most commonly extra hepatic portal venous obstruction) and, in intensive care settings infections and drugs are other etiological factors associated with bleeding. Massive upper Gl bleeding is life threatening and requires immediate resuscitation measures in the form of protection of the airways, oxygen administration, immediate volume replacement with ringer lactate or normal saline, transfusion of whole blood or packed cells and also monitoring the adequacy of volume replacement by central venous lines and urine output. Upper Gl endoscopy is an effective initial diagnostic modality to localize the site and cause of bleeding in almost 85–90% of patients. Antacids supplemented by H2-receptor antagonists, proton pump inhibitors and sucralfate are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, emergency endoscopy is the treatment of choice after initial haemodynamic stabilization of patient. If facilities for endoscopic sclerotherapy (EST) are not available, pharmacotherapy which decreases the portal pressure is almost equally effective and should be resorted to. Shunt surgery is reserved for patients who do not respond to the above therapy. β blockers combined with sclerotherapy have been shown to be the most effective therapy in significantly reducing the risk of recurrent rebleeding from varices as well as the death rates, as compared to any other modality of treatment. Based on studies among adult patients, presence of shock, co-morbidities, underlying diagnosis, presence of stigmata of recent hemorrhage on endoscopy and rebleeding are independent risk factors for mortality due to upper Gl bleeding. Rebleeding is more likely to occur if the patient has hematemesis, liver disease, coagulopathy, hypotension and or anemia. There is a great need for conducting therapeutic trials as well as identifying predictors of outcome of upper Gl bleeding in children to develop evidence based management protocols.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Yachha SK, Khanduri A, Sharma BC, Kumar M. Gastrointestinal bleeding in children.J Gastroenterol Hepat 1996; 11: 903–907.

    CAS  Google Scholar 

  2. Oslon AD, Hillemeier AC. Gastrointestinal hemorrhage. In Walker WA, ed.Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. St. Louis, Mosby 1996, 251–270.

    Google Scholar 

  3. Mittal SK, Kalra KK, Agarwal V. Diagnostic upper GI endoscopy for hemetemesis in children. Experience from a pediatric gastroenterology center in North India.Indian J Pediatr 1994; 61: 651–654.

    Article  PubMed  CAS  Google Scholar 

  4. Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents.Pediatrics 1979; 63 (3): 408–413.

    PubMed  CAS  Google Scholar 

  5. Fleischer D. Etiology and prevalence of severe persistent upper gastrointestinal bleeding.Gastroenterology 1983; 84: 538–543.

    PubMed  CAS  Google Scholar 

  6. Gostout CJ, Kenneth KW, Ahlquist DAet al. Acute gastrointestinal bleeding. Experience of a specialized management team.J Clin Gastroenterol 1992; 14(3): 260–267.

    Article  PubMed  CAS  Google Scholar 

  7. Lacorix J, Nadeau D, Lakerge S, Gauthier M, Lapierre G, Farrel CA. Frequency of upper gastrointestinal bleeding in a pediatric intensive care unit.Crit Core Med 1992; 20: 35–42.

    Article  Google Scholar 

  8. Gormally S. Gastritis and Peptic Ulcer Disease. In Walker WA ed.Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. St. Louis, Mosby 1996; 506–527.

    Google Scholar 

  9. Drumm B, Rhoads JM, Stringer DAet al. Peptic ulcer disease in children: Etiology, clinical findings and clinical course.Pediatrics 1988; 82 : 410–414.

    PubMed  CAS  Google Scholar 

  10. Drumm B, Perez-Perez GI, Blaser MJ, Sherman PM. Intra familial clustering in helicobacter pylori infection.N Engl J Med 1990; 322 (6): 359–363.

    Article  PubMed  CAS  Google Scholar 

  11. Yeung CKet al. Helicobacter pylori and associated duodenal ulcer.Ardi Dis Child 1990; 65: 1212–1216.

    CAS  Google Scholar 

  12. Labenz J, Peitz U, Kohl H, Kaiser J, Malfertheiner P, Hackersbergeret al. Helicobacter pylori increases the risk of peptic ulcer bleeding: a casecontrol study.Ital J Gastroenterol Hepatol 1999; 31(2): 110–115.

    PubMed  CAS  Google Scholar 

  13. Chan FK, Chung SC, Suen BY, Lee YT, Leung WK, Leung VKet al. Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking lowdose aspirin or naproxen.N Engl J Med 2001; 344 (13): 967–973.

    Article  PubMed  CAS  Google Scholar 

  14. Katelaris PH, Tippet GH, Norbu P, Lowe DG, Brennan R, Farming MJ. Dyspepsia, helicobacter pylori and peptic ulcer in a randomly selected population in India.Gut 1992; 33: 1462–1466.

    Article  PubMed  CAS  Google Scholar 

  15. Gill HH, Majumdar P, Shankaran K, Desai HG. Age related prevalence of helicobacter pylori antibodies in Indian subjects.Indian J Gastroenter 1994; 13(3): 92–94.

    CAS  Google Scholar 

  16. Roduquez LAG, Herschel J. Risk of upper gastrointestinal bleeding and perforation associated with individual non steroidal anti inflammatory drugs.Lancet 1994; 343: 769–772.

    Article  Google Scholar 

  17. Iichtehberger LMet al. Effect of 16 — dimethyl prostaglandin E2 on the surface hydrophobicity of aspirin treated canine gastric mucosa.Gastroenterology 1985; 88: 308–314.

    Google Scholar 

  18. Fromm D. How do non steroidal anti inflammatory drugs affect gastric mucosal defences ?Clin Invest Med 1987; 10: 251–258.

    PubMed  CAS  Google Scholar 

  19. Messer JMet al. Association of adreno corticosteroid therapy and peptic ulcer disease.N Engl J Med 1983; 309: 21–24.

    Article  PubMed  CAS  Google Scholar 

  20. Prandi D, Rueff B, Roche-Sicot Jet al. Life threatening hemorrhage of the digestive tract in cirrhotic patients.Am J Surg 1976; 131: 204–209.

    Article  PubMed  CAS  Google Scholar 

  21. Arora NK, Lodha R, Arora N. Portal hypertension. In Suraj Gupte, ed.Recent Advances in Pediatr 1998 : 317-348.

  22. Alvarez F, Bernard O, Brunelle Fet al. Portal hypertension in children: Clinical investigatons and hemorrhage risk.J Pediatr 1983; 103: 696–702.

    Article  PubMed  CAS  Google Scholar 

  23. Arora NK, Lodha R, Gulati S, Gupta AK, Mathur P, Joshi Medha S. Portal Hypertension in North Indian Children.Indian J Pediatr 1998; 65: 585–591.

    Article  PubMed  CAS  Google Scholar 

  24. Rector WG, Reynolds TB. Risk factors for hemorrhage from esophageal varices and acute gastric erosions.Clin Gastroenterol 1985; 14: 139–153.

    PubMed  Google Scholar 

  25. Sarin SK, Sundaram KR, Ahuja RK. Predictors of variceal bleeding.Gut 1989; 30: 1757–1764.

    Article  PubMed  CAS  Google Scholar 

  26. Prolla J, Diehl AS, Benvenuti GAet al. Upper gastrointestinal fiberoptic endoscopy in pediatric patients.Gastrointest Endosc 1983; 29: 279–281.

    PubMed  CAS  Google Scholar 

  27. Leincke J, Schaffer R, Hogan W. Emergency endoscopy in acute upper GI bleeding(UGB): does timing affect the significance of diagnostic yield?Gastrointest Endosc 1976; 22: 32–38.

    Google Scholar 

  28. Boyan C. Cold or warm blooded for massive transfusion.Am Surg 1964; 160–182.

  29. Katon R. Complications of upper gastrointestinal endoscopy in the gastrointestinal bleeder.Dig Dis Sd 1981; 26: 475–545.

    Google Scholar 

  30. Hoare AM. Comparative study between endoscopy and radiology in acute upper gastrointestinal hemorrhage.Br Med J 1975; 1: 27.

    PubMed  CAS  Google Scholar 

  31. Driscoll D. The role of radionudide imaging in the diagnosis of gastrointestinal bleeding in children.Radiography 1986; 52: 237–239.

    PubMed  CAS  Google Scholar 

  32. Afshani E, Bergee P. Gastrointestinal tract angiography in infants & children.J Pediatr Gastroenterol Nutr 1986; 5: 173–186.

    PubMed  CAS  Google Scholar 

  33. Alavi A, Ringh E. Localisation of gastrointestinal bleeding: superiority of 99mTc sulfur colloid compared with angiography.Am J Roent 1981; 137: 741–748.

    CAS  Google Scholar 

  34. Keller F, Rosch J. Value of angiography in diagnosis and therapy of acute upper gastrointestinal hemmorrhage.Dig Dis Sd 1981; 26: 785–895.

    Google Scholar 

  35. Meyerontz M, Fellows K. Angiography in gastrointestinal bleed in children.Am J Roentgenol 1984; 143: 837–840.

    Google Scholar 

  36. Levine RS, Steinberg WM. Antacids: in Gastrointestinal Pharamacotherapy. WB Saunders & Co. Philadelphia. 1st edn. 1993.

    Google Scholar 

  37. Zeldir JB, Friedman LS, Isselbacher KJ. Ranitidine: A new H2 receptor antagonist.N Eng J Med 1983; 309: 1368.

    Article  Google Scholar 

  38. Clissold SP, Campoli-Richard DM. Omeprazole-A prelimnary review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential in peptic ulcer disease and Zollinger-Ellison syndrome.Drugs 1986; 32: 15–47.

    Article  PubMed  CAS  Google Scholar 

  39. Nasgashima R. Mechanism of action of sucralfate.J Clin Gastroenterol 1981; 3 (suppl 2): 117.

    Google Scholar 

  40. D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: A meta analytic review.Hepatology 1995; 22(1): 332–354.

    Article  PubMed  CAS  Google Scholar 

  41. Boles ET. Portal hypertension. In, Holder TM, Ashoraft WF, eds.Pediatric Surgery WB Saunders, London, 1980; 534.

    Google Scholar 

  42. Westaby D, Melia WM, MacDougal BRet al. Injection sclerotherapy for esophageal varices. A prospective randomized controlled trial of different treatment schedules.Gut 1984; 25: 129–132.

    Article  PubMed  CAS  Google Scholar 

  43. Baillie J, Yudelman P. Complications of endoscopic sclerotherapy of esophageal varices.Endoscopy 1992; 24: 284–291.

    Article  PubMed  CAS  Google Scholar 

  44. Hill ID, Bowie ND. Endoscopic sclerotherapy for control of bleeding varices in children.Am J Gastroenterol 1991; 86 (4): 472–476.

    PubMed  CAS  Google Scholar 

  45. Sasaki T, Hasegawa T, Nakajima K, Tanano H, Wasa M, Fukui Yet al. Endoscopic variceal ligation in the management of gastroesophageal varices in the post-operative biliary atresia.J Ped Surg 1998; 33(11): 1628–1632.

    Article  CAS  Google Scholar 

  46. Fleischer D. Endoscopic therapy of upper gastrointestinal bleeding in humans.Gastroenterol 1986; 90: 217–234.

    CAS  Google Scholar 

  47. Papp JP. Endoscopic electro coagulation in the management of upper gastrointestinal bleeding.Surg Clin of North Am 1982; 62: 797–806.

    CAS  Google Scholar 

  48. Sharara Al, Rockey DC. Gastresophageal variceal hemmorhage.N Engl J Med 2001; 345(9): 669–681.

    Article  PubMed  CAS  Google Scholar 

  49. Haddock G, Garden OJ, MeKee RFet al. Esophageal tamponade in the management of acute variceal hemorrhage.Dig Dis Sci 1989; 34: 913–918.

    Article  PubMed  CAS  Google Scholar 

  50. Evans S, Stovroff M, Heiss K, Ricketts R. Selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension.J Pediatr Surg 1995; 30(8): 1115–1118.

    Article  PubMed  CAS  Google Scholar 

  51. Shah R, Nagral SS, Mathur SK. Results of a modified Sugiura’s devascularisation in the management of ‘unshuntable’ portal hypertension.HPB Surg 1999; 11: 235–239.

    Article  PubMed  CAS  Google Scholar 

  52. Prasad AS, Subhash G, Vivek K, Pande GK, Shani P, Nundy S. Proximal splenorenal shunts for Extrahepatic portal Venous obstruction in children.Ann Surg 1994; 219(2): 193–196.

    Article  PubMed  CAS  Google Scholar 

  53. Goncalves ME, Cardosos SR, Maksoud JG. Prophylactic sclerotherapy in children with esophageal varices: Long term results of a controlled prospective randomized controlled trial.J Pediatr Surg 2000; 35: 401–405.

    Article  PubMed  CAS  Google Scholar 

  54. Hayes PC, Davis JM, Lewis JA, Bouchier IAD. Meta — analysis of the value to propranolol in prevention of variceal hemorrhage.Lancet 1990; 336: 153–156.

    Article  PubMed  CAS  Google Scholar 

  55. Rockall TA, Logan RFA, Devlin HB, Northfield TC. Variation in outcome after acute upper gastrointestinal hemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage.Lancet 1995; 346: 346–349.

    Article  PubMed  CAS  Google Scholar 

  56. Rockall TA, Logan RFA, Devlin HB, Northfield TC. Risk assessment after upper gastrointestinal hemorrhage.Gut 1996; 38: 316–321.

    Article  PubMed  CAS  Google Scholar 

  57. Terdimann JP, Ostroff JW. Risk of persistent or recurrent and intractable upper gastrointestinal bleeding in the era of therapeutic endoscopy.Am J Gastroenterol 1997; 92(10): 1805–1811.

    Google Scholar 

  58. Corley DA, Stefan AM, Michael W, Cook EF, Lee TH. Early indicators of prognosis in upper gastrointestinal hemorrhage.Am J Gastroenterol 1997; 93(3): 336–340.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, All India Institute of Medical Sciences, 110029, New Delhi, India

    N K Arora (Additional Professor), S. Ganguly, P. Mathur, A. Ahuja & A. Patwari

Authors
  1. N K Arora
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. Ganguly
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. Mathur
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Ahuja
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Patwari
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N K Arora.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Arora, N.K., Ganguly, S., Mathur, P. et al. Upper gastrointestinal bleeding: Etiology and management. Indian J Pediatr 69, 155–168 (2002). https://doi.org/10.1007/BF02859378

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02859378

Key words

Search

Navigation