This guideline is currently awaiting formal ratification through the PIER governance process. It is being made available for use before formal sign off due to the need for the guideline to be available to clinical teams throughout the region to manage this condition. Please use with your own clinical discretion. 
Management of Significant Upper Gastrointestinal Bleeding in Secondary Care
Introduction
Upper Gastrointestinal Bleeding is uncommon in children, affecting approximately 1-2 per 10000 each year. The majority are benign and self-limiting. Significant upper gastrointestinal bleeds are exceptional and pose a challenge to those treating.
Scope and Purpose
This guideline is intended for the use of all clinicians managing children presenting with an acute, significant upper gastrointestinal bleed. To provide an aid in stabilising the child and commencing recommend preliminary treatment.
Background
Upper gastrointestinal bleeding is defined as blood loss proximal to the ligament of Treitz in the distal duodenum. Upper GI bleeds may present with melena, haematemesis or occasionally PR bleeding. The underlying cause varies with age and co-existing disease. A variceal bleed may be the first presentation of a child with portal hypertension, which may be secondary to underlying liver disease or isolated portal vein thrombosis.

Upper GI bleed should ALWAYS be considered as an emergency.

This guidance is appropriate for an acute GI bleed that may be due to undiagnosed varices, with clinical suspicion of portal hypertension. Intravenous octreotide is referred to within this guidance. It is a relatively safe drug, with minimal side effects and should be used early. Hypotension is the main side effect of Octreotide to be aware of.

Octreotide is used to stabilise the acute GI bleed. It works by reducing splanchnic blood flow and portal pressure. The largest retrospective series in 2004 by Eroglu et al, found that Octreotide stopped GI bleeding in 71% of children with portal hypertension, although 52% rebleed, with mortality of 19%. 
​
USS is helpful in a non-emergency situation to confirm portal hypertension.  In acute situation, CXR is a good tool to eliminate button battery ingestion.
Differential Diagnosis
For the list of age-related differential diagnosis see appendix A. This includes battery ingestion, duodenal ulceration and Meckel’s diverticulum (melaena only). There are potential pitfalls that may lead to a misdiagnosis of melena or PR bleeding. Red food colouring, fruit juices and beetroot may colour the vomit or stool red. Stool may also be black after ingestion of iron, grape juice, spinach, and blueberries. If in doubt and in a non-emergency situation, send a sample for occult blood.
Suspected Variceal Bleed
The following features would support a potential variceal bleed:
  1. Pre-existing liver disease/portal hypertension
  2. Splenomegaly +/- hepatomegaly
  3. Deranged liver function (LFTs)/low platelets (Plt) /prolonged clotting​
Management
For flowchart and checklist see points 10 + 11

Ask for HELP Early
​
Discussion with tertiary paediatric gastroenterology +/- SORT +/- Liver Team is essential in children with upper GI bleeding and should be considered as an urgent transfer if required as there are specific treatment and interventions. (Contact Details in Appendix B).
​
For adolescent patients consider discussing with local adult endoscopy team.
Quick history / handover
  • Newborn – ask if Vitamin K has been given
  • Recurrent Vomiting
  • Use of NSAIDS / Steroids / possible ingestion
  • Any history of liver disease / bleeding tendency / IBD / recent illness
Physical Assessment
ABC ( locate the octreotide) DE Approach

All cases should be approached using ABCDE manner. If in shock then proceed with immediate resuscitation, as per APLS
  • A: opt for early intubation if there is severe uncontrolled bleeding, encephalopathy, drowsiness, unable to maintain saturations above 90%, or signs of aspiration pneumonia
  • B: Aim for saturations >95%. Administer oxygen via face mask if required.
  • C: Monitor heart rate, blood pressure, urine output (catheterise).​
Vascular Access
  • Aim for ≥2 large bore peripheral intravenous cannulas
  • Intra-osseous (IO) access if peripheral IV access is poor, inaccessible, or delayed
  • Take baseline blood samples:
    • Blood gas and Blood sugar
    • Cross-match
    • FBC, Clotting Screen (INR/APTR/Fibrinogen), U&Es, renal, liver and bone profiles and blood cultures 
    • Consider sending an ammonia sample if encephalopathy suspected (check local hospital policy – for ammonia samples)
Fluid Resuscitation
  • Commence IV fluids
  • Resuscitation with blood as soon as available, O -ve blood if haemodynamically unstable and activate local major haemorrhage pathway. The blood available to use is likely to be packed cells as whole blood unlikely to be readily available.
  • Aim initially to transfuse to haemoglobin level of 90g/l:
  • After shock and metabolic acidosis corrected transfuse slowly to reduce risk of increasing portal pressure and re-bleeding. Do NOT over transfuse.​
  • Blood Pressure – DO NOT AIM TO HAVE A HIGH SYSTOLIC BP
    • ​Newborns to 1 month old: Systolic >60mmHg
    • <1yr old: Systolic >70mmHg
    • >1yr old: (Agex2) + 70mmHg
  • Give platelets, FFP and cryoprecipitate if indicated (plts<100, INR>1.5, fibrinogen <2g/l or bleeding not controlled)
Strict Fluid balance
Correct electrolyte abnormalities
  • D: Monitor Blood Glucose 2-4 hourly and maintain normal blood sugar (4-8mmols/l). Keep child nil by mouth (NBM). 
  • E: Keep child warm.
Drugs
Prophylactic antibiotics are recommended for all cases of upper GI bleeding. Intravenous Piperacillin and tazobactam (e.g Tazocin) first line antibiotic choice.
​
Following drugs are beneficial in decreasing the bleed:
Medication
Information
IV Octreotide
(Recommend that this drug is kept available within the wards emergency drug cupboard.)
Dose: Loading dose:1mcg/kg (max 50mcg/hr) over 5 mins, then maintenance infusion 1-3 mcg/kg/hr (max 50mcg/hr)
Preparation: Loading dose – no dilution required. Maintenance infusion - Dilute 500mcg octreotide in 40ml with 0.9% sodium chloride (1ml/hr = 12.5mcg/hr)
Notes
  • Use dedicated IV cannula. Ideally via a central line or large peripheral cannula due to low pH can cause extravasation injury but do not delay giving as can be given via small cannula if access difficult and can be changed when stable.
  • Continue octreotide Infusion until bleeding is controlled, then wean slowly over 24 hours to reduce risk of rebound bleeding
  • Octreotide has a short half- life, therefore re-site cannula immediately if drip tissues​. 
IV Vitamin K
(phytimenadione)
Dose: 300mcg/kg; max 10mg as slow IV injection over 5-10 minutes
​IV Omeprazole
Dose: 2mg/kg/day; max 40mg/days IV infusion over 20 minutes OR
IV Esomeprazole
Dose: Under 1 year of age: 0.5 mg/kg, 1-11 years old body weight up to 20kg – 10mg, 1-11 years old body weight over 20kg – 20mg, 12-17 years old – 40mg as IV infusion over 20 minutes
​IV Tranexamic acid
Dose: 10 mg/kg max dose 1g as slow IV injection over 10 minutes.
Note: evidence for benefit is unclear and is not in the national guidance but may help to prevent rebleed. Do not delay giving Octreotide..

Do NOT use NSAIDS

Interpretation of Blood Results 
Haemoglobin
Initial Hb may be normal if taken after initial blood loss and falsely reassuring
Aim for Hb of 90g/l
Platelets
If <100x109/l may warrant platelet transfusion
INR
>1.5 may warrant FFP or octoplas
Fibrinogen
Target >2g/l may warrant Cryoprecipitate
Urea and Creatinine
High urea may indicate a significant bleed took place or insidious bleeding. If raised creatinine alongside low Hb and high Urea think HUS.
Preparation for Transport and Liaison with Specialist Teams
Discuss critically unwell patients with SORT, or if signs of shock or clinical concerns. SORT will provide guidance on safe transfer of patient for ongoing care. If SORT transfer not required, complete STOPP form located on the SORT website:

https://www.sort.nhs.uk/Media/Guidelines/Referral-forms/Wessex-PICU-Network-interhospital-transfer-form-Aug2020.pdf

Liaise early with haematology team – to organise blood products agreed with tertiary team for transfer. May only require Packed Red Cells if clinically stable on Octreotide infusion. 

If strong clinical suspicion of varices call Lings liver – numbers on flow chart. Also consider calling local adult gastroenterologists.

If bleeding non variceal and clinical concerns discuss with on call paediatric gastroenterology consultant UHS by calling switch board at UHS​
Flow Chart
Paediatric Upper GI Bleeding Checklist
References
  1. Assessment and Management of Oesophageal Varices in Children – July 2017; Joint Guideline of the Children’s Specialised Liver Services in Birmingham, Leeds and King’s
  2. Management of Upper Gastro-Intestinal Bleeding in Children Guidance: A Transport Team Perspective (Embrance; Sheffield Children’s NHS Foundation Trust
  3. Upper Gastrointestinal Bleeding in Children: A tertiary United Kingdom Children’s Hospital; Experience. Nasher et al. Children 2017, 4(11), 95; https://doi.org/10.3390/children4110095
  4. Management of Portal Hypertension in Children. Mileti et al. Curr Gastroenterol Rep. 2011; 13(1): 10–16.
  5. Emergency Management of Major Upper Gastrointestinal Haemorrhage in Children. Hussey et al. Clinical Pediatric Emergency Medicine, 11(3), 207-216
  6. Approach to upper gastrointestinal bleeding in children. Up To Date.​
Appendix A - Differential Diagnosis

Common Causes of Upper GI Bleeding by Age Group

Neonates
​1 month - 2 years
> 2 years
Swallowed maternal blood
​Oesophagitis
Oesophageal varices
Haemorrhagic disease of the newborn
​Gastritis
​Gastric Varices
Coagulopathy
Gastro-duodenal ulcer
Mallory Weiss tears
Oesophagitis
NSAID-induced ulcers
Dieulafoy's lesions
Stress Gastritis
Oesophageal varices
Swallowed blood from epistaxis
Gastroduodenal ulcers
Gastric Varices
​.
Duplication Cyst
Foreign body ingestion (especially 'button batteries')
​.
Necrotising Enterocolitis
.
​.
Take a focussed history:​
  • Neonate? Has vitamin K been given?
  • Recurrent vomiting
  • Recent trauma to region e.g., NG tube passage
  • Use of NSAIDs/steroids
  • Possible ingestion e.g., of button battery especially
  • History of liver disease, bleeding tendency, IBD, recent illness
 
Assess
  • Volume lost
  • Fresh blood (including up NG/gastrostomy)?
  • Altered blood? Coffee grounds, melaena
  • Hepato / Splenomegaly? Evidence of undiagnosed Portal HTN?
 
Notes
  • Button battery ingestion can rapidly lead to significant bleeding and death.
  • Even with small, self-resolving bleeds, where button battery ingestion or varices have been excluded, consider discussion with relevant teams.
  • Small, isolated coffee ground aspirates from NG tubes or gastrostomies should not need onward referral (but consider causes)
  • Don’t forget to consider blood not from the GI tract
Appendix B - Contact Details
Referral may be needed to: Paediatric gastroenterology/Paediatric surgeons/Paediatric liver team
  • SORT: 023 8077 5502 (Referral Process)
  • King’s Liver Team in suspected varices (see below)
09:00-17:00 On-call registrar 0203 299 7812 (or 020 3299 9000 extension 37812) Or consultant on-call 07970226070
17:00 - 09:00 On-call registrar 07866 792368

Alternative: Call Rays of Sunshine Ward: 020 3299 3577 (they can often find the registrar for you)
​
https://www.kch.nhs.uk/service/a-z/paediatric-liver (“Referring to this service” tab; also has information about non-urgent referral pathway) There is also a good patient information leaflet ‘OGD and proctoscopy for portal hypertension surveillance and endoscopic therapy in children and young people’ to be downloaded on this page.
Document Version: 
1.0

Lead Authors: 
Dr Jennie Pridgeon, PHU
Dr Emma Knight, PHU
​Dr Reynella Morenas, HHFT
Approving Network:
Wessex Gastroenterology, Hepatology and Nutrition Network
​
Date of Approval: 
Pending

Review Due:
Pending