1. ATAN BAAS SINUHAJI Sub Division of Pediatrics Gastroentero-Hepatology Department of Child Health, School of Medicine University of Sumatera Utara/ Adam Malik Hospital MEDAN 1 GASTROINTESTINAL BLEEDING

2. GI Bleeding 2 Acute Stable 4 important points

3. 3 GI bleeding Blood ? Gut Out In Upper or lower Spesific site 1 2 3 4

4. 4 Materials Heme protein Hydrogen peroxidase Colorless guaiac Blue quinone

5. 5 Tabel 1. Substances that interfere with Guaiac test for fecal occult blood

6. 6 GI Bleeding Gut Out In Ingestion Non ingestion UpperLower

7. 7 Non ingestion - Blood disorders : leukemia,ITP, etc - Systemic : sepsis - Rupture aortic aneurysma with enteric fistula - Hemorrhagic Disease of the Newborn

8. 8 Ingestion Newborn Swallowed maternal blood APT Downey Test Infants & young children - Nipples - Epistaxis - Oropharyngeal bleeding - Blood tinged sputum

9. 9 Newborn Hb F Hb A Hb A2 50-90%

10. 10 Manifestation of GI Bleeding Blood per os Hematemesis Upper GIT Blood per anum OccultOvert Melena Hematochezia Upper GIT

11. 11 Dysentry syndrome Blood strike Anorectal area Anal fissure Polyps Currant jelly stools Intussusception

12. 12 Causes Non lesion GITLesion GIT

13. 13 Lesion GIT Mucosal lesion Variceal bleeding Surgical Non surgical Emergency Elective Inflammation

14. 14 Clinical presentation Hematemesis Melena Hematochezia Hystory & physical examination Laboratory evaluation Stable Nasogastric tube Blood (+) Blood (-) Upper GIT bleeding Lower GIT bleeding Contrast radiography Endoscopy

15. 15 Gastric aspiration The site of bleeding The amount of bleeding The bleeding stop ? Not totally exclude upper GIT bleeding Competent pyloric No reflux Bleeding stopped

16. 16 Clinical presentation Hystory and physical examination Laboratory evaluation Stable Nasogastric tube Blood (+) Blood (-) Upper GIT bleedingLower GIT bleeding Plain abdominal X-ray (erect & supine) Obstruction No obstruction Barium enema Surgery Stool examination / culture Meckel’s scan Double contrast barium enema Colonoscopy Figure 2. A diagnostic approach of lower bleeding GIT

17. 17 Treatment A General measures B Control of upper GIT bleeding C Control of lower GIT bleeding

18. 18 A General measures 1.To restore iv volume & O2 carrying capacity 2. To increased hematocrit 3. Underlying coagulopathies NaCl 0,9% Lactate Ringer Blood/product Vit K 1 mg/year (max 10 mg) Fresh Frozen Plasma Platelets

19. 19 B Control of upper GIT bleeding Gastric lavage with ice saline Specific

20. 20 Specific treatment of upper GIT bleeding Mucosal lesion Acid neutralizing / supressor agent Variceal bleeding Vasoactive agent Balloon tamponade Sclerosing Surgery

21. 21 Gastric lavage with ice saline Standart treatment Clearing of fresh blood and clots Adverse effect: Hypothermia and electrolytes abnormalities in infant

22. Gastric lavage with ice saline  The recommended volume:  50 mL (infants)  100-200 mL (older children)  Rapidly infused to stomach  Allow to stay for 2-3 minutes and gently aspirated out  The tube left in place to monitoring any subsequent hemorrhage 22

23. 23 Mucosal lesion - Self limiting (spontaneously / ice saline) - Acid neutralizing / supressor agent Do not stop active bleeding Antacid 1 mL/kg/dose (max 30 mL/dose) Every 1-2 hours  gastric pH ≥ 5 Thereafter: 1-3 hours after meal & at bed time 6 weeks

24. 24 Stop spontaneously Vasoactive agent (vasopressin & octreotide) Splanchnic arterial blood flow ↓↓ Portal pressure ↓↓

25. 25 Variceal bleeding Radical/surgical consultation ICU Resuscitation Endoscopy to visualize varices Vasoactive agent Sengstaken – Blackmore tube Sclerosing therapy Emergency therapy Figure 3. An approach to the management of variceal bleeding

26. VASOPRESSIN  Bolus dose: 0,3 U/kg (max 20 U/kg) dilluted in 2 mL/kg 5 % Dextrose  20 minutes  Continous infusion: 0,2-0,4 U/ 1,73 m 2 /min,if necessary  The bleeding cases: the infant is maintained at the initial dose for 12 hours and then gradually tapered  24-36 hours  Side effect: hypertension, myocardial ischemic, arrhythmias, water retention and venous thrombosis 26

27. OCTREOTIDE  Bolus dose: 1 μg/kg  Continued infusion: 1 μg/kg/h with titration of both bolus and constant infusion up to 5 μg/kg/h  The bleeding cases: doses should be tapered by 50 % for 12 hours, can be discontinued when dose is 25 % initial dose 27

28. 28 Balloon tamponade Sengstaken-Blackmore tube Indication: Massive life threatening bleeding Continued bleeding despite 4-6 hours of i.v. vasopressin Complication: Ulceration Airway obstruction Aspiration Esophageal rupture

29. 29 CControl of lower GIT bleeding Severe lower GIT bleeding is uncommon Definitive treatment: depend on the cause

30. 30 B  Ongoing bleeding L  Low systolic blood pressure E  Elevated prothrombine time E  Erratic in mental status D  Comorbid disease (other than bleeding) requiring admission to ICU Figure 4, Predictors of outcome

31. 31 CONCLUSION GI Bleeding Not unusual Life threatening problem Stable Bleeding source

32. 32 Thank You