Critical Care Medicine
Gastrointestinal Emergencies: Peptic Ulcer Disease - Gastric/Duodenal Ulcer; Non-Variceal Upper GI Bleeding
Also known as: Non-Variceal Upper GI Bleeding
1. Description of the problem
Non-variceal upper gastrointestinal (UGI) bleeding in children is most often from gastric or duodenal ulcers, although severe gastritis and esophagitis can cause bleeding. Ulcer bleeding is often associated with critical illness.
Key management points
2. Emergency Management
1. Stabilize patient - fluid resuscitation
2. Consider blood transfusion
3. Evaluate for liver disease with AST, ALT, PT, PTT - to differentiate UGI bleeding for the need for esophageal band ligation
4. Consider octreotide - bolus of 1 mcg/kg (max 100 mcg) then 1 mcg/kg/hr continuous infusion - there are minimal data to suggest the use for octreotide in non-variceal UGI bleeding in adults, although it may be helpful in slowing a bleeding ulcer prior to endoscopy.
5. Endoscopy (see treatment section )
6. Evaluate for H. pylori as a cause
UGI bleeding in children often presents with large-volume hematemesis and can be from either a variceal or non-variceal (peptic-ulcer) source or with coffee-ground emesis or melena. Laboratory evaluation including hemoglobin and evaluation for liver disease are important. The presence of liver disease (via history or through laboratory evaluation) is helpful to plan endoscopy and banding. If no liver disease is present, endoscopy with planned hemostasis of a presumed ulcer can be planned.
Epistaxis - evaluate for nasopharyngeal source
Variceal UGI bleeding - see Liver Chapter - evaluate for liver disease
Foreign body - often present for weeks
Mallory-Weiss tear - if history of vomiting is present
4. Specific Treatment
Endoscopy - endoscopic managment of non-variceal UGI bleeding is the modality of choice and is safe, typically within 48 hours of a bleeding episode.
Endoscopic management includes the use of two of the three methods below to produce hemostasis (typically injection plus either thermocoagulation or endoscopic clipping). Multiple studies confirm a decreased rebleeding rate when two methods of hemostasis are used.
Injection - Epinephrine 1:10,000 (or 1:20,000) - 0.5- to 1.5-ml injections into four quadrants within 2-3 mm of ulcer. A total of 6 ml of epinephrine is often injected in adults and this total is likely appropriate in adolescents but should be decreased in younger children.
Thermocoagulation - both multipolar probes and heater probes are used, although multipolar probes may be slightly safer as deep tissue coagulation is limited. Firm contact to produce tamponade and thermocoagulation at the ulcer base is recommended to produce hemostasis.
Endoscopic clipping - multiple different types of endoscopic clips are available and can be deployed in multiple positions around an ulcer to produce hemostasis.
When to treat an ulcer
Bleeding or oozing ulcer - TREAT - typical approach includes injection with epinephrine followed by thermocoagulation or endoscopic clip.
Non-bleeding ulcer with visible vessel - TREAT - typically with epinephrine injection first, then with thermocoagulation or an endoscopic clip.
Non-bleeding ulcer with adherent clot - OPTIONAL - the rebleeding rate in young adults is significantly lower than in older adults with other comorbidities, and thus treatment of an ulcer with an adherent clot in children is often considered optional. If treated, the clot should be washed off, then injected with epinephrine, then treated with thermocoagulation or an endoscopic clip.
Ulcer with clean base - NO ENDOSCOPIC TREATMENT - medical managment.
Post-bleeding medical management
Evaluate for H. pylori - treat if detected on endoscopic biopsies, CLO test, or Stool test
High-dose proton pump inhibitor treatment
If endoscopic treatment is performed, consider hospitalization for 72 hours with IV bolus of PPI and a continuous infusion (adult dosing of 80-mg bolus with 8-mg/hr continuous infusion). Adult dosing is appropriate for most adolescents but may need to be decreased in younger children.
5. Disease monitoring, follow-up and disposition
Repeat endoscopy is not recommended.
PPI therapy should be continued as an outpatient, although the duration of therapy is not clear. Given the low side effect profile in otherwise healthy children, PPI therapy for up to a year can be considered.
H. pylori testing should be performed during the acute bleeding episode, and repeating if negative with a non-invasive stool H. pylori test should be considered in children.
The prognosis of an adequately treated peptic ulcer in children is excellent.
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