Immediate Questions

A. What are the vital signs? Hypotension and tachycardia, in the presence of bleeding, are indicative of volume loss that requires prompt correction.

B. What is the character of the NG bleeding? Lightly blood-tinged fluid or "coffee-ground" emesis is less worrisome than fresh red blood.

C. How much bloody drainage has there been? Large amounts of bloody drainage are of concern. Blood volume in children aged 1-3 years is approximately 75 mL/kg.

D. Has patient had recent or remote GI surgery? If surgery was recent, there may be bleeding from a new anastomotic site, or there may be a marginal ulcer at an old anastomotic site.

E. Is patient passing flatus or stool? What is the character of the stools? Often, decreased NG output correlates with return of bowel function. Abdominal obstruction or ileus may result in decreased passage of gas or bowel movements. Fresh red blood from the rectum along with bloody NG drainage is very serious. Melena suggests upper tract or small bowel bleeding. Stools that are normal in appearance and occult blood-positive are suggestive of slower GI bleeding. Stools that are negative for occult blood suggest very early or insignificant bleeding.

F. How long has NG tube been in place? A tube that has been recently placed may have a small amount of bloody drainage secondary to the insertion. A tube that has been in place for

> 48 hours may cause oozing from gastric or esophageal mucosal irritation.

G. Is patient receiving antacids, H2 blockers, or proton pump inhibitors (PPIs)? What is the pH of the drainage? Presence of acidic gastric secretions may predispose to formation of gastritis and "stress" ulcers. Gastric pH > 4 may enhance mucosal protection.

H. Is there associated abdominal distention? If patient develops ileus or obstruction, the amount of aspirate may increase.

I. Is output bilious? Bilious NG output indicates bile reflux into the stomach, or NG tube that has been placed distal to the pylorus. J. Is tube functioning? Tubes often become obstructed with mucous or medications. While the tube is on suction, listen for a whistle, which indicates patency. K. Is patient taking, or being given, extra fluid by mouth? Often, excessive amounts of ice chips are given to patients with NG tubes. This can lead to high NG outputs. Careful questioning of family and caregivers can identify this possibility. L. Are there any respiratory symptoms? If NG tube is misplaced in the esophagus or oropharynx, patient may have a cough or complain of throat pain.

Differential Diagnosis

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