Gastrointestinal bleeding

To the upper gastrointestinal bleeding (GIB) (90% of all cases) include the place of bleeding that is located above the ligament of Treitz (from the esophagus to the end of duodenum; to the lower gastrointestinal bleeding – with a place of hemorrhage below the ligament of Treitz (from the small intestine to the anus).

Symptoms of gastrointestinal bleeding:

The main clinical criteria for diagnosis GIB from the upper gastrointestinal tract are:

  • hematomesis (vomiting blood in the form of unchanged blood with clots);
  • melaena (dark black, tarry feces);
  • vomiting "coffee grounds" (the color of vomiting masses is due to the occurrence of hydrochloric hematin, which is formed by reaction of blood interaction with the hydrochloric acid of the stomach).

The main clinical criteria for the diagnosis of GIB from the lower parts of the gastrointestinal tract are:

  • the presence of "raspberry jelly" stool, which is characteristic of the distal parts of the small intestine. Stool with streaks of blood is observed in the presence of bleeding from all parts of the colon except the rectum, which is characterized by bloody discharge at the end of the act of defecation.

At a small amount of bleeding, there are no obvious signs, but there is a presence of chronic hypochromic anemia, in which blood is hidden in feces.

 Table. Causes of gastrointestinal bleeding in children of different age groups

Causes of gastrointestinal bleeding depending on age

Bleeding from the upper parts

Age

Newborn children

<1 month

Children from 1 month to 2 years

Children from 2 years to 12 years

Teenagers

(> 12 years)

Common causes

-swallow maternal

blood (during feeding)
-hemolytic disease of the newborns

-esophagitis

-gastritis

-esophagitis 
-esophageal and gastric varices

-esophagitis /gastritis

-esophageal and gastric varices

-stress ulcers

Rare causes

-coagulopathy

-ulcers

-ulcers

-Mallory–Weiss syndrome

Bleeding from the lower parts

Common causes

- enterocolitis
- anal fissure

 

-intussusception
-Meckel's diverticulum

 

 

-polyps

-polyps
-infectious

-colitis

-inflammatory

colon disease

Rare causes

-intussusception

-Meckel's diverticulum

-enterocolitis

-intussusception
-enterocolitis

-intussusception
-enterocolitis

If there are clinical signs of gastrointestinal bleeding from the upper gastrointestinal tract (Video) or gastrointestinal bleeding from lower gastrointestinal tract (Video) and the patient admits to hospital, you need to follow the steps to establish the main characteristics of bleeding:

  • intensity of bleeding;
  • localization of bleeding;
  • prolonged bleeding or stopped bleeding with determination of the level of hemostasis.

Ваш браузер не поддерживает JWPlayer

Video. Gastrointestinal bleeding from the upper gastrointestinal tract

Ваш браузер не поддерживает JWPlayer

Video. Gastrointestinal bleeding from the lower gastrointestinal tract

In the presence of absolute signs of gastrointestinal bleeding, the following list of laboratory methods of research is included:

Ваш браузер не поддерживает JWPlayer

Video. Signs of gastrointestinal bleeding

At signs of bleeding from distal parts of a small intestine, US of abdominal organs with doppler scanning is carried out. This study provides an opportunity to establish the presence of pathological formations that can cause bleeding (intestinal intussusception, Meckel's diverticulum), to assess the level of small intestine blood flow (blood flow in the intussusception), as well as to detect changes in the lumen of the intestinal tract in intestinal intussusception.

In the presence of a clinical picture of bleeding from the large intestine (colon), a decision is made for the necessity of a colono- or rectoromanoscopy, after preliminary preparation of the colon for examination.

Providing emergency care at GIB

1.    General measures: confinement to bed, cold on the epigastric region, a probe into the stomach to control hemostasis and hemostatics (gastric lavage with cold solutions of 0.9% sodium chloride, 2% sodium bicarbonate, 5% aminocaproic acid to reduce blood impurities), central venous access catheter for effective infusion and transfusion therapy, prohibition of food and water.

2.    Infusion-transfusion therapy (for the restoration of circulating blood volume, correction of water-electrolyte disorders, elimination of metabolic acidosis, restoration of colloid-osmotic pressure and rheological properties of blood, elimination of anemia) is perfomed.

3.    Hemostatic therapy:

  • administration in age doses of 12.5% ​​etamsylate solution IV or intramuscularly  – 5-8 mg/kg in 3-4 injections;
  • 5% solution of aminocaproic acid – 50-100 mg/kg IV for the first hour, then 33 mg/kg/h (maximum daily dose 18 g/m2);
  • 1% solution of vicasol intramuscularly in 2 injections: children under one year ­­­– 2-5 mg/day, 1-2 years  – 6 mg/day, 3-4 years – 8 mg/day, 5-9 years – 10 mg/day, 10-18 years – 15 mg/day;
  • tranexamic acid IV – 10 mg/kg (daily dose 20 mg/kg), fibrinogen  0.5-4g IV.

4.    After detecting of blood group and Rh-factor – transfusion of one-group single-rhesus erythrocyte mass, fresh-frozen plasma, plasma substitutes if necessary.

5.    Antiulcer therapy (prescription of PPIs to reduce the risk of bleeding from gastric erosions).

6.    Therapeutic and diagnostic endoscopy (aims to diagnose the source of bleeding and its stop, monitor the effectiveness of hemostasis and predict the recurrence of bleeding). Endoscopic hemostasis: diathermocoagulation, photocoagulation, adhesive application, irrigation with hemostatic drugs. Endovascular hemostasis: intravascular administration of pituitrin, ethamsylate, aminocaproic acid, embolization of the arteries.

7.    At inefficiency of conservative treatment operative treatment is suggested.

8.    Treatment of the underlying disease.

Treatment of bleeding from esophageal and gastric varices in the emergence of PH:

  • restoration of water-electrolyte balance
  • blood transfusion if necessary (at a hemoglobin level <80 g/l)
  • prescription of drugs that reduce portal pressure (octreotide)
  • prescription  to reduce the risk of bleeding from gastric erosions
  • prescription of antibiotic therapy for the prevention of antibacterial infections
  • administration of vitamin K in patients with pre-existing coagulopathy
  • administration of fresh-frozen plasma or cryoprecipitate, as well as thromboconcentrate in the presence of thrombocytopenia
  • mechanical tamponade using a balloon probe (Sengstaken-Blakemore tube) provides mechanical compression of the esophagus and stomach