Patients with severe or significant GI bleeding

a. Order immediate blood studies, including type and cross-match, CBC, PT and PTT, and electrolyte panel with liver function studies.

b. Insert a nasogastric tube. Nasogastric aspirate that is positive for occult blood will differentiate upper GI from lower GI bleeding. If gastric contents clear following initial lavage, gastric irrigation can be performed every 15 minutes for 1 hour, and than every 2-3 hours to assess continued bleeding.

4. Medications. Early use of antacid therapy and an H2 antagonist is recommended because of the prevalence of peptic disease.

B. Recurrent Hemorrhage. Patients with significant and recurrent hemorrhage should undergo endoscopy. Medications, including vasopressin and octreotide, may be indicated to control active bleeding. Arteriographic embolization can be used in treatment of vascular anomalies.

VI. Problem Case Diagnosis. On arrival in the emergency department, infant appeared happy, playful, and in no apparent distress. Vital signs were within normal limits except for mild tachypnea. Upon questioning, parents indicated that infant had coughed up blood-tinged secretions earlier in the day, and they had been aggressively suctioning copious nasal secretions, which were also blood tinged. Infant had no history of feeding intolerance or previous bleeding. Physical exam was significant only for nasal mucosal inflammation and excoriation. Clinician suspects that this minimal amount of bleeding is secondary to swallowed epistaxis. As in this case, good history-taking and clinical exam can avert unnecessary workup in patients with minimal, self-limited bleeding.

VII. Teaching Pearl: Question. What are the five most common causes of upper GI bleeding in children?

VIII. Teaching Pearl: Answer. The most common causes of GI bleeding in children are (1) duodenal ulcer, (2) gastric ulcer, (3) esophagitis, (4) gastritis, and (5) varices.

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