UPPER GASTROINTESTINAL

BLEEDING & PORTAL HYPERTENSION IN

CHILDREN

MANIFESTATIONS OF GI BLEED

Melaena – the passage of black, tarry stools indicates likely UGI bleed (proximal to the

ligament of Treitz)

Haematemesis – vomitus containing frank blood or brown-black “coffee grounds”

Haematochezia – passage of bright or dark red blood per rectum

In general, the redder the blood, the more distal the site of bleeding

SPURIOUS GI BLEED

Red: beets, laxatives, phenytoin, rifampin 

 

Black: bismuth, activated charcoal, iron, spinach, blueberry, licorice

GUAIAC TEST

ETIOLOGY

ETIOLOGY

ETIOLOGY

“plucked chicken appearance”

HISTORY Drugs Retching or vomiting Jaundice Procedures Recurrent abdominal pain Bleeding disorders in family Odynophagia

EXAMINATION Stigmata of chronic liver disease

General condition

External vascular malformation

Hyperpigmented lips

Dilated abdominal wall veins, Splenomegaly

NASO GASTRIC LAVAGE Removes blood from stomach –

facilitates easier endoscopy

Confirmation of bleed/ongoing blood loss

Prevents development of encephalopathy in cirrhotic patients

ASSESSMENT OF BLOOD LOSS Disproportionate tachycardia

“Tilt” test

Capillary refill time

Signs of shock

THERAPY

PORTAL HYPERTENSION

CIRRHOSIS - PATHOLOGY

EXTRAHEPATIC PORTAL HYPERTENSION Portal vein agenesis, atresia, stenosis

   Portal vein thrombosis or cavernous

transformation  

Splenic vein thrombosis     

Arteriovenous fistula

VASOPRESSIN Acts by increasing splanchnic vascular tone

0.3 units per kg per hour after a bolus of 0.3 U/kg over 20 min

The addition of nitroglycerin (skin patch) decreases the systemic .effects of vasopressin

Terlipressin-longer duration of action and lesser cardiac side effects

SOMATOSTATIN & ANALOGUES much better side-effect profile and

similar efficacy

3 to 5 μg per kg per hour

Octreotide has a longer half-life- bolus (2 μg/kg) followed by continuous infusion (1 to 5 μg per kg per hour)

OTHER DRUGS antibiotic prophylaxis directed at

intestinal flora (third-generation cephalosporin) should be started from admission

H2 receptor blocker or proton pump inhibitor intravenously

ENDOSCOPIC SCLEROTHERAPY (EST) Acts by producing intimitis

Injected either intra- or paravariceal

Intravariceal cyanoacrylate or histacryl glue and thrombin for gastric varices

Complications of EST include ulceration, pain, perforation, and bacteremia.

ENDOSCOPIC VARICEAL LIGATION (EVL) Draws a visible varix into the lumen of

the ligator and a band is placed around the varix

EVL is just as effective as EST but was associated with fewer complications and faster obliteration of varices.

BALLOON TAMPONADE

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPSS)

TIPSS Indications: Recurrent variceal hemorrhage Refractory ascites Hepatorenal syndrome

Contraindications Polycystic liver disease Right heart failure Systemic infection Portal vein thrombosis Severe hepatic encephalopathy

PROPHYLAXIS Primary prophylaxis - propranolol

Secondary prophylaxis – EVL/EST

Surgical treatment: Patients with EHPVO bleeding gastric or other nonesophageal

varices severe hypersplenism

SURGICAL TREATMENT OPTIONS Decompressive shunts Devascularization Liver transplantation

THANK YOU!!!