🩸 Chapter 74: Acute Gastrointestinal Bleeding

Haematemesis · Melena · Haematochezia · Variceal vs Non-Variceal · Octreotide · Endoscopy · PICU Admission Criteria

🩸 Acute GI Bleeding: Upper vs Lower — Life-Threatening Emergency

📊 Definitions
• Haematemesis: vomiting blood (UGI source)
• Coffee-ground vomitus: bleeding ceased or modest
• Melena: black tarry stools (usually UGI, 50-100 mL needed)
• Haematochezia: fresh blood per rectum (usually lower GI)
🩸 Causes by Age
• 0-2y: anal fissure, Meckel's, allergic colitis, intussusception
• 2-12y: polyps, Meckel's, infectious colitis, HSP, IBD
• >12y: IBD, haemorrhoids, ulcers, varices (cirrhosis)
⚠️ PICU Admission Criteria
• Massive bleeding, haemodynamic instability
• All variceal bleeding
• Comorbid conditions (liver disease, malignancy, renal failure)
• Multiple transfusions
• Need for emergency surgery
💊 Variceal Bleeding
• Octreotide: 1 mcg/kg bolus + 1-5 mcg/kg/h infusion
• Empirical antibiotics (7-10 days)
• Endoscopy: band ligation, sclerotherapy, glue
• TIPS for refractory bleeding
💊 Non-Variceal Bleeding
• PPI (proton pump inhibitor) — increase gastric pH >6
• Endoscopy: cautery, hemoclip, epinephrine injection
• H. pylori eradication if positive
• Avoid NSAIDs/aspirin
🔬 Diagnostic Tools
• NG lavage (differentiates UGI vs LGI)
• Upper endoscopy (diagnostic + therapeutic)
• Colonoscopy (for LGI bleeding)
• Tagged RBC scan (bleeding >0.5 mL/min)
• Meckel's scan (Tc-99m pertechnetate)
📌 Key Pearls: Resuscitate FIRST — airway, two large-bore IVs, fluid bolus 20 mL/kg. O-negative blood if exsanguinating. Variceal bleeding has higher mortality. Octreotide is first-line for varices.

🩺 Step-by-Step: Acute GI Bleeding Management

1
Initial resuscitation — ABCs FIRST!
Assess airway, breathing. Intubate if massive bleeding (airway protection). Two large-bore IVs or IO. 100% O2 by NRM. Obtain blood for CBC, coagulation, cross-match.
2
Fluid resuscitation & blood products
20 mL/kg isotonic crystalloid rapid bolus. If haemodynamically unstable despite fluids → transfuse PRBC (O-negative if urgent). Correct coagulopathy (FFP, vitamin K, platelets).
3
Determine upper vs lower GI source
NG tube lavage: blood/coffee-ground = UGI. Clear aspirate does NOT rule out duodenal bleed. Haematemesis = UGI. Melena = UGI. Haematochezia = LGI (or massive UGI).
4
Identify variceal vs non-variceal bleeding
Signs of liver disease (splenomegaly, ascites, jaundice, spider angiomas) → variceal. History of NSAID/aspirin use, vomiting preceding bleed (Mallory-Weiss) → non-variceal.
5
Variceal bleeding management
Octreotide 1 mcg/kg bolus → 1-5 mcg/kg/h infusion. Start empirical antibiotics (cefotaxime/ceftriaxone). Urgent endoscopy for band ligation/sclerotherapy. TIPS if refractory.
6
Non-variceal bleeding management
IV PPI (pantoprazole/omeprazole) loading dose then infusion. Urgent endoscopy for epinephrine injection, cautery, hemoclip. Test for H. pylori, eradicate if positive.
7
Lower GI bleeding management
If haemodynamically stable → colonoscopy. Tagged RBC scan if bleeding rate >0.5 mL/min. Angiography with embolisation for refractory bleeding. Surgery for uncontrolled bleed.