Hematemesis

Hematemesis: Excerpt from In A Page: Pediatric Signs and Symptoms

Hematemesis or blood in emesis can occur as recent or ongoing hemorrhage proximal to the ligament of Treitz. Hematemesis is relatively uncommon in the pediatric population, and its overall occurrence in an ambulatory setting has not been reported. The most common diagnoses vary based on the age of presentation of the patient.

Differential Diagnosis

• Gastritis
  –More common in pediatrics than ulcers
  –Medications (e.g., NSAIDs, aspirin)
  –Infections (e.g., Helicobacter pylori, CMV, herpes)
  –Crohn disease
• Esophagitis
  –Gastroesophageal reflux disease
  –Crohn disease
  –Infection (e.g., Candida, Aspergillus, CMV, HSV)
  –Medications (e.g., tetracycline, aspirin, NSAIDs, potassium chloride)
• Peptic ulcer disease
• Zollinger-Ellison syndrome
  –Gastrinoma
  –Results in multiple small bowel ulcers
• Milk protein allergy
• Eosinophilic enteropathy
• Portal hypertension
  –Esophageal varices
  –Gastric varices
  –Hypertensive gastropathy
• Traumatic
  –Mallory-Weiss tear (located at LES)
  –Prolapsing gastropathy
  –Foreign body ingestion
  –Direct abdominal trauma
• Vascular malformations
  –Hemangiomas
  –Aortoenteric fistulas
  –Dieulafoy lesion
  –Osler-Weber-Rendu syndrome
  –Watermelon stomach
  –Hemorrhagic telangiectasia
  –Blue rubber bleb nevus syndrome
• Tumors
  –Polyps
  –Lipomas
  –Adenocarcinoma
  –Lymphoma
• Miscellaneous
  –Hemosuccus pancreaticus
  –Hemobilia
  –Swallowed maternal blood
  –Gastric duplication
  –Munchausen by proxy syndrome
  –Coagulopathy
  –Epistaxis (initially swallowed blood)
  –Hemoptysis

Workup and Diagnosis

• History
  –Quantity, frequency, type of blood (bright red vs “coffee grounds”); abdominal pain
  –Dysphagia/odynophagia, chest pain/burning, hematochezia, melena, bruising, bleeding
  –Birth history: Stressors, medications before delivery, medications in delivery room (vitamin K), lines placed (umbilical lines can result in clotting of portal vein)
  –Past history: History of liver disease, ingestions, history of pancreatitis, GI surgeries
  –Medications: NSAID use, aspirin use, recent meds
  –Diet history: Formula intolerance, food allergies

• Physical exam
  –Vital signs (tachycardia, tachypnea, hypotension), blood in nares, conjunctival/palatal pallor, flow murmur, hepatosplenomegaly, abdominal tenderness, abdominal bruising, petechiae
• Diagnostics
  –Limited labs: CBC, liver function tests, coagulation studies, type and screen/cross
  –Upper endoscopy most sensitive and specific for diagnosis and provides therapeutic options
  –Ultrasound with Doppler to assess liver disease and portal hypertension
  –Reserve nuclear medicine studies (e.g., tagged red cell study, angiography) as second line and for brisk bleeding

Treatment

• Large bleeds require two large-bore IVs and volume support with normal saline or packed red blood cells
• Closely monitor vital signs
• Acid blockade with histamine receptor antagonist or proton pump inhibitor
• Endoscopic therapy including
  –Heater probe and bipolar coagulation for ulcers
  –Band ligation or sclerotherapy for varices
• Octreotide or vasopressin to reduce splanchnic blood flow for variceal bleeding
  
• Selective embolization
• Surgical repair rarely indicated
• Treat infections including triple therapy (antibiotics and proton pump inhibitor) for H. pylori
  
• Remove allergen in case of allergy

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Vomiting (In A Page: Pediatric Signs and Symptoms)

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