Emergency Management of Major Upper Gastrointestinal Hemorrhage in Children

Abstract:Major upper gastrointestinal hemor-rhage is an alarming clinical pre-sentation in infants and children.Although the etiology varies accord-ing to age at presentation, theshared principles of diagnosis andmanagement include prompt as-sessment, resuscitation, investiga-tion and therapeutic intervention.Patients with portal hypertensionand other significant medical co-morbidities warrant special consid-eration and medical management.Data on the epidemiology and out-comes of children with major uppergastrointestinal hemorrhage arelimited and further research to ad-dress these questions is keenlyawaited.

Keywords:children; hematemesis; melena;

abdominal pain; portal

hypertension

*Division of Gastroenterology, Hepatol-

ogy and Nutrition, Hospital for Sick

Children, Toronto, Canada; †Department

of Paediatrics, University of Toronto,

Toronto, Canada; ‡Division of Gastroen-

terology, Hepatology and Nutrition, Our

Lady’s Children’s Hospital, Crumlin,

Dublin 12, Ireland.

Reprint requests and correspondence:

Simon C. Ling, Hospital for Sick Chil-

dren, 555 University Avenue, Toronto,

Ontario, Canada, M5G 1X8.

1522-8401/$ - see front matter

© 2010 Elsevier Inc. All rights reserved.

EMERGENCY MANAGEMENT OF MAJOR UPPER GI H

EmergencyManagement ofMajor Upper

GastrointestinalHemorrhage in

Children

EMORRHAGE IN CHILDREN / HUS

Seamus Hussey, MB MRCPI*†‡,Kathleen T. Kelleher, MB MICGP*,

Simon C. Ling, MBChB*†

he presenting symptoms and signs of major uppergastrointestinal hemorrhage in children are alarming for
Tchildren, parents, and clinicians alike and usually promptan urgent visit to the emergency department. Much of the
limited published pediatric literature on this potentially life-threatening clinical problem concerns unusual presentations,manifestations, and etiologies of gastrointestinal hemorrhage.Remarkably, there is a paucity of well-designed, population-baseddata on the incidence, etiology, and outcomes of children whopresent acutely for assessment of major upper gastrointestinalhemorrhage. Consequently, therapeutic and management trials formajor upper gastrointestinal hemorrhage (MUGIH) in children arelimited. By comparison, MUGIH is more prevalent in adults,particularly in older age groups, and the published adult literaturecontains robust well-designed, geographic-specific epidemiologicstudies.1-5 This depth of information has enabled the generation ofuseful clinical and endoscopic scoring systems to facilitate triageandmanagement of adults presentingwithMUGIH.6,7 The inclusionof age as a major component in adult-derived scores renders themunhelpful in the pediatric setting. Major therapeutic advances in the

SEY, KELLEHER, AND LING • VOL. 11, NO. 3 207

TABLE 2. Common causes of major upperintestinal bleeding in children.

Peptic ulcer diseaseHelicobacter pyloriIdiopathic

Idiopathic mucosal erosive diseaseMedication (especially NSAID)-induced mucosal diseaseSevere esophagitisMallory-Weiss syndromeDietary protein intolerance/allergyVariceal hemorrhagePortal hypertensive gastropathyGastric antral vascular ectasiaCoagulopathyPrimary factor deficiencySecondary to liver disease, sepsis, etcSecondary to drug or naturopathic therapy ingestion

Vascular malformationLymphoma or other malignancyOther less common causesBleeding from endoscopic biopsy sitesHemobilia after liver biopsy

Undetermined cause

NSAID indicates nonsteroidal anti-inflammatory drug.

208 VOL. 11, NO. 3 • EMERGENCY MANAGEMENT OF MAJOR UPPER GI HEMORRHAGE IN CHILDREN / HUSSEY, KELLEHER, AND LING

management of adult MUGIH have flowed from theevidence base of clinical trials. Recent changes in thenatural history of MUGIH in adults have beendocumented and likely reflect the advent of powerfulacid-suppressant medication, therapeutic endoscop-ic technologies, and most importantly, the recogni-tion and eradication of Helicobacter pylori, thepredominant causative agent in peptic ulcer disease.8

We will focus here on the presentation of MUGIHin children and suggest a strategy for the assessmentand management of such patients based on both thepublished literature and our own experience. Theapproach to minor gastrointestinal bleeding inwhich patients present with small amounts ofhematemesis or “coffee ground” emesis, and with-out shock or drop in hemoglobin, is beyond thescope of this review.

The common clinical manifestations of MUGIH inchildren include hematemesis, melena, and abdom-inal pain. Brisk blood loss may occasionally manifestas hematochezia, owing to the cathartic effect offresh blood on intestinal transit. Such symptomsand signs should be confirmed, via Hemocculttesting, by the attending medical team, given thattheir appearances could also be explained by otherless sinister entities (Table 1). The preinvestigationprobability of particular underlying causes will varydepending on the child's age, geographic locationand any comorbid medical conditions (Table 2).9-12

Neonatal-onset MUGIH may reflect underlyingcoagulopathy or vascular malformations, but idio-pathic mucosal erosive disease has been describedin otherwise healthy infants.13 Rare causes mustalways be considered in the differential diagnosis ofMUGIH in children, such as foreign body ingestion,vascular malformations and anomalies, vasculartumors, coagulation disorders, idiopathic thrombo-cytopenic purpura, Henoch-Schönlein purpura,vasculitis, eosinophilic mucosal diseases, immuno-deficiency, idiopathic inflammatory bowel disease,gastrointestinal malformations, polyposis syn-dromes, and intestinal tumors.

TABLE 1. Differential diagnosis of major uppergastrointestinal hemorrhage.

Ingested maternal blood in neonatesNongastrointestinal blood loss—nasopharynx, airway, etcIngested foodstuffs—colored foods and drinks, fruit, berries,fruit juices, etcIngested red/dark medicines or supplements

PRIMARY MANAGEMENTChildren with MUGIH require multidisciplinary

team care for optimal outcomes. The initial steps inmanaging children with MUGIH include assessment,resuscitation, reevaluation, identification of thecause and source of bleeding, and commencingappropriate treatment (Figure 1). Children present-ing with symptoms and signs of MUGIH requireprompt recognition in triage so that timely resusci-tation can be initiated and hemodynamic stabilityrestored. Urgent assessment and resuscitation algo-rithms should be followed, as for any pediatricmedical emergency, and maintaining a patent, safeairway, and effective breathing are foremost prior-ities.14 The next objective is to determine thepresence of shock and hemodynamic instabilityand to identify factors that could aid in riskstratification for subsequent management, includingany underlying comorbidities.

Support for and reestablishment of an effectivecirculating volume is a fundamental resuscitationpriority.15,16 Ideally, at least 2 large bore intrave-nous (IV) access points should be established tofacilitate resuscitation and administration of medi-cation. At cannulation, appropriate blood samplesfor laboratory investigation should be obtained andsent for urgent processing (Table 3). Point-of-care

EMERGENCY MANAGEMENT OF MAJOR UPPER GI HEMORRHAGE IN CHILDREN / HUSSEY, KELLEHER, AND LING • VOL. 11, NO. 3 209

testing should be performed in unstable patientswhen available because this may improve testturnaround time. Initial fluid bolus resuscitation,using an isotonic solution, can then follow and itseffectiveness subsequently assessed. Early intensive

Figure 1. Algorithm for management of upper ga

resuscitation of adult patients with MUGIH has beenshown to reduce mortality.17 Normal hemoglobinresults should be interpreted cautiously in a patientwith hematemesis and/or melena and signs ofcirculatory compromise; fluid resuscitation should

strointestinal hemorrhage in children.

TABLE 4. Summary of selectedrecommendations on management of adult

patients with nonvariceal uppergastrointestinal bleeding.10

Patients should undergo immediate evaluation andappropriate resuscitationConsider blood transfusion for patients with a hemoglobin b70 g/LNasogastric tube placement may be considered inselected patientsPromotility agents are not indicated routinely pre-endoscopyPPI therapy may decrease the need for endoscopic interventionHistamine-2 receptor antagonists are not recommended forpatients with acute ulcer bleedingOctreotide is not routinely recommended for patients with acuteulcer bleedingEndoscopy within 24 h of presentation is recommended formost patientsPatients receiving endoscopic hemostasis should be admitted for72 h thereafter

PPI, proton pump inhibitor.

TABLE 3. Suggested investigations atpresentation—first line, patient specific.

Investigations forAll Patients

Investigations forSelected Patients

Blood group and cross-match Blood gas and lactateComplete blood countand differential

Blood culture(if varices or fever present)

Coagulation profile (INR/PT, PTT) Abdominal imagingUrea and creatinineAST, ALT, GGT, alkaline phosphataseAlbumin, conjugated bilirubinElectrolytes

INR indicates international normalized ratio; AST, aspar-tate aminotransferase; ALT, alanine aminotransferase;GGT, gamma-glutamyl transferase; PT, prothrombin time;PPT, partial thromboplastin time.


be administered and blood transfusion ordered asappropriate if bleeding continues. Subsequent mea-surements of hemoglobin should be undertaken inan unstable patient or one in whom bleedingcontinues, initially hourly or at intervals dictatedby the patient's condition.

Patients' heart rate, blood pressure, respiratoryrate, and capillary refill must be reassessed fre-quently throughout the initial management, andcontinuous monitoring should be used wherepossible. Placement of a nasogastric tube andaspiration of blood provides evidence of an uppergastrointestinal source of bleeding in a patient withmelena and may support a role for early endoscopy.There is no clear benefit obtained by gastric lavage,and therefore, this does not form part of ourmanagement of children with MUGIH.

In the absence of any individual contraindications(eg, previous hypersensitivity, concomitant clopi-dogrel therapy), prompt institution of acid suppres-sive therapy with an appropriately dosed IV proton-pump inhibitor (PPI) is recommended (eg, panto-prazole or omeprazole). A significant evidence basesupports the use of PPI in MUGIH and not just incases of suspected ulcer disease.16,18 Clot stability isenhanced at pH higher than 6, and preendoscopyPPI therapy reduces the need for therapeuticintervention at endoscopy and may facilitate earlierhospital discharge.19-21 Given that the etiology ofMUGIH in patients with portal hypertension mayarise from causes other than variceal hemorrhage,acid suppression can also be justified.

The clinical history should not only document thesequence of preceding events, it should also con-

tribute to the risk stratification for each patient.Focused questions should include comorbid ill-nesses; recent medication ingestion (including pre-scribed, “over-the-counter,” and “alternative”medical preparations/supplements); symptoms ofundiagnosed chronic liver disease, coagulopathy,or peptic ulcer disease; previous bleeding episodes;and recent illnesses. By extrapolation from studies ofadults, clinical factors that might predict increasedlikelihood of rebleeding or life-threatening hemor-rhage in children include hypotension, tachycardia,or syncope at presentation; comorbid cardiacdisease, cirrhosis, or malignancy; low hemoglobinor high blood urea; and American Society ofAnesthesiologists grade higher than 3. 6,22,23

Early consultation with pediatric gastroenterolo-gy is warranted in all cases of MUGIH. Apart frommedical management advice, the gastroenterologistwill also need to determine whether endoscopy isindicated and optimal timing for such a procedure.Timing of endoscopy has been an area of intensedebate in the field. Consensus from adult-basedliterature advises that endoscopy within 24 hours ofpresentation is justified; emergent endoscopy (with-in 12 hours) is associated with an increased need forintervention procedures without improving majoroutcomes—suggesting that medical treatment canfavorably improve the characteristics of certainlesions if given some time.16,24-26 The role ofendoscopy is considered further below.

TABLE 5. Controversial areas inpediatric MUGIH.

Blood transfusion thresholdNasogastric tube placementUse of empiric PPI therapy in patients with suspectedvariceal bleedingOptimal pharmacologic agent for children with variceal bleedingIndications for and timing of endoscopyPostendoscopy duration of hospitalizationUse of second-look endoscopy

PPI, proton pump inhibitor.


There may be a limited role for radiologicinvestigation in the emergent evaluation of childrenwith MUGIH, but such investigations should notdelay initiation of treatment. Children with MUGIHand a tender/guarded, distended abdomen may havea perforated viscus, and abdominal imaging may beof diagnostic value. If an endoscopist is not available,or after a negative endoscopy result in a child whocontinues to bleed, diagnostic imaging modalitiesmay be considered, including angiography, labeledred blood cell scintigraphy, and contrast-enhancedmultidetector helical computed tomography.27

These modalities are diagnostically less sensitivethan endoscopy for upper gastrointestinal bleeding.Limitations of angiography include risks of vascularinjury, contrast-induced nephropathy, and poorsensitivity to detect lesions bleeding less than 0.5mL/min. Red cell scintigraphy is more sensitive atdetecting actively bleeding lesions with a bleedingrate as low as 0.05 to 0.1 mL/min, but it has poorsensitivity and specificity and fails to accuratelylocalize the bleeding site for subsequent surgicalintervention. Multidetector helical computed tomog-raphy has been well described in the adult literatureas a potentially useful investigation to detect thesource of gastrointestinal hemorrhage; however, it isassociated with radiation exposure, there are asso-ciated pitfalls in image interpretation, and pediatricdata are lacking to date.28

Consultation with pediatric surgery, interven-tional radiology, and anesthesia/intensive carecolleagues is indicated in cases of seeminglytorrential bleeding, in cases of significant hemody-namic instability, and in patients with a poorAmerican Society of Anesthesiologists physicalstatus classification. A summary of selected recom-mendations on management of children withMUGIH based primarily on adult patients withnonvariceal upper gastrointestinal bleeding isgiven in Table 4.

Special Considerations for Patients With PortalHypertension or Chronic Liver Disease

Children with portal hypertension secondary toliver disease presenting with MUGIH warrant specialconsideration and are the largest single patientpopulation subgroup that present with MUGIH.9 Theetiology of portal hypertension varies according toage of onset, but its clinical manifestations neithersensitively nor specifically discriminate between itsunderlying causes. Common findings includesplenomegaly (±hepatomegaly) and thrombocyto-penia (±leucopenia), whereas some patients havevisible ectatic veins on their abdominal wall (caput

medusae) or ascites. Other well-described stigmataof chronic liver disease should be sought anddocumented. Hematemesis or melena in childrenwith liver disease is an ominous sign that warrants aprompt, thorough assessment.29-31

Variceal hemorrhage may be the first presenta-tion of portal hypertension and/or liver disease inchildren. Coagulopathy, thrombocytopenia, bacte-rial peritonitis or other sepsis, hepatopulmonarysyndrome, hepatorenal syndrome, anemia, enceph-alopathy, and poor glycemic control are allsignificant potential comorbid sequelae of chronicliver disease that could also directly affect theassessment and management of MUGIH in thispatient group. Patients with portal hypertensionoften have bounding/large volume peripheral pulsesclinically, reflecting their hyperkinetic circulatorystate. In some centers, selected children may beprescribed beta-blockers as a medical prophylaxisagainst variceal bleeding and therefore may nothave significant compensatory tachycardia. Cau-tion is strongly advised against the misinterpreta-tion of such clinical signs as reassuring.Degradation of blood in the intestinal lumen mayprecipitate encephalopathy in patients with signif-icant hepatic dysfunction, which may manifestclinically as disorientation or somnolence.

For children with known chronic liver diseaseand/or confirmed portal hypertension, varicealhemorrhage is a substantial complication thatcarries a significant risk of morbidity and mortalitywith each bleeding episode.32,33 Rupture of distalesophageal or gastric varices is the most commonsource of variceal hemorrhage.34 A seemingly smallvolume of hematemesis (herald bleed) may in factportend an actual massive variceal hemorrhage.Recent interest in the noninvasive diagnosis ofvarices in children, using commonly measuredvariables linked to portal hypertension and hepaticsynthetic function such as platelet count and spleen


size, may help in the future to identify thosechildren with liver disease likely to have esophagealvarices “at the bedside.”35

Major upper gastrointestinal hemorrhage inpatients with portal hypertension may result fromcauses other than variceal hemorrhage such as;portal hypertensive gastropathy, peptic ulcer dis-ease and diffuse mucosal inflammatory or erosiveconditions. The other general age-appropriatecauses of MUGIH must be considered while formu-lating a differential diagnosis (Table 2).

Management: Fluids and Blood ProductsThe goal of resuscitation and stabilization of a

portal hypertensive child with MUGIH remainsthe prompt restoration of the effective circulatingvolume and correction of any bleeding diathesisto support hemostasis. The vigor of resuscitationshould be proportional to the severity of bleeding,and inadequate volume resuscitation will be tothe patient's detriment.17 Maintenance of thehemoglobin and hematocrit at modest levels(hemoglobin approximately 100 g/L, hematocritapproximately 25%) is suggested; excessive bloodtransfusion and intravascular volume overexpan-sion could exacerbate the already increasedsplanchnic venous pressure and further contributeto variceal bleeding.36 A randomized trial compar-ing liberal with restricted transfusion practice iscurrently underway in adults.37 Patients withadvanced chronic liver disease often struggle tomaintain their fluid and electrolyte equilibrium.Although the primary resuscitation aim must be toquickly and adequately restore effective circulatingvolume, excessive saline resuscitation at the ex-pense of blood or blood products may not be in thepatient's best interests.

Management: CoagulopathyOnce coagulation profile tests have been obtained,

and in the absence of contraindications (eg, previoussevere reaction), parenteral vitamin K could beadministered empirically, although results are pend-ing (infants, 1-2 mg/dose; children, 5-10 mg/dose).Coagulopathywith an international normalized ratiohigher than 1.5 or abnormal partial thromboplastintime (PTT) should be corrected with fresh frozenplasma (10 mL/kg initially), and this volumeincluded in the calculated resuscitation fluids.

Management: Acid SuppressionEmpiric acid suppressive medication may be

initiated, especially given the possibility of non-

variceal causes of MUGIH. Although parenteralPPIs (eg, pantoprazole) are the usual drugs ofchoice, some clinicians still prescribe histamine-2receptor antagonists. The use of PPIs in patientswith chronic liver disease is not without contro-versy, given that PPIs require a hepatic reserve fortheir metabolism.38 However, there remains a lackof pediatric data to suggest that PPIs are unsafe inthis setting. Major areas of controversy in themanagement of children with MUGIH are listed inTable 5.

Management: Pharmacologic Managementof Varices

Somatostatin analogues (eg, octreotide, 1-2 μg/kgbolus followed by 1-5 μg/kg per hour, IV infusion)remain a mainstay of pharmacologic managementof acute variceal bleeding in children.39,40 Thevasopressin analogue, terlipressin, may have cer-tain advantages over octreotide; however, it is notyet widely available in North America. Thereremains a paucity of pediatric trials of theseanalogues in this setting, and so pediatric practiceis largely extrapolated from adult practice. Inter-estingly, a recent Cochrane analysis concluded thatthe use of somatostatin analogues in the acute adultsetting resulted in less blood transfusions perpatient but that an overall benefit on mortalityoutcome was not apparent.41 Terlipressin waspreviously reported to have a benefit on mortalityin acute variceal bleeding in adults,42 although arecent randomized trial comparing octreotide andterlipressin showed no difference in efficacy andmortality outcomes, apart from a shorter length ofstay (approximately 1 day) in those treated withterlipressin.43 Terlipressin has generated interest inpediatric critical care settings for children withrefractory shock.44

Management: AntibioticsBacterial infection is a frequent complication for

patients with liver disease and MUGIH. Whetherbacterial translocation occurs as a sequela or plays arole in the pathogenesis of variceal hemorrhageremains unclear.45 Prescribing broad spectrumantibiotic prophylaxis at bleeding presentationhowever improves survival and reduces sepsiscomplications in adults, and we recommend that italso be incorporated as part of routine managementof children, even in the absence of fever.46,47 Ourusual choice of antibiotic combination therapy isampicillin and cefotaxime.


EMERGENCY MANAGEMENT: BEYOND THEEMERGENCY DEPARTMENT

A gastroenterologist should be consulted foradvice on patient management and to determinethe timing of endoscopy, if indicated. Childrenwith MUGIH have the potential to becomeunstable or experience further hematemesis orvomiting. Optimum resuscitation must be under-taken before endoscopy because this procedure isdangerous in the hemodynamically compromisedor hypoxic patient. Consultation with an anesthe-siologist is therefore advisable in advance of theendoscopic procedure, and children should beintubated to protect their airway from aspirationof gastric contents during endoscopy.

EndoscopyThe goals of endoscopy in this setting are to

establish an accurate diagnosis, to obtain prognosticinformation, and to provide endoscopic therapywhere indicated to reduce the risk of rebleeding.Adult guidelines call for the availability of suitablytrained and experienced staff and appropriateequipment to perform early endoscopy (within 24hours of presentation).16,48 Given the relativelysmall volume of sophisticated, technically demand-ing therapeutic endoscopy procedures requiredannually in children, many pediatric centers haveestablished partnerships with local adult therapeu-tic endoscopist colleagues who provide their exper-tise in emergency situations. Although this may notbe feasible in all centers, it is a model of care thatprovides for the safe and timely expert endoscopicmanagement of children with MUGIH.

Figure 2. Bleeding duodenal ulcer (A) with control

Robust validated pediatric data to address theoptimal timing of endoscopy in children are lacking.Emergent endoscopy (within 12 hours) has notshown significant benefits over early endoscopy(within 24 hours) in adults, but extrapolation ofthese data to children may not be justified becauseof different physiological characteristics and comor-bidities in children. Emergent endoscopy may beappropriate in selected pediatric cases.49 The risksof anesthesia and endoscopy may outweigh thepotential benefits of endoscopic therapy for selectedchildren with significant comorbidities in whombleeding appears to have stopped with conservativetherapy (eg, IV infusion of a PPI).

Common therapeutic modalities used at endos-copy include variceal band ligation or sclerotherapyfor bleeding varices and a combination of saline orepinephrine injection, thermocoagulation, argonplasma coagulation, hemostatic clips (Figure 2), orinjection of sclerosants for nonvariceal mucosallesions harboring high risk endoscopic stigmata.Variceal band ligation (Figure 3) is preferred oversclerotherapy in older children and adults. Howev-er, the actual size of currently available bandingappliances precludes their use in infants, hence, thecontinued use of injection sclerotherapy for varicesin pediatrics. Endoscopic findings after peptic ulcerbleeding may be classified as features of ongoingactive bleeding (spurting, oozing) or those of recenthemorrhage (an ulcer with an overlying adherentclot without oozing; ulcers with nonraised darkspots).50 Emerging endoscopic ultrasound technol-ogy may also help to more accurately evaluatelesions and target endoscopic therapy according-ly.51 Current adult-based guidelines do not recom-mend hemostatic therapy for patients with low-risk

achieved via the use of hemostatic clips (B).

image of Figure 2

Figure 3. Esophageal varices (A) treated via the use of band ligation (B).


stigmata, such as those ulcers with a clean base orulcers with flat spots, and even recommend earlydischarge in selected patients with a low risk ofrebleeding after endoscopic evaluation.16 Again,such guidelines cannot be directly applied to allchildren but could be used to guide the developmentof management strategies locally.

Surgical and Radiologic ApproachesConsultation with a pediatric surgeon and inter-

ventional radiologist is advisable for children withmassive MUGIH, children with ongoing significantblood loss, and children who fail to fully improvewith fluid resuscitation, in case attempted endo-scopic intervention is neither feasible nor success-ful. The success of therapeutic endoscopy hasmeant that radiologic or surgical approaches arethankfully rarely required to achieve hemostasis.The morbidity and mortality associated with suchprocedures to control variceal bleeding in patientswith portal hypertension is not insignificant.Approaches to manage refractory variceal hemor-rhage include insertion of transjugular intrahepaticportosystemic shunt stents, selective or nonselec-tive surgically created portosystemic shunts, andnonshunt procedures aimed at interrupting andligating varices directly.34 Transjugular intrahepaticportosystemic shunt stent has been shown toeffectively control refractory variceal bleeding butcarries risks of subsequent shunt thrombosis andhepatic encephalopathy.52

For patients with major nonvariceal bleeding, thetype of emergency surgery or radiologic emboliza-tion intervention required will depend on thelocation and etiology of bleeding.53 The goal ofsurgery is to stop bleeding, and it is indicated for

patients with large ulcers, those with uncontrolledhemorrhage, and those in whom repeat endoscopictherapy has failed.54 Ulcers along the greatercurvature of the stomach may be resected followedby vessel ligation and reapproximation; a bleedingduodenal arterial branch may be oversewn.55

Transcatheter angiography with intervention(TAI) offers a nonoperative approach to locate andthen control bleeding using coils or injectablematerials to embolize the bleeding vessel. Trans-catheter angiography with intervention has alsobeen used successfully to treat bleeding fromvascular anomalies not amenable to endoscopictherapy and likely unsuited to a conservativesurgical approach. Potential complications of TAIinclude intestinal ischemia, intestinal stenosis, orsolid organ infarction, whereas up to one quarter ofpatients may continue to bleed, often due toabundant collateral vessels.54,55 Preprocedural coa-gulopathy is a major risk for rebleeding post-TAI.Surgery and TAI were equally effective after failedtherapeutic endoscopy in one retrospective adultstudy, with the latter approach being preferable forhigh-risk surgical patients and those with hemobi-lia.56,57 However, no large prospective randomizedtrials comparing these approaches have been pub-lished to date, and the selection of either approachshould be guided by local available expertise.

PEDIATRIC OUTCOMESProspective population-based data on the out-

come of pediatric MUGIH have not been reported inthe published literature. Among the outcomes ofgreatest significance are mortality and rates of earlyrebleeding (within 72 hours). Children appear to

image of Figure 3


“tolerate” variceal bleeding better than adults asevidenced by their lower short-term mortality ratesof 10% or lower.58,59 This may reflect their lowersystemic blood pressure, lack of atheroscleroticvessel changes, and a different spectrum of medicalcomorbidities compared with adults. Decliningpopulation prevalence of H pylori coupled withpostendoscopy eradication has likely influencedthe outcome from peptic ulcer disease in childrenfor the past 2 decades. In the 1979 study by Cox andAment,12 14 of 68 patients with MUGIH died, with11 of 14 having active bleeding at death, althougheach mortality had significant comorbidities.

SUMMARYEvidence-based management of MUGIH in chil-

dren has been hampered by a lack of qualitypediatric epidemiologic data and, given its relativelyrare occurrence, few controlled management ortherapeutic trials in children. Our clinical practiceis therefore based on adult-derived data coupledwith experiential or anecdotal pediatric evidence. Itis unlikely that the management and outcomes ofMUGIH in children are perilously suboptimal.However, the paucity of evidence in this field surelychallenges all clinicians responsible for thosepractices to consider and appropriately addressthe fundamental gaps in our knowledge base forthe benefit of those children in our care. Data fromsuch studies are therefore long overdue and keenlyawaited.

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Emergency Management of Major Upper Gastrointestinal Hemorrhage in Children