Category: Gastrointestinal Emergencies

Upper Gastrointestinal Bleeding (2024)

~ iEM Education Project Team ~ Leave a comment

by Resshme Kannan Sudha & Thiagarajan Jaiganesh

Authors
Listen

You have a new patient!

A 55-year-old male with alcoholic liver cirrhosis was brought to the emergency department by his wife, presenting with two episodes of haematemesis (containing fresh blood) and light-headedness. This is the first occurrence of such symptoms. Vital signs: Temperature: 36.8°C, Heart Rate: 115 bpm, SpO₂: 95%, BP: 88/65 mmHg. On examination, the patient appears pale, lethargic, and jaundiced, with abdominal distension noted.

The image was produced by using ideogram 2.0.

What do you need to know?

Upper gastrointestinal (GI) bleeding is defined as bleeding occurring above the level of the ligament of Treitz. It is more common than lower GI bleeding [1]. Upper GI bleeding is a significant clinical condition that can lead to morbidity and mortality if not promptly diagnosed and managed. It encompasses bleeding from the esophagus, stomach, or duodenum, often presenting as hematemesis or melena. The importance of recognizing and treating upper GI bleeding lies in its potential to indicate serious underlying conditions. Early intervention is crucial, as the severity of bleeding can lead to hypovolemic shock, necessitating urgent medical care. Upper GI bleeding is a common emergency, with an estimated incidence of 50 to 150 cases per 100,000 individuals annually [2]. The prevalence varies based on demographic factors such as age, gender, and geographical location. The condition is more prevalent in older adults, particularly those over 60 years.

The most common cause is peptic ulcer disease, with duodenal ulcers being the most frequent. Other causes include varices, erosive esophagitis, duodenitis, Mallory-Weiss tear, gastrointestinal malignancies, and arterial and venous malformations (e.g., aorto-enteric fistula, Dieulafoy lesion) [1,3]. Causes of peptic ulcer disease include NSAID (Non-Steroidal Anti-inflammatory Drug) intake, Helicobacter pylori infection, and stress ulcers. In recent years, the incidence of upper gastrointestinal bleeding admissions due to peptic ulcer disease has decreased in the USA. This trend has been attributed to the use of triple therapy for Helicobacter pylori and the co-administration of proton pump inhibitors with NSAIDs [4].

Clinical manifestations include vomiting coffee ground material or fresh blood, and/or passing fresh blood in the stool or black, tarry stool (melena) [1].

Goals in the management of a patient with upper gastrointestinal bleeding include identifying the site and nature of the bleeding, stabilizing the patient, and controlling the source of the bleed [4].

Medical History

After performing a primary survey and stabilizing the patient, it is important to fine-tune your history, physical examination, and investigations to identify the source of bleeding and guide further management and disposition.

Upper GI bleeding commonly presents with haematemesis (coffee-ground or fresh blood), haematochezia, and/or melena [4]. Certain foods, such as beets, and medications like cefdinir, can cause red-colored stool, while bismuth and iron supplements may cause black-colored stool [4].

Associated Symptoms
  • Peptic ulcer disease may be associated with epigastric pain (gastric ulcer) and dysphagia, gastroesophageal reflux disease (GERD), or odynophagia (esophageal ulcer).
  • Haematemesis associated with retching may indicate a Mallory-Weiss tear.
  • The presence of jaundice and ascites suggests variceal bleeding [4].

A prior history of GI bleeding should be assessed, as patients are more likely to bleed from the same lesion.

Key Past Medical History and Risk Factors

Peptic Ulcer Disease:

  • Ulcers can occur in the esophagus, stomach, or duodenum, with duodenal ulcers being more common.
  • However, gastric ulcers account for a higher incidence of bleeding.
  • Known causes include Helicobacter pylori, NSAIDs, alcohol, and steroid use.
  • Symptoms may include epigastric pain, nausea, vomiting, upper GI bleeding (painless haematemesis and melena), and signs of anaemia.
  • Upper GI bleeding after NSAID use, stress, or a history of dyspepsia may indicate erosive gastritis [5,6].

Esophageal Varices:

  • Caused by portal hypertension secondary to liver diseases such as cirrhosis.
  • Symptoms include jaundice, spider angiomata, palmar erythema, hepatic encephalopathy (confusion), coagulopathy (petechiae/purpura), ascites, and variceal bleeding (painless haematemesis with large amounts of fresh blood) [6].
  • Ask about chronic alcohol use, hepatitis, and hepatocellular carcinoma.
  •  

Mallory-Weiss Syndrome:

  • Caused by forceful retching or vomiting, often after heavy alcohol intake.
  • Leads to a tear in the esophagus or stomach, resulting in haematemesis (large amounts of fresh blood).
  • This condition is usually self-limiting [6].

Malignancy:

  • Gastric cancers may present with haematemesis, anaemia, and dyspepsia [6].
  • Enquire about sudden weight loss, loss of appetite, and risk factors like prior Helicobacter pylori infection.

Angiodysplasia:

  • Dieulafoy’s disease is a rare vascular malformation affecting young individuals.
  • It involves small aneurysms in the stomach that rupture, leading to massive spontaneous haematemesis [6].

Aorto-enteric Fistula:

  • A rare condition, usually occurring post-repair of an abdominal aortic aneurysm.
  • Presents with profuse haematemesis and rectal bleeding [6].

Gastro-enteric Anastomosis:

  • Ulcers may develop at the site of gastro-enteric anastomosis, presenting with upper GI bleeding [7].
Comorbid Illnesses

Enquire about conditions such as:

  • Ischemic heart disease or pulmonary conditions (higher haemoglobin levels required).
  • Coagulopathies (may necessitate additional therapies).
  • Dementia or hepatic encephalopathy (risk of aspiration due to altered mental state).
  • Heart failure or renal failure (risk of fluid overload during blood transfusion).
Medication History

Assess for [8]:

  • NSAIDs (associated with peptic ulcers).
  • Anticoagulants and antiplatelets.
  • Chemotherapeutic agents.
  • Iron supplements (black stool).
Symptoms of Severe Bleeding and Poor Prognosis [1,4,7,9]
  • Light-headedness, confusion, syncope (cerebral hypoperfusion).
  • Chest pain and palpitations (coronary hypoperfusion) .

Physical Examination

The severity of bleeding should be assessed based on clinical signs of shock rather than the color of the blood [4]. Upper GI bleeding typically presents with haematemesis (frank blood or coffee-ground emesis) and/or melena [4]. In cases of brisk upper GI bleeding, the patient may present as vitally unstable with haematochezia [4].

Vital Signs

Monitor for signs of hemodynamic instability, including:

  • Tachycardia, tachypnea, and hypotension [1,7].
  • Supine hypotension is associated with greater blood loss than orthostatic hypotension [1].

General Examination

  • Confusion may indicate hemodynamic instability.
  • Gynecomastia may be seen in patients with liver disease [10].
  • Haematemesis strongly suggests an upper GI bleed [4].

ENT Examination

  • Inspect the nose for epistaxis, which can present as haematemesis if the blood is swallowed [11].

Skin Examination

  • Palmar erythema, spider angiomata, caput medusae, and jaundice are suggestive of liver disease [11].

Abdominal Examination

  • Abdominal tenderness, guarding, rigidity, and rebound tenderness may indicate perforation.
  • The presence of ascites suggests liver disease [4,7].

Rectal and Stool Examination

  • A digital rectal examination and stool analysis can help identify the location of the bleed:
    • Melena typically indicates an upper GI bleed.
    • Haematochezia may suggest a lower GI bleed or a massive upper GI bleed [4].

Alternative Diagnoses

The differential diagnosis for gastrointestinal bleeding includes several conditions that may mimic an upper or lower GI bleed:

  1. Epistaxis: Bleeding from the nose can present as haematemesis if the blood is swallowed. Careful examination of the nasal cavity is essential to rule this out.

  2. Vaginal Bleeding: In some cases, vaginal bleeding can be mistaken for haematochezia. A thorough history and physical examination can help differentiate these sources.

  3. Food-Induced Discoloration: Certain foods may alter the color of stool, leading to a false suspicion of GI bleeding. For example, beets can cause red-colored stools, which may mimic haematochezia.

  4. Medication-Induced Changes: Some medications can also discolor stool:

    • Cefdinir may produce red-colored stool.
    • Iron supplements and bismuth-containing products can result in black stool, resembling melena [4].

  5. Neonatal Swallowed Blood: In neonates, vomiting swallowed maternal blood during delivery or breastfeeding may be mistaken for upper GI bleeding [12].

Acing Diagnostic Testing

Bedside Tests

Several bedside tests can aid in the initial evaluation of upper GI bleeding:

  • Point-of-care venous blood gas: Useful for detecting acidosis, electrolyte disturbances, and haemoglobin levels. Haemoglobin levels < 8 g/dL in previously healthy patients, or < 9 g/dL in patients with known coronary artery disease or anaemia-related complications, suggest the need for blood transfusion [4].
  • Point-of-care PT (Prothrombin Time) and INR (International Normalized Ratio): Essential for patients taking medications like warfarin to determine the need for reversal agents.
  • Bedside ultrasound: Helpful in identifying ascites, which may aid in diagnosing variceal bleeding.
Ascites in Cirrhotic Patient

Laboratory Tests

The following blood tests are useful when there is a clinical suspicion of upper GI bleeding [4,6,11,13]:

  • Complete Blood Count (CBC): To assess haemoglobin and haematocrit levels.
  • Blood Urea Nitrogen (BUN), Creatinine, and electrolytes: A BUN:Creatinine ratio > 35 is highly suggestive of upper GI bleeding (90%).
  • Coagulation Screen: INR levels are important in patients on anticoagulant therapy (e.g., warfarin) to guide reversal strategies.
  • Liver Function Tests: Elevated parameters are suggestive of liver disease and potential variceal bleeding.
  • Type and Crossmatch: Crucial for patients who may require blood transfusion.

Imaging

Radiological imaging is rarely needed in hemodynamically unstable patients as it may delay resuscitation. In such cases, endoscopy should take precedence [4].

  • Upright chest X-ray: Helpful in detecting free air under the diaphragm, which is suggestive of perforation.
  • CT Angiography: Recommended for hemodynamically stable patients when identifying the bleeding etiology before endoscopy is crucial. It can detect slow bleeding (approximately 0.3 mL/min) and guide management decisions (endoscopy, surgery, or angiography). However, it is not suitable for unstable patients due to delays in management. In such cases, conventional angiography with embolization is preferred [4].

Endoscopy

Endoscopy is both diagnostic and therapeutic [14,15]:

  • There is no evidence to support that emergent endoscopy is superior to routine endoscopy.
  • Immediate gastroenterology consultation for emergent endoscopy is advised in patients with ongoing severe upper GI bleeding.
  • Endoscopy is recommended within 24 hours for all admitted patients with UGIB after stabilizing hemodynamic parameters and addressing other medical issues.
  • Patients with high-risk clinical features such as tachycardia, hypotension, haematemesis, or blood in nasogastric aspirate should undergo endoscopy within 12 hours, as this may improve clinical outcomes.

Additional Considerations

  • A screening ECG is recommended in patients > 35 years of age with cardiac risk factors, as co-existing acute coronary syndrome may complicate GI bleeding [4].
  • Nasogastric lavage is generally not recommended due to risks of perforation, pneumothorax, and aspiration [4].
  • Erythromycin can be used as an alternative prokinetic to clear gastric contents before endoscopy [4,8].

Risk Stratification

To effectively manage gastrointestinal (GI) bleeding, patients must be categorized into high-risk and low-risk groups. High-risk patients require prompt intervention, whereas low-risk patients can be managed through outpatient treatment [4]. A combination of clinical, endoscopic, and laboratory features, along with risk scores, can aid in risk stratification. While risk scores may not always predict high-risk patients accurately, they are effective in identifying patients at very low risk of harm. When selecting patients for outpatient management, ensuring high sensitivity is essential to prevent the inadvertent discharge of high-risk individuals [16].

Risk Assessment Tools

Commonly used scoring systems for GI bleeding include:

  1. Glasgow-Blatchford Score (GBS)
  2. Rockall Score
  3. AIMS65 Score

The AIMS65 score assesses parameters such as:

  • Albumin < 3 mg/dL
  • International Normalized Ratio (INR) > 1.5
  • Altered mental status
  • Systolic blood pressure < 90 mmHg
  • Age > 65 years

Studies show that the GBS is more effective at predicting a combined outcome of intervention or death [16].

Glasgow-Blatchford Score (GBS)

The Glasgow-Blatchford Score is particularly useful for predicting the need for intervention, hospital admission, blood transfusion, surgery, and mortality. A significant advantage of the GBS is that it can be calculated at the time of patient presentation, as it does not require endoscopic data (unlike the Rockall score).

The GBS includes the following parameters:

  • Blood urea nitrogen (BUN)
  • Haemoglobin levels
  • Systolic blood pressure
  • Pulse rate
  • Symptoms such as melena, syncope, and a history of hepatic disease or cardiac failure.

The score ranges from 0 to 23, with a higher score indicating a greater risk of requiring endoscopic intervention [4].

Glasgow-Blatchford Risk Score

CategoryScore
BUN in mg/dL
18.2 to 22.42
22.5 to 283
28.1 to 704
70.1 or greater6
Hemoglobin, men g/dL
12 to 131
10 to 11.93
9.9 or less6
Hemoglobin, women g/dL
10 to 121
9.9 or less6
Systolic Blood Pressure, mmHg
100-1091
90-992
<903
Heartrate >100 peats per minute1
Melena1
Syncope2
Hepatic Diseases2
Heart failure2
Glasgow-Blatchford Risk Score is useful for predictive of inpatient mortality, blood transfusions, re-bleeding, ICU monitoring, and hospital length of stay. Patients with a score of zero may be discharged home, those with score 2 or higher are usually admitted, and those with score of 10 or more are at highest risk for morbidity and resource utilization. Maximum score is 23.
Outpatient Management

Patients with a Glasgow-Blatchford Score of 0 are considered at low risk for rebleeding. According to international consensus guidelines, these patients may be safely discharged with early outpatient follow-up [8,17].

Management

Initial Stabilization

Airway and Breathing:
Patients with massive upper GI bleeding presenting with uncontrollable haematemesis, respiratory distress, or severe shock require immediate airway protection and intubation. It is essential to improve hemodynamic status before administering induction and paralytic drugs for intubation and initiating positive pressure ventilation, as this can mitigate a sharp decrease in cardiac output. However, intubation is associated with poor outcomes and should only be performed when absolutely necessary [4].

Circulation:
Massive GI haemorrhage is characterized by ongoing active bleeding (haematemesis or haematochezia), signs of hemodynamic compromise (e.g., tachycardia, hypotension, altered mental status), or a shock index ≥ 0.9 [4].

Immediate volume resuscitation is critical and includes:

  • Placement of two large-bore IV catheters.
  • Infusion of balanced isotonic crystalloids (e.g., 2 liters of normal saline or Plasmalyte over 30 minutes).
  • Transfusion of uncrossmatched blood, if required [4].
Transfusion Strategies

For stable patients, a restrictive transfusion strategy is recommended. While the ideal haemoglobin target is not universally defined:

  • In stable patients without known coronary artery disease (CAD), maintain haemoglobin ≥ 8 g/dL.
  • For patients with known CAD, a higher target of ~9 g/dL is appropriate to reduce the risk of anaemia-related complications [4].

In patients requiring massive transfusion (more than 4 units of PRBCs), a balanced transfusion ratio of 1:1:1 (PRBC:Platelets:Fresh Frozen Plasma) is advised. Cryoprecipitate should be administered if fibrinogen levels remain < 1.5 g/L [18]. A platelet count > 50,000 platelets/μL should be maintained [4].

Coagulation Management
  • Vitamin K antagonists (e.g., warfarin) should be stopped and reversed to achieve a target INR of 1.5–2.5. Treatment options include Fresh Frozen Plasma (FFP) and Prothrombin Complex Concentrate (PCC). Vitamin K is an appropriate choice for hemodynamically stable GI bleeding.
  • Direct oral anticoagulant reversal:
    • Idarucizumab for dabigatran reversal.
    • PCC or coagulation factor Xa (recombinant/inactivated-zhzo) for factor Xa inhibitors.
  • For heparin reversal, protamine sulfate may be used.

Before administering reversal agents, the risks of reversing anticoagulant therapy must be carefully weighed against the risk of thromboembolism [19].

PCC is preferred over FFP for rapid coagulopathy correction, especially in patients at risk of fluid overload, as it requires lower volume administration [4]. Over-transfusion or empiric correction of PT/INR with FFP or PCC in portal hypertension may worsen portal hypertension and exacerbate bleeding [4].

Medications

Proton Pump Inhibitors (PPIs)

PPIs are the mainstay in the management of acute GI bleeding. They work by inhibiting the hydrogen potassium ATPase pump, thereby reducing gastric acid secretion [20]. Studies have shown that PPIs reduce the risk of re-bleeding, the need for surgery, and mortality in patients with bleeding ulcers [4].

Both intermittent PPI therapy and continuous infusion are equally effective in reducing bleeding [8]. Available IV formulations include esomeprazole and pantoprazole. The recommended dose is:

  • Pantoprazole or esomeprazole: 80 mg IV as a single initial dose, followed by either:
    • Continuous infusion at 8 mg/hr, or
    • 40 mg IV BID [8].

If IV formulations are unavailable, oral alternatives such as 40 mg of esomeprazole twice daily may be used [8].

PPIs are classified as Category B in pregnancy, except for omeprazole, which is Category C [21]. Caution should be exercised due to the risk of Clostridium difficile infection, Steven Johnson syndrome, kidney and liver impairment, and pancreatitis [20]. Omeprazole is particularly associated with the risk of acute interstitial nephritis [22].

Somatostatin Analogues

Somatostatin and its synthetic analogue, octreotide, are predominantly used in variceal bleeding. These agents reduce the risk of bleeding, need for transfusion, and portal hypertension. Indications include acute GI bleeding in patients with variceal bleeding, abnormal liver function tests, liver disease, or alcoholism [4].

The dosing regimen for octreotide is:

  • Adults: 50 mcg IV bolus, followed by 25–50 mcg/hr continuous infusion [23,24].
  • Paediatrics: 1 mcg/kg IV bolus (maximum: 100 mcg), followed by 1 mcg/kg/hr infusion [23,24].

Octreotide crosses the placenta and is expressed in breast milk. Common adverse effects include arrhythmias, pancreatitis, abnormal glucose regulation, and low platelet count [23]. It also crosses the blood-brain barrier [23].

Terlipressin

Terlipressin is a synthetic vasopressin receptor agonist that causes splanchnic vasoconstriction, thereby reducing portal hypertension. It is primarily indicated for variceal bleeding [25].

The recommended dose is 2 mg IV every 6 hours [26]. Terlipressin may cause teratogenic effects (limited data available) [27] and can result in painful hands and feet due to peripheral vasoconstriction [26]. While studies suggest that terlipressin, somatostatin, and octreotide have similar efficacy, data regarding their use in paediatric patients remains limited [24,28].

Prokinetic Agents (Erythromycin and Metoclopramide)

Prokinetic agents are used to improve visualization during endoscopy by clearing gastric contents.

  • Erythromycin:

    • Adult dose: 3 mg/kg IV, administered over 20–30 minutes, 20–90 minutes before endoscopy [29].
    • Classified as Category B in pregnancy and is safe for breastfeeding mothers [29].
    • Adverse effects include QT prolongation, pseudomembranous colitis, seizures, and hypertrophic pyloric stenosis [4,29].

  • Metoclopramide:

    • Adult dose: 10 mg IV.
    • Paediatric dose: 0.1–0.2 mg/kg IV [30].
    • Classified as Category B in pregnancy [30].
    • Caution is advised in patients with a history of extrapyramidal symptoms due to its association with extrapyramidal side effects [30].

Tranexamic Acid

Tranexamic acid is an antifibrinolytic agent. However, according to the HALT-IT Trial, it has not been shown to reduce mortality associated with gastrointestinal bleeding. As a result, its routine use in GI bleeding is not recommended [31].

Antibiotic Prophylaxis

Antibiotic prophylaxis is recommended for patients with cirrhosis or suspected cirrhotic liver disease to reduce the risk of infection and mortality [4].

The recommended antibiotics include:

  • Fluoroquinolones (e.g., ciprofloxacin 400 mg IV)

  • Third-generation cephalosporins (e.g., ceftriaxone 1–2 g IV) [4].

  • Ceftriaxone: Classified as Category B in pregnancy but contraindicated in hyperbilirubinemic neonates due to the risk of kernicterus and those receiving IV calcium-containing solutions due to ceftriaxone–calcium precipitation [32].

  • Ciprofloxacin: Classified as Category C in pregnancy. Adverse effects include Clostridium difficile infection, dysglycemia, tendon rupture, neurotoxicity, QT prolongation, hepatotoxicity, and Stevens-Johnson syndrome/toxic epidermal necrolysis [33].

Procedures

Balloon tamponade [4,6,34], using devices such as the Sengstaken-Blakemore tube, Minnesota tube, or Linton-Nachlas tube, can serve as a temporizing measure for suspected life-threatening variceal bleeding when endoscopy is not immediately available. These devices must be stored in refrigerators to maintain readiness.

Before the procedure, patients must be intubated to reduce the risk of aspiration. The device is inserted through the mouth, passed via the esophagus into the stomach. The tube consists of two balloons—a gastric balloon and an esophageal balloon:

  • The gastric balloon of the Sengstaken-Blakemore tube can be inflated with 250–300 cc of air, while the Minnesota tube can accommodate up to 450–500 cc to secure the tube in place.
  • The esophageal balloon can be inflated to a pressure of 20–40 mmHg, with a strict upper limit of 45 mmHg to avoid injury. Pressure should be carefully monitored using a manometer.

Balloon tamponade is a temporary measure, and definitive management, such as endoscopic therapy, should be arranged as soon as possible. The procedure is associated with significant risks, including ulceration, esophageal rupture, and aspiration [4].

Special Patient Groups

Paediatrics

The causes of upper GI bleeding in the pediatric population are generally similar to those seen in adults [12,15,35]. However, there are additional causes specific to neonates and infants that require consideration. In neonates, vitamin K deficiency, also referred to as the haemorrhagic disease of the newborn, is an important cause. Other causes include congenital vascular anomalies, such as telangiectasia, and coagulopathy, which may result from infections, liver disease, or coagulation factor deficiencies. Milk protein intolerance is also a recognized cause of upper GI bleeding in this age group. During the neonatal period and the first few months of life, it is crucial to differentiate swallowed maternal blood from true upper GI bleeding. The Apt-Downey test is a reliable diagnostic tool used to confirm the presence of fetal blood and rule out swallowed maternal blood as the source.

The management of upper GI bleeding in children largely follows the same principles as in adults, with necessary adaptations for the pediatric population. Intravenous proton pump inhibitors (IV PPIs) are effective and can be administered to reduce gastric acid secretion, thereby promoting hemostasis. In cases of suspected variceal bleeding, somatostatin analogues can be given to reduce portal hypertension and minimize bleeding risk. When severe acute bleeding is ongoing, endoscopy plays a key role in diagnosis and intervention. It is recommended that endoscopy be performed within 24 to 48 hours of presentation. However, it is critical to ensure that the patient is as hemodynamically stable as possible before proceeding with the procedure to minimize complications.

In cases where endoscopy cannot control the bleeding or fails to identify the source, further interventions may be necessary. Angiography with embolization is a useful modality in such instances, as it can help detect and address underlying vascular abnormalities contributing to the bleeding. This approach is particularly helpful when other methods have proven unsuccessful.

Overall, a multidisciplinary approach that includes appropriate stabilization, pharmacologic therapy, and procedural intervention is essential to effectively manage upper GI bleeding in the pediatric population [12,15,35].

Geriatrics

Upper GI bleeding in elderly patients presents unique challenges due to the high-risk nature of this population and the limitations of existing risk assessment tools. Studies indicate that traditional pre-endoscopic risk scores, such as the Glasgow-Blatchford and AIMS65, often fail to accurately predict outcomes like mortality and hospital stay length in geriatric patients, particularly those aged 82 and older, suggesting a need for age-adjusted scoring systems [36]. Despite these challenges, emergency oesophagogastroduodenoscopy is generally safe for elderly patients, with a high survival rate at 90 days post-procedure, although a significant proportion of OGDs yield normal findings, highlighting the importance of careful patient selection [37]. The management of Upper GI bleeding in the elderly is further complicated by recurrent bleeding, as seen in cases involving peptic ulcer disease, which necessitate a multidisciplinary approach and close monitoring to improve outcomes [38]. Recent efforts to develop novel risk scores tailored for the elderly have shown promise, with a new score incorporating factors like comorbidity index and blood pressure demonstrating good discriminative performance for identifying patients suitable for outpatient management [39].

Pregnant Patients

The causes of upper GI bleeding in pregnant women are similar to those in the general population, including conditions such as esophageal ulcers, gastroesophageal reflux disease, and portal vein thrombosis leading to esophageal varices [40]. Haematemesis, or the vomiting of blood, is a common manifestation of upper GI bleeding and can present as bright red or coffee-ground emesis, indicating bleeding from the upper gastrointestinal tract [1, 40]. In rare cases, UGIB in pregnancy can be caused by gastrointestinal stromal tumors (GISTs), as illustrated by a case where a pregnant woman presented with coffee-ground vomiting and was diagnosed with a bleeding GIST at the stomach cardia [41]. Endoscopy is a critical diagnostic and therapeutic tool for upper GI bleeding, but its use in pregnant women is generally reserved for severe or persistent cases due to potential risks to the mother and fetus [42]. Despite the need for endoscopic evaluation in over 12,000 pregnant women annually in the U.S., research on the safety and outcomes of such procedures remains limited [43]. Therefore, careful consideration of the risks and benefits is essential when managing upper GI bleeding in pregnant patients.

When To Admit This Patient

Admission is required for elderly patients over the age of 60 years, those who require blood transfusions, and patients with a Glasgow-Blatchford Score (GBS) greater than 0 [4,8]. Patients with high-risk bleeding sources should be admitted to a monitored setting or an intensive care unit (ICU) to allow close monitoring for signs of rebleeding and other potential complications.

The decision to discharge a patient following endoscopy depends on the identification of the bleeding source and the associated risk of rebleeding. Patients can be considered for discharge if they meet all of the following criteria: a GBS of 0, blood urea nitrogen (BUN) less than 18 mg/dL, haemoglobin >13 g/dL in men and >12 g/dL in women, heart rate less than 100 beats per minute, systolic blood pressure greater than 110 mmHg, no evidence of melena or syncope since the initial presentation, absence of heart failure or liver failure, and prompt access to outpatient follow-up care.

However, it is important to note that this recommendation is based on low-quality evidence, and clinical judgment should play a significant role in the final decision to discharge a patient. Clinicians should carefully assess each patient’s overall condition, risk of rebleeding, and ability to follow up in an outpatient setting to ensure safe discharge planning [15].

Revisiting Your Patient

In managing this patient, the immediate priority is to assess airway, breathing, and circulation and provide stabilization. Given the patient’s vital instability, they should be promptly transferred to the resuscitation bay for further management.

The image was produced by using ideogram 2.0.

Airway and Breathing: The patient’s airway is currently patent, and they are communicating comfortably, with no signs of obstruction such as pooling of blood or secretions. There have been no further episodes of haematemesis, and the patient is maintaining adequate oxygen saturation on room air. Chest auscultation is clear. At this time, the patient does not require airway adjuncts or intubation, but close observation is essential to detect any deterioration.

Circulation: The patient is hypotensive, indicating the need for immediate intervention. Two large-bore IV cannulas should be inserted to initiate intravenous fluid resuscitation. Crossmatched and uncrossmatched blood should be arranged as a precaution. A point-of-care venous blood gas test must be performed to quickly evaluate acidosis, haemoglobin levels, and other critical parameters. Care should be taken to avoid fluid overload, especially in patients with underlying liver disease.

Further History and Review of Systems: On further evaluation, the patient denies haematochezia, haemoptysis, epistaxis, melena, chest pain, palpitations, syncope, loss of consciousness, or confusion.

Past Medical and Surgical History and Risk Factors: The patient has a history of alcoholic liver disease and is a smoker. There is no history of chronic NSAID use, Helicobacter pylori infection, recent forceful retching, or ingestion of foods or medications that might cause red-colored secretions. There are no known coagulopathies, recent anticoagulant use, vascular abnormalities, weight loss, or loss of appetite. Additionally, the patient has no history of prior surgery.

Examination: Clinical signs of hemodynamic instability, such as hypotension, suggest hypovolemic shock, requiring prompt management with IV fluids and blood transfusion. Examination findings of jaundice, abdominal distension with shifting dullness, and caput medusae are consistent with alcoholic liver disease and indicate probable variceal bleeding. There is no abdominal tenderness, guarding, rigidity, or rebound tenderness to suggest another abdominal pathology.

Laboratory Investigations: Laboratory tests sent include a complete blood count, urea, electrolytes, creatinine, coagulation screen, liver function tests, and type and crossmatch for transfusion. The point-of-care venous blood gas reveals acidosis, haemoglobin <8 g/dL, negative base excess, and elevated lactate, indicating ongoing active bleeding. These findings necessitate urgent gastroenterology consultation for endoscopic intervention and the arrangement of blood transfusion. In addition, the patient must be monitored for liver disease-induced coagulopathy, and a haematology consultation is warranted.

Diagnostic Test: The patient’s Glasgow-Blatchford Score is greater than 0, further confirming the need for urgent endoscopy to identify and control the source of bleeding, which is most likely esophageal varices. Simultaneously, resuscitation measures must continue.

Medications: Given the patient’s history of alcoholic liver disease and suspected variceal bleeding, appropriate pharmacological management should include vasoactive agents such as somatostatin, octreotide, or terlipressin to reduce portal pressure. Empirical antibiotics (fluoroquinolones or third-generation cephalosporins) should be administered to reduce the risk of infection. Additionally, proton pump inhibitors (PPIs) should be started as part of the management protocol.

Disposition: This patient requires urgent gastrointestinal consultation for endoscopy to achieve source control of the bleeding. Admission is necessary to allow for close monitoring of potential complications, including rebleeding and complications of alcoholic liver cirrhosis, such as hepatic encephalopathy and renal failure.

Authors

Picture of Resshme Kannan Sudha

Resshme Kannan Sudha

Resshme Kannan Sudha graduated from RAK Medical and Health Sciences University and is currently an Emergency Medicine Graduate Resident at STMC Hospital, Al Ain. She is a keen follower of FOAMed projects and an enthusiastic educator. Her special interests include critical care, POCUS, global health, toxicology and wilderness medicine.

Picture of Thiagarajan Jaiganesh

Thiagarajan Jaiganesh

STMC Hospital, Al Ain

Listen to the chapter

References

  1. Antunes C, Copelin II EL. Upper gastrointestinal bleeding – StatPearls – NCBI Bookshelf. Upper Gastrointestinal Bleeding. Published July 18, 2022. Accessed March 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470300/
  2. Southwood KE. Upper gastrointestinal bleeding. Gastroenterology Nursing. Published ahead of print. 2023. doi:10.1097/SGA.0000000000000743
  3. Carrol M, Mudan G, Bentley S. Gastrointestinal bleeding. International Emergency Medicine Education Project. Published February 18, 2019. Accessed March 17, 2023. https://iem-student.org/gi-bleeding/
  4. DeGeorge LM, Nable JV. Gastrointestinal bleeding. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:240-244.
  5. Donaldson R, Swartz J, Ong M, et al. Peptic ulcer disease – WikEM. WikEM. Published December 7, 2022. Accessed April 11, 2023. https://www.wikem.org/wiki/Peptic_ulcer_disease
  6. Leach T. Upper GI bleed. Almostadoctor. Published December 5, 2020. Accessed April 8, 2023. https://almostadoctor.co.uk/encyclopedia/upper-gi-bleed
  7. Pace R. Upper GI bleeding. Core EM. Published January 24, 2018. Accessed March 20, 2023. https://coreem.net/core/upper-gi-bleeding/
  8. Undifferentiated upper gastrointestinal bleeding – WikEM. WikEM. Accessed March 23, 2023. https://www.wikem.org/wiki/Undifferentiated_upper_gastrointestinal_bleeding
  9. Kaur G. Upper gastrointestinal bleeding: Evaluation, management, and disposition. emDOCs.net – Emergency Medicine Education. Published June 7, 2021. Accessed April 11, 2023. https://www.emdocs.net/upper-gastrointestinal-bleeding-evaluation-management-and-disposition/
  10. Chen ZJ, Freeman ML. Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations. World J Emerg Med. 2011;2(1):5-12. doi:10.5847/wjem.j.1920-8642.2011.01.001
  11. (Sokolosky MC. Gastrointestinal bleeding. In: Tintinalli’s Emergency Medicine Manual. New York, NY: McGraw-Hill Education; 2018:237-238.
  12. Donaldson R, Swartz J, Claire, et al. Gastrointestinal bleeding (peds) – WikEM. WikEM. Updated March 29, 2022. Accessed April 10, 2023. https://www.wikem.org/wiki/Gastrointestinal_bleeding_(peds)
  13. Wilkins T, Wheeler B, Carpenter M. Upper gastrointestinal bleeding in adults: Evaluation and management. American Family Physician. Published March 1, 2020. Accessed March 20, 2023. https://www.aafp.org/pubs/afp/issues/2020/0301/p294.html
  14. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. Am J Gastroenterol. 2021;116(5):899-917. doi:10.14309/ajg.0000000000001245
  15. Woodfield A, Donaldson R, Reynolds C, Young N. Upper GI bleeding guidelines. WikEM. Published March 12, 2022. Accessed March 20, 2023. https://www.wikem.org/wiki/Upper_GI_bleeding_guidelines
  16. Stanley AJ, Laine L. Management of acute upper gastrointestinal bleeding. BMJ. 2019;364:l536. Published March 25, 2019. Accessed February 15, 2023. https://www.bmj.com/content/364/bmj.l536
  17. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Ann Intern Med. 2019;171(11):805. doi:10.7326/m19-1795
  18. Farkas J. GI bleeding. EMCrit Project. Published September 18, 2021. Accessed April 11, 2023. https://emcrit.org/ibcc/gib/
  19. Gnanapandithan K, Muniraj T. Management of antithrombotics around gastrointestinal procedures. PubMed. Published 2023. Accessed April 11, 2023. https://www.ncbi.nlm.nih.gov/books/NBK553210/
  20. Carmen Fookes B. List of proton pump inhibitors + uses, side effects. Drugs.com. Accessed April 11, 2023. https://www.drugs.com/drug-class/proton-pump-inhibitors.html
  21. Richter JE. Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin North Am. 2003;32(1):235-261. doi:10.1016/s0889-8553(02)00065-1
  22. Reynolds C, Cunningham R, Ostermayer D, Donaldson R, Young N. Omeprazole. WikEM. Updated March 5, 2021. Accessed April 11, 2023. https://wikem.org/wiki/Omeprazole
  23. Ostermayer D, Murray B, Lee E, Donaldson R, Cunningham R. Octreotide. WikEM. Published February 10, 2021. Accessed March 20, 2023. https://wikem.org/wiki/Octreotide
  24. Sandostatin, Sandostatin LAR (octreotide) dosing, indications, interactions, adverse effects, and more. Medscape. Accessed April 11, 2023. https://reference.medscape.com/drug/sandostatin-lar-octreotide-342836
  25. Nickson C. Terlipressin. Life in the Fast Lane. Published January 4, 2019. Accessed April 11, 2023. https://litfl.com/terlipressin/
  26. Tripathi D, Stanley AJ, Hayes PC, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1691-1692. doi:10.1136/gutjnl-2015-309262
  27. Terlivaz. Medscape. Published July 15, 2024. Accessed December 7, 2024. https://reference.medscape.com/drug/terlivaz-terlipressin-4000107#6
  28. Seo YS, Park SY, Kim MY, et al. Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage. Hepatology. 2014;60(3):962. doi:10.1002/hep.27006
  29. Donaldson R, Claire, Lee E, Ostermayer D, Holtz M. Erythromycin. WikEM. Published September 22, 2019. Accessed March 20, 2023. https://www.wikem.org/wiki/Erythromycin
  30. Fernando T, Donaldson R, Grove G, et al. Metoclopramide. WikEM. Updated March 7, 2021. Accessed April 11, 2023. https://www.wikem.org/wiki/Metoclopramide
  31. Roberts I, Shakur-Still H, Afolabi A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi:10.1016/s0140-6736(20)30848-5
  32. Donaldson R, Shah M, Ostermayer D, Young N, Claire. Ceftriaxone. WikEM. Updated September 19, 2019. Accessed April 10, 2023. https://www.wikem.org/wiki/Ceftriaxone
  33. Donaldson R, Gausepohl A, Janeway H, et al. Ciprofloxacin. WikEM. Updated October 17, 2021. Accessed April 11, 2023. https://wikem.org/wiki/Ciprofloxacin
  34. Balloon tamponade for massive GI bleeding – WikEM. WikEM. Accessed March 23, 2023. https://www.wikem.org/wiki/Balloon_tamponade_for_massive_GI_bleeding
  35. Lirio RA. Management of upper gastrointestinal bleeding in children. Gastrointest Endosc Clin N Am. 2016;26(1):63-73. doi:10.1016/j.giec.2015.09.003
  36. Di Gioia G, Sangineto M, Paglia A, et al. Limits of pre-endoscopic scoring systems in geriatric patients with upper gastrointestinal bleeding. Sci Rep. 2024;14(1). doi:10.1038/s41598-024-70577-2.
  37. McWhirter A, Mahmood S, Mensah E, Nour H, Olabintan O, Mrevlje Z. Evaluating the safety and outcomes of oesophagogastroduodenoscopy in elderly patients presenting with acute upper gastrointestinal bleeding. Cureus. 2023. doi:10.7759/cureus.47116.
  38. Ahmad H, Khan U, Jannat HE. Recurrent gastrointestinal bleeding in an elderly patient with peptic ulcer disease: successful management through multidisciplinary intervention and close monitoring. Cureus. 2023. doi:10.7759/cureus.41468.
  39. Li Y, Lu Q, Song M, Wu K, Ou XL. Novel risk score for acute upper gastrointestinal bleeding in elderly patients: a single-centre retrospective study. BMJ Open. 2023;13(6):e072602. doi:10.1136/bmjopen-2023-072602.
  40. Shahid S, Chandra N. Haematemesis in pregnancy. In: Gastrointestinal Emergencies in Pregnancy. CRC Press; 2015:149-153. doi:10.1201/B18646-36.
  41. Parampalli U, Crossland C, Longley J, Morrison I, Sayegh M. A rare case of gastrointestinal stromal tumour in pregnancy presenting with upper gastrointestinal bleeding. J Gastrointest Cancer. 2012;43(1):80-83. doi:10.1007/s12029-011-9360-3.
  42. Bjorkman DJ. Is endoscopy safe for pregnant women with upper gastrointestinal bleeding. NEJM J Watch. 2011. doi:10.1056/JG201101070000004.
  43. Rabiee A, Moshiree B. Upper and lower endoscopy for gastrointestinal (GI) bleeding in pregnancy. In: Gastrointestinal Bleeding. Springer; 2019:155-164. doi:10.1007/978-3-319-90752-9_12.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Abdominal Pain in Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Prassana Nadarajah

Authors
Listen

You have a new patient!

An 18-month-old boy is brought to the emergency department (ED) by his parents due to lethargy that has persisted for the last few hours. He is a term-born child with no significant antenatal history or pre-existing medical conditions. The child had been well until five days ago when he experienced a case of viral gastroenteritis. His feeding and urine output were adequate until about three hours ago, after which he began experiencing progressive episodes of crying, accompanied by vomiting and abdominal distension. There was no diarrhea or dark-colored stools noted.

a-photo-of-a-1-and-a-half-year-old-boy-(the image was produced by using ideogram 2.0)

During the triage assessment, the child appeared unsettled but was afebrile, with other vital signs within age-appropriate ranges. There were no rashes observed on his body, and there were no blood-stained stools in his diaper.

What do you need to know?

Importance

Abdominal pain is a common reason for children to present to the Emergency Department (ED) and represents up to 5% of all presentations in some institutions [1]. The most common causes are non-surgical, and at times it may be difficult to arrive at a specific diagnosis before discharge. However, it is crucial to identify causes of abdominal pain that require early surgical intervention, particularly when a clear diagnosis cannot be made before discharge. Pay special attention to red flags such as lethargy (in neonates and infants), severe pain or irritability, bilious emesis, abdominal distension, peritoneal signs, or signs of sepsis.

The differential diagnoses (DDx) for abdominal pain vary with age groups. In younger children who cannot express themselves, reliance on parental history and a thorough physical examination is essential. Blood investigations and radiology may not be helpful, especially in early presentations, making serial examinations and observation more valuable. Additionally, remember that pain from other sites can be referred to the abdomen, particularly testicular pain.

Epidemiology

Pediatric abdominal pain is a common reason for emergency department (ED) visits, accounting for approximately 12% of all visits [2]. The median age of children presenting with abdominal pain is around 9 years, with a higher incidence in girls [2, 3]. Non-specific abdominal pain is the most prevalent diagnosis, affecting 40% of children, followed by functional abdominal pain (FAP), constipation, and viral infections [2, 4]. Despite the high prevalence of abdominal pain, a significant portion of children (62.7%) are discharged directly from the ED, while 37.3% require admission [3]. However, follow-up studies indicate that about 50% of children report ongoing pain after discharge, highlighting the chronic nature of abdominal pain [3]. 

Pathophysiology

The sensation of abdominal pain is transmitted either by somatic or visceral afferent fibres [5]. Visceral pain from the visceral peritoneum is poorly localised and is often referred to its corresponding dermatome on the abdominal wall. If you recall the human embryological development of abdominal organs, the organs developing from the foregut (oesophagus to the second part of the duodenum) have pain referred to the T8 dermatome (i.e., the epigastric area), those developing from the midgut (from the third part of the duodenum to the proximal two-thirds of the transverse colon) have pain referred to the T10 dermatome (i.e., the umbilical area), and those from the hindgut (distal one-third of the transverse colon to the rectum) refer to the T12 dermatome [6].

Somatic pain from the parietal peritoneum is more localised. Thus, any abdominal condition that progresses to involve the parietal peritoneum will result in the patient complaining of migrating pain. In unfortunate situations where this advances to bowel rupture or peritonitis (i.e., surgical abdomen), the patient will exhibit signs of peritonism. You can observe this in the history of appendicitis, where the pain initially starts in the periumbilical region and migrates to the right lower quadrant.

Referred pain also occurs due to the convergence of visceral and somatic pathways in the spinal column. Two examples of referred pain are diaphragmatic irritation leading to pain at the shoulder tip due to the convergence of visceral and somatic pathways at C4, and somatic pain from pneumonia leading to T10–11 pain perceived in the lower abdomen [5].

Initial Assessment and Stabilization

Airway & Breathing

  • Provide supplemental oxygen and attach an SPO2 probe.

Circulation

  • Assess for signs of sepsis, shock, dehydration, or the need for IV pain relief. If any of these are present, obtain IV access.
  • If in shock, administer an IV crystalloid fluid bolus of 20 ml/kg. Reassess and repeat if necessary.
  • If sepsis is suspected, obtain blood cultures via IV and administer Ceftriaxone 50 mg/kg (up to 2 g) AND metronidazole 10 mg/kg (up to 500 mg). Follow your local antibiotic guidelines.
  • If not in shock but dehydrated, initiate IV maintenance therapy.
  • Provide adequate pain control. Consider IV morphine 0.05–0.1 mg/kg or IV fentanyl 1 μg/kg.

Disability

  • Check a point-of-care glucose level in sick children. Consider hypoglycemia or DKA as alternative diagnoses.

Exposure

  • Examine the abdomen for abdominal distension, masses, or peritonism. Involve the surgical team early. This is further discussed in the physical examination section.
  • Always examine the genitals (e.g., for testicular torsion or strangulated hernia).

Medical History

In history, focus on the following:

Age of the child – DDx varies with the child’s age and the initial presenting complaints. Remember that neonates and infants often present with lethargy, irritability, poor feeding, or vomiting.

Age

Surgical diagnoses

Medical diagnoses

Birth to 3 months

  • Necrotizing enterocolitis
  • Pyloric stenosis
  • Malrotation with Midgut volvulus
  • Incarcerated hernia
  • Duodenal atresia
  • Testicular torsion
  • Non-Accidental Injury
  • Constipation
  • Reflux
  • Colic

3 months to 3 years

  • Malrotation with midgut volvulus
  • Intussusception
  • Appendicitis
  • Testicular torsion
  • Trauma
  • Non-Accidental Injury
  • Henoch-Schönlein purpura (HSP)
  • Anaphylaxis
  • Acute gastroenteritis
  • Urinary tract infection
  • Constipation
  • Mesenteric adenitis
  • Sickle cell–related vaso-occlusive crisis

3 years and above

  • Appendicitis
  • Ectopic pregnancy
  • Cholecystitis
  • Malignancy
  • Trauma
  • Testicular or ovarian torsion
  • Henoch-Schönlein purpura
  • Diabetic ketoacidosis
  • Urinary tract infection
  • Pancreatitis
  • Anaphylaxis
  • Constipation
  • Acute gastroenteritis
  • Mesenteric adenitis
  • Strep pharyngitis
  • Pneumonia
  • Renal stones
  • Inflammatory bowel disease
  • Irritable bowel disease
  • Functional abdominal pain
  • Gastritis/gastric ulcer
  • Ovarian cyst
  • Pregnancy
  • Pelvic inflammatory disease
  • Toxic ingestion

Timing of the symptoms:
a. Intussusception may follow a bout of diarrhoeal illness.
b. Appendicitis typically presents as a gradual onset of pain migrating from the periumbilical area to the right lower quadrant.

Pain character – Episodic pain is observed in intussusception and mesenteric adenitis.

Blood in stool – Consider necrotizing enterocolitis, intussusception, and volvulus.

Bilious or non-bilious vomiting – Bilious vomiting is indicative of obstruction below the ampulla of Vater. It is a classic presentation of malrotation with midgut volvulus and may also present in incarcerated/strangulated hernia or Hirschsprung disease with enterocolitis. Non-bilious vomiting is classically associated with pyloric stenosis.

Associated symptoms – A rash may be present in Henoch-Schönlein purpura. Fever, when associated with inflammation (e.g., appendicitis) or the translocation of gut bacteria, may lead to sepsis.

Oral intake, urine output (UOP), and activity levels – These are important. Escalate to a senior opinion for admission or IV hydration if these parameters are below 50% of the child’s baseline.

Other relevant history:

  • Past medical and surgical history, including birth history such as prematurity in neonates and infants.
  • Social history, especially when suspecting non-accidental injury.
  • Menstrual and sexual history in adolescent females.
  •  

Physical Examination

A good history and physical examination are very important in managing undifferentiated paediatric abdominal pain patients. You must perform an abdominal examination, including genitourinary and inguinal exams, especially in children who cannot express themselves. Remember that you may find little or no helpful clinical signs initially; however, serial examinations may reveal the condition as it evolves. A digital rectal examination is very rarely indicated, and even then, it should ideally be limited to once and performed by the surgeon [7].

Also, remember that these are children, and they may intentionally exhibit voluntary guarding during palpation if they are distressed, regardless of the cause. Covering the art of paediatric abdominal examination is beyond the scope of this chapter, but consider providing analgesia, employing distraction techniques, and building good rapport with the child.

Please ensure that your patients receive adequate analgesia before the examination, as this will make the patient cooperative, simplify the examination, and highlight clinical signs.

General Examination

  • Assess general appearance and determine whether the child looks ill or well.
  • Record temperature and other vital signs.
  • Observe for pallor and jaundice. Obtain an accurate body weight.
  • Observe the child walking to the examination bed or within the department. Children with peritonism may refuse to walk or walk slowly with a stooped posture.
  • Observe for signs of pain when coughing or jumping.

Inspection

  • Look for asymmetry and abdominal distension. Abdominal distension is less pronounced in higher bowel obstructions (e.g., midgut volvulus) than in lower bowel obstructions.
  • Check for purpuric patches, which are diffusely seen in Henoch-Schönlein purpura (HSP).

Palpation

  • Feel for any masses, tenderness, and peritonism. Remember that classic presentations of masses (e.g., an olive-shaped mass in pyloric stenosis or a sausage-shaped mass in intussusception) may not be palpable in the emergency department, as the condition may be intermittent or in an early stage.
  • Palpable bowel loops are classically associated with necrotizing enterocolitis.
  • Pyloric stenosis typically presents with a non-tender abdomen.
  • For most surgical causes, peritoneal findings can occur late. Consider the possibility of septic shock in a drowsy child presenting with abdominal tenderness on palpation.

Other Systems to Examine for Abdominal Pain [7]

  • Respiratory: Assess for signs of basal pneumonia.
  • ENT: Consider upper respiratory tract infections (URTI), tonsillitis, or adenopathy.
  • Neurological: Rule out meningitis.
  • Endocrine: Check blood glucose levels for diabetic ketoacidosis.
  • Haematological: Look for pallor and lymphadenopathy.
  • Dermatological: Look for rashes, particularly purpura/petechiae in Henoch-Schönlein purpura or zoster.
  • Renal: Check for oliguria, haematuria, or hypertension in haemolytic uraemic syndrome.

In Our Patient

Physical Examination: Abdominal examination revealed an ill-defined mass in the right upper quadrant (RUQ). No pain was elicited on testicular palpation. No anal fissures or bleeding were noted on rectal examination. There were no signs of peritonism.

When To Ask for Senior Help

Do not hesitate to contact your seniors if you are concerned about your patient. The points below serve as a guide:

  1. An ill-looking patient.
  2. May require IV access for hydration or analgesia.
  3. Presence of peritoneal signs.
  4. Signs of sepsis.
  5. Bilious vomiting.
  6. Non-accidental injury or inconsistent history.
  7. Neonates (especially premature babies), if you lack experience in treating them.
  8. Parental anxiety.

Not-To-Miss Diagnoses

Pediatric abdominal pain is a common and complex issue in emergency departments, requiring a thorough differential diagnosis to identify serious underlying conditions [8]. The etiologies of abdominal pain vary by age, with infants (<2 years) commonly presenting with congenital anomalies, malrotation, and intussusception [8]. In children aged 2-5 years, appendicitis, gastroenteritis, and mesenteric adenitis are frequent diagnoses [9], while school-aged children (5-12 years) are more likely to experience constipation, urinary tract infections, and respiratory infections [8]. Adolescents (>12 years) are at risk for pelvic inflammatory disease, pregnancy-related issues, and ovarian torsion [8]. Common conditions such as appendicitis, constipation, and gastroenteritis are prevalent across different age groups, and non-gastrointestinal causes like pneumonia and acute asthma can also manifest as abdominal pain [10]. A comprehensive approach to diagnosis and management is essential to identify serious underlying conditions that may require urgent intervention.

Causes Requiring Early Surgical Intervention

  • Peritonitis.
  • Appendicitis.
  • Testicular torsion.
  • Incarcerated hernia.
  • Necrotizing enterocolitis.
  • Intussusception.
  • Volvulus.
  • Hirschsprung’s disease.
  • Pregnancy or ectopic pregnancy in adolescent girls.
  • Ovarian torsion in adolescent girls.

Medical Causes Not to Miss

  • UTI in very young children (<5 years).
  • Diabetic ketoacidosis.
  • Sepsis.
  • Haemolytic uraemic syndrome.
  • Non-accidental injury.

Acing Diagnostic Testing

Remember that blood investigations are useful as supportive evidence for your history and physical examination, but they can be normal in surgical conditions. Avoid unnecessary venepuncture and/or IV cannulation in children unless the patient is sick or you are concerned about a not-to-miss diagnosis.

Bedside Tests

In sick patients, useful point-of-care tests include blood sugars, urine analysis, and capillary gas analysis. Blood sugars can indicate hypoglycaemia or DKA, and capillary gas analysis is useful for assessing lactate levels and metabolic acidosis. Urine analysis is helpful in confirming UTI, but ensure a proper uncontaminated sample has been collected [11]. Point-of-care ultrasound can be used for diagnosing intussusception, pyloric stenosis, or appendicitis.

Laboratory Tests

If venipuncture is performed, a full blood count, CRP, and renal function tests should be considered for all children. These tests may reveal evidence of inflammation or infection, as well as the extent of dehydration. You may also consider adding VBG and blood cultures for sicker children and tailor other testing depending on the patient (e.g., lipase for pancreatitis or beta HCG if pregnancy is suspected).

Imaging

Consider avoiding radiation or utilizing the lowest possible radiation dose. Ultrasound is the initial imaging modality of choice. In addition to point-of-care ultrasound, arrange an urgent departmental ultrasound if needed. If x-ray facilities are available, you can obtain a supine abdomen and upright/lateral decubitus view to look for free air. Computed tomography can be considered for life-threatening conditions when other modalities have failed. Magnetic resonance imaging is used in some parts of the world. It avoids radiation but may be time- or cost-prohibitive.

In Our Patient

  • Point-of-care ultrasound (POCUS) showed a target sign over the abdominal mass.
  • A diagnosis of intussusception was made.

Risk Stratification

Effective clinical decision rules (CDRs) for risk stratification of pediatric abdominal pain in emergency departments include the Pediatric Appendicitis Score (PAS) and the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Intra-Abdominal Injury rule. The PECARN rule is for trauma patients and out of the discussion in this chapter. The PAS is a valuable tool for assessing the likelihood of acute appendicitis in children presenting with abdominal pain, with studies showing that PAS scores correlate significantly with the severity of appendicitis [12]. A score below 4 has been found to rule out appendicitis, while higher scores indicate a higher risk of appendicitis [12]. Additionally, a recent Non-Specific Abdominal Pain (NSAP) Model has been developed to differentiate non-specific abdominal pain from organic causes, identifying key clinical predictors such as pain location and associated symptoms, and achieving a sensitivity of 71.8% [13]. These CDRs assist clinicians in identifying patients at risk for serious conditions, optimizing diagnostic processes, and reducing unnecessary interventions.

Management

Empiric and Symptomatic Treatment

Correct dehydration either orally in stable children or via IV in children who may need to be kept nil-by-mouth or are too sick to tolerate oral intake.

Consider keeping possible surgical patients nil-by-mouth. For bowel obstruction, consider inserting a nasogastric tube for gastric decompression.

Treat pain and distress.

  • Consider non-pharmacological methods (e.g., examine the child on the parent’s lap).

Paracetamol

  • Dose per kg: 15 mg/kg
  • Frequency: Every 4 hours (q4h)
  • Maximum Dose: 60 mg/kg/day
  • Cautions/Comments:
    • Ask for allergies.
    • Check if/when the patient took acetaminophen at home.

Fentanyl

  • Dose per kg: Intranasal 1.5 mcg/kg (for >12 months of age)
  • Frequency: Every 15 minutes
  • Maximum Dose: 3 mcg/kg
  • Cautions/Comments:
    • Not recommended for children <12 months of age.
    • Divide the dose between nostrils.
    • Consider alternative analgesia after the second dose.

Morphine

  • Dose per kg:
    • IV/Subcutaneous: 0.05–0.1 mg/kg
  • Frequency: Every 2–4 hours
  • Maximum Dose:
    • For <1 month: 0.1 mg/kg every 4–6 hours
    • For 1–12 months: 0.1 mg/kg every 2–4 hours
    • For >12 months: 0.2 mg/kg every 2–4 hours
  • Cautions/Comments:
    • There is a chance of respiratory depression if the dose exceeds the recommended amount.

If sepsis is suspected, administer IV Cefotaxime and IV Metronidazole, or follow your local antibiotic guidelines.

Cefotaxime

  • Dose per kg: IV 50 mg/kg
  • Frequency: Every 12 hours
  • Maximum Dose: 2000 mg
  • Cautions/Comments:
    • Can be given intramuscularly (IM) if IV access is difficult.

Metronidazole

  • Dose per kg: IV 10 mg/kg
  • Frequency: Every 8 hours
  • Maximum Dose: 500 mg
  • Cautions/Comments:
    • Consider alternative analgesia after the second dose.

Piperacillin + Tazobactam

  • Indication: For pseudomonal coverage in sepsis or hospital-acquired infections.
  • Dose per kg:
    • 2 months to 9 months: IV 80 mg/kg
    • 9 months: IV 100 mg/kg
  • Frequency: Every 8 hours
  • Maximum Dose: 3000 mg
  • Cautions/Comments:
    • The dose is calculated based on the piperacillin component.

IV Fluids

  • Use isotonic crystalloids. Avoid hypotonic solutions in the ED, except in rare circumstances as advised by paediatric nephrologists or paediatricians.
  • For resuscitation, use 0.9% saline in 10–20 ml/kg boluses for all ages. You can repeat the boluses as necessary, but assess for signs of heart failure before administering each bolus.
  • For IV maintenance, use a 0.9% saline and 5% dextrose combination if available. This can be prepared by mixing 450 ml of 0.9% saline with 50 ml of 50% dextrose. Alternatively, you can use 0.9% saline, Hartmann’s solution, or follow local guidelines.

When To Admit This Patient

If you are able to arrive at a diagnosis for these patients, then the disposition is often straightforward. On the other hand, patients with severe pain despite a negative physical examination and unclear diagnosis will require admission for observation and serial physical examinations.

If parents confirm that oral intake, UOP, and activity levels are less than 50% of the child’s baseline, the child should be admitted for IV hydration and observation. A short-stay unit may be suitable for such patients.

If there is a suspicion of non-accidental injury or any social circumstances (e.g., inability to return for review due to financial constraints or travel issues in rural areas), discuss admission with your senior doctor. Consider reviewing well-appearing neonates with seniors, especially if you think they can be safely discharged home.

Otherwise, well children with likely benign causes can be discharged home. Ensure that clear and close follow-up is arranged with their general practitioner or pediatrician.

Advise parents on when to return (e.g., if the child’s oral intake, UOP, or activity level reduces to less than 50% of their usual baseline, or if symptoms of sepsis or shock develop) and provide guidance on follow-up (either with their general practitioner or the nearest hospital with surgical capacity to review the child). If any outpatient radiological investigations are planned for the coming days, educate parents about the importance of attending these procedures as well.

Revisiting Your Patient

Our 18-month-old patient was confirmed to have an intussusception by point-of-care ultrasound.

On reviewing his history, the episodic crying and preceding viral illness are supportive of this diagnosis, and the lack of fever or other associated symptoms rules out most other diagnoses. The classical triad of abdominal pain, vomiting, and red-currant jelly stool described in patients is present in less than 50% of patients with the disease [14]. However, a better clue is that it is associated with lethargy even without signs of sepsis or dehydration.

His examination revealed normal vital signs, was afebrile, and had a soft, non-tender abdomen with an ill-defined lower abdominal mass, which also supports this diagnosis.
The ABCDE or primary survey did not show any other abnormalities.

He was kept nil-by-mouth, IV maintenance fluids were started, and an urgent surgical referral was made. Antibiotics were not needed at this stage as there was no other supportive evidence of associated sepsis. He was prescribed PRN pain relief with fentanyl and morphine but did not require any during the ED stay.

The surgical team reviewed him and took him to the operating theatre for air enema reduction.

Authors

Picture of Prassana Nadarajah

Prassana Nadarajah

Listen to the chapter

References

  1. Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal pain. Pediatrics. 1996;98(4):680-685. doi:10.1542/peds.98.4.680
  2. Magnúsdóttir MB, Róbertsson V, Þorgrímsson S, Rósmundsson Þ, Agnarsson Ú, Haraldsson Á. Abdominal pain is a common and recurring problem in paediatric emergency departments. Acta Paediatr. 2019;108(10):1905-1910. doi:10.1111/apa.14782
  3. Lee WH, O’Brien S, Skarin D, et al. Pediatric Abdominal Pain in Children Presenting to the Emergency Department. Pediatr Emerg Care. 2021;37(12):593-598. doi:10.1097/PEC.0000000000001789
  4. Pant C, Deshpande A, Sferra TJ, Olyaee M. Emergency department visits related to functional abdominal pain in the pediatric age group. J Investig Med. 2017;65(4):803-806. doi:10.1136/jim-2016-000300
  5. Simpson E, Smith A. The management of acute abdominal pain in children. Journal of Paediatrics and Child Health. 1996;32(2):110-112. doi:10.1111/j.1440-1754.1996.tb00905.x
  6. Sadler TW, Langman J, Langman J. In: Langman’s Medical Embryology. Wolters Kluwer Health; 2012:208-229.
  7. Cameron P, Brown G, Biswadev M, Dalziel S, Craig S. Textbook of Paediatric Emergency Medicine. Elsevier; 2019.
  8. Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016;93(10):830-836.
  9. Yang WC, Chen CY, Wu HP. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World J Clin Cases. 2013;1(9):276-284. doi:10.12998/wjcc.v1.i9.276
  10. Kandamany N, O’Neill M. The Aetiology of Acute Abdominal Pain in Children 2–12 Years of Age. Archives of Disease in Childhood 2012;97:A478.
  11. The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. Accessed May 25, 2023. https://www.rch.org.au/kidsinfo/fact_sheets/Urine_samples/#:~:text=Clean%20the%20skin%20around%20the%20genital%20area%2C%20using%20gauze%20if,sample%20container%20touch%20the%20skin.
  12. Vevaud K, Dallocchio A, Dumoitier N, et al. A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process. BMC Pediatr. 2024;24(1):131. Published 2024 Feb 19. doi:10.1186/s12887-024-04619-z
  13. Bouënel M, Lefebvre V, Trouillet C, Diesnis R, Pouessel G, Karaca-Altintas Y. Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department. Acta Paediatr. 2023;112(10):2218-2227. doi:10.1111/apa.16911
  14. Simon R.A, Hugh T.J, Curtin A.M. Childhood intussusception in a regional hospital. Aust N Z J Surg. 1994;64:699–702.

Reviewed and Edited By

Picture of Erin Simon, DO

Erin Simon, DO

Dr. Erin L. Simon is a Professor of Emergency Medicine at Northeast Ohio Medical University. She is Vice Chair of Research for Cleveland Clinic Emergency Services and Medical Director for the Cleveland Clinic Bath emergency department. Dr. Simon serves as a reviewer for multiple academic emergency medicine journals.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Gastroenteritis and Dehydration In Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Neha Hudlikar & Abdulla Alhmoudi 

Authors
Listen

You have a new patient!

14-month-old Zoey is brought to A&E by her mother with complaints of vomiting and diarrhea for one day. She has had six episodes of vomiting and eight episodes of loose stools since last night. She has also not had a wet diaper for almost 12 hours now. In triage, her vitals are HR 165 b/min, RR 45 br/min, Temperature 38.5 C, SpO2 97% CR 3 seconds. The nurse in triage notes that she has a glazed look. She is otherwise fit and well, with no past medical history. Zoey’s weight – 10 kg.

What will be your approach for this patient?

a-photo-of-a-baby (image produced by using ideogram2.0)

What do you need to know?

Importance

Acute gastroenteritis is one of the most common reasons for visits to pediatric emergency departments [1]. The World Health Organization (WHO) defines diarrhea as the passage of three or more liquid stools per day, or a more frequent passage than what is normal for the individual. When diarrhea occurs alongside vomiting, it is referred to as acute gastroenteritis (AGE).

Diarrhea can be categorized into three clinical types based on the presence or absence of blood and the timing of symptoms:

1. Acute watery diarrhea – lasts from hours to several days, but less than 14 days.
2. Acute bloody diarrhea – also known as dysentery, lasts less than 14 days.
3. Persistent diarrhea – lasts longer than 14 days.

Infectious gastroenteritis can be caused by various pathogens, including viruses, bacteria, and parasites. Rotavirus is the most common causative agent worldwide, responsible for 37% of diarrhea-related deaths in children under five years of age.

Epidemiology

Gastroenteritis is the second leading cause of death in children below the age of 5 and a leading cause of malnutrition in this age group. Globally, there are approximately 1.7 billion cases of childhood diarrheal diseases yearly, and the burden is substantial [2]. There is a direct impact of admission costs on the hospital budget and direct and indirect societal costs when children are admitted to hospitals.

In low-income countries, children under three years old, on average, have three episodes of diarrhea every year. This puts them at risk of malnutrition and, in turn, makes them vulnerable to further episodes of infectious diarrhea.

Pathophysiology

The loss of water and electrolytes via stools, vomit, sweat, and urine without adequate replacement leads to dehydration, a serious complication of gastroenteritis. Physiologic factors that predispose children to serious complications from dehydration include limited stores of fat and glycogen, relatively larger extracellular fluid compartments, and a limited ability to conserve water through their kidneys compared to adults.

Bicarbonate loss in stools, decreased tissue perfusion leading to anaerobic metabolism and lactic acid production, ketosis due to starvation, and decreased excretion of hydrogen ions due to poor renal perfusion are some of the mechanisms contributing to metabolic acidosis in pediatric dehydration due to acute gastroenteritis.

The exact pathophysiology depends on the causative agent. Infectious agents cause diarrhea via adherence, mucosal invasion, enterotoxin, and cytotoxin production.S. aureus and Bacillus cereus produce heat-stable enterotoxins in the food, which once consumed, lead to rapid onset of symptoms and are usually self-limiting. C. Perfingens, Enterotoxigenic E.coli produce enterotoxins in the small intestine leading to watery diarrhea. Other pathogens like enterohemorrhagic E. Coli (EHEC), Salmonella, Shigella, and Campylobacter jejuni produce toxins that directly invade the bowel leading to inflammatory diarrhea. Viruses often destroy the villus surface of the intestinal mucosa, and parasites often adhere to the mucosa.

Medical History

A focused and detailed history is essential to narrowing our differential diagnoses and guiding management. The history should include the timing, frequency, and severity of symptoms. We should also ask about any contact with someone with similar symptoms, known or suspected outbreaks in school or nursery, and recent travel.

All patients with acute gastroenteritis are at risk of dehydration, and the initial evaluation should include questions to assess its severity. The child’s oral intake, amount of urine passed, mental status (lethargy/irritability), etc., should be asked for in the initial evaluation. 

It is also important to ask for associated symptoms such as fever, abdominal pain, blood in the stools, and rash. Children with inflammatory diarrhea can develop serious illnesses like hemolytic uremic syndrome (HUS) with renal involvement. 

Other important questions in history include the child’s vaccination status, recent hospitalization/antibiotic use, and whether the child has any underlying chronic medical conditions/immunosuppression.

Physical Examination

Examining the child should be systematic, looking for the severity of dehydration and differentiating gastroenteritis from other causes of vomiting and diarrhea in children.

General examination should include the child’s appearance, alertness, lethargy, irritability, and weight. Vital signs should be assessed relative to the age. Physicians should look for explicit signs of dehydration, such as dry mucous membranes, sunken eyes, depressed fontanelle, and the presence/absence of tears. The cardiovascular exam should include heart rate, quality of pulses, and central and peripheral capillary refill times. Deep, acidotic breathing suggests severe dehydration. An abdominal examination assesses tenderness, bowel sounds, guarding, and rebound. Flank tenderness increases the likelihood of pyelonephritis. Examine the skin to check skin turgor, peripheral temperature, and other signs such as jaundice/rash.

Abnormal skin turgor, prolonged capillary refill time, and abnormal respiratory pattern are the three most useful examination findings in children with more than 5% dehydration [3]. It is important to note that these signs can be subtle, and determining the severity of dehydration accurately is challenging for physicians.

Alternative Diagnoses

Dehydration most commonly results from acute gastroenteritis in children. However, other diagnoses should be considered based on physical examination and history. Children with fever who are very ill-looking should have sepsis as one of the differential diagnoses. Other diagnoses to consider are urinary tract infection, appendicitis, hemolytic uremic syndrome, intussusception, and diabetic ketoacidosis. Symptoms immediately after ingestion should prompt physicians to consider ingestion of a foreign body or toxic substance. 

Vomiting and diarrhea are two important components that ED practitioners need a careful evaluation to rule in or out various diseases.

When evaluating vomiting in children, it is essential to consider a wide range of differential diagnoses spanning several systems. Central nervous system causes include space-occupying lesions, hydrocephalus, and infections. Cardiac-related vomiting may be attributed to congestive heart failure from various etiologies. Gastrointestinal conditions such as intussusception, midgut volvulus, pyloric stenosis, appendicitis, and esophageal or hepatic disorders are significant considerations. Renal issues like urinary tract infections, pyelonephritis, renal insufficiency, and renal tubular acidosis can also manifest as vomiting. Furthermore, metabolic and endocrine abnormalities, including diabetic ketoacidosis, Addisonian crisis, congenital adrenal hyperplasia, and inborn errors of metabolism, are key causes. Infectious conditions such as sepsis, pneumonia, otitis media, streptococcal pharyngitis, and gastroenteritis must also be included in the diagnostic workup.

Diarrhea in children can arise from diverse causes. Gastrointestinal disorders such as intussusception, Hirschsprung’s disease with toxic megacolon, inflammatory bowel disease, and appendicitis are prominent. Renal conditions, including urinary tract infections and pyelonephritis, can also lead to diarrhea. Infectious etiologies like sepsis, pneumonia, gastroenteritis, and pseudomembranous colitis are frequent contributors. Other causes include drug effects or overdose, hemolytic uremic syndrome, and congenital secretory diarrhea.

Understanding these potential causes is essential for accurate diagnosis and effective management.

Acing Diagnostic Testing

The workup should be guided by history and physical examination to determine the level of dehydration. In most cases, it is a self-limiting disease, and the principal goal of testing in ED should be to identify and correct fluid, electrolyte, and acid-base deficits. 

Most children with mild to moderate disease require no diagnostic testing. Children requiring IV hydration should have blood gas, serum electrolytes, bicarbonate, urea, and creatinine levels tested. It is common for young children to have hypoglycemia, and checking serum glucose levels is important. In children presenting with fever or mucous/blood in their stools, consider testing for fecal leucocytes to support a diagnosis of invasive diarrhea. A positive test should be followed by a stool culture, and it is important to note that a negative test does not rule out invasive disease.

Consider additional testing, such as blood and urine cultures, chest X-rays, and lumbar puncture, in immunosuppressed patients, infants less than 2 months old, or children with suspicion of bacteremia or localized invasive disease. 

Risk Stratification

The Gorelick scale and The Clinical Dehydration Score (CDS) are two of the most widely used scoring systems to predict the presence and severity of dehydration in the pediatric population. It is important to note that neither can definitively rule in or out dehydration in children and infants. Physicians should continue to use a structured approach to patients presenting with acute gastroenteritis and use these scores to aid clinical decision-making [4,5,6].

Clinical Dehydration Scale

 

0

1

2

 

0: No dehydration (<3%)

1-4: Some dehydration (≥3%- <6%)

5-8: Moderate dehydration (≥6%)

General appearance

Normal

Thirsty, restless or lethargic but irritable when touched

Drowsy, limp, or comatose

Eyes

Normal

Slightly sunken

Very sunken

Mucous membranes

Moist

“Sticky”

Dry

Tears

Present

Decreased

Absent

 

Gorelick Scale for Dehydration

characteristic

no or minimal dehydration

moderate to severe dehydration

general appearance

alert

restless, lethargic, unconscious

capillary refill

normal

prolonged or minimal

tears

present

absent

mucous membrane

moist

dry, very dry

eyes

normal

sunken; deeply sunken

breathing

present

deep; deep and rapid

quality of pulses

normal

thready; weak or impalpable

skin elasticity

instant recoil

recoil slowly; recoil > 2 s

heart rate

normal

tachycardia

urine output

normal

reduced; not passed in many hours

Evaluating dehydration with Gorelick scale [6];

4-Point Scale (Italics):

  • 4 points: Presence of 2 or more clinical signs correlating with ≥5% body weight loss from baseline.
  • 4 points: Presence of 3 or more clinical signs correlating with ≥10% body weight loss from baseline.

10-Point Scale (Based on All Signs and Symptoms):

  • ≥3 clinical signs: Associated with ≥5% body weight loss from baseline.
  • ≥7 clinical signs: Associated with ≥10% body weight loss from baseline

Some groups are at higher risk of developing complications from acute gastroenteritis. These include premature infants, very low birth weight infants, and infants below the age of 3 months. Children who are malnourished, immunosuppressed, and with chronic underlying medical conditions are also at higher risk of developing complications.

Indications for inpatient management of children presenting with acute diarrhea have been proposed, and the Table below summarizes these recommendations.

Indications for Inpatient Management of Children with Acute Diarrhoea

  • Difficulties in administrating oral rehydration therapy (patient refusal, intractable vomiting)
  • History of premature birth, chronic medical conditions, or concurrent illness, very young age
  • Parental/caregiver concern about continuing ORT at home/unable to provide adequate care
  • Persistent vomiting, high output diarrhoea, persistent dehydration
  • Uncertainty of diagnosis warranting further observation
  • Progressive symptoms or unusual irritability/drowsiness
  • Lack of easy access to hospital care if needing to return

Adapted from King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.

Management

Management in the Emergency Department should initially focus on correcting dehydration. Oral rehydration solution (ORS) is recommended for all children with mild to moderate dehydration.

To calculate the volume of oral replacement therapy (ORT), the first step is to estimate the degree of dehydration based on history and physical examination findings (see Table below). The desired volume of ORS is then calculated based on the degree of dehydration (30 to 50 mL/kg for mild and 60 to 80 mL/kg for moderate dehydration). 25% of the calculated volume of ORS is given every hour for the first four hours and ongoing losses can be replaced at 10 mL/kg for each stool and 2 mL/kg for each emesis. The patient needs reassessment at the end of the first few hours and those with no clinical deterioration may have a 2 to 4-hour trial with ORT. If the child is unable to keep up with ongoing losses and if volume replacement is not adequate at the end of 8 hours, IV rehydration is recommended. Ondansetron is a selective 5-hydroxytryptamine type 3 receptor antagonist, a useful adjunct in treating AGE. It acts on peripheral and central chemoreceptors to alleviate nausea. It has been shown to decrease vomiting, improve oral intake, and reduce the need for intravenous fluid resuscitation and hospital admissions [7].

Assessment of Degree of Dehydration

Mild dehydration (3%-5%)

Moderate dehydration (5%-10%)

Severe dehydration (> 10%)

Mental status

Alert

Irritable

Lethargy

Heart rate

Normal

Increased

Increased

Quality of pulses

Normal

Normal to decreased

Decreased to thready

Mucous membranes

Wet

Slightly dry

Dry

Capillary refill

< 2 seconds

> 2 seconds

> 2 seconds

Blood pressure

Normal

Normal

Normal to decreased

Respirations

Normal

Tacypnea

Tachypnea, deep

Fontanelle

Normal

Sunken

Sunken

Eyes

Normal

Slightly sunken, decreased tears

Sunken, cries without tears

Urine output

Normal to decreased

Decreased

Oliguric or anuric

Skin turgor

Normal

Slightly reduced

Reduced

Children with severe dehydration, signs of shock, failed attempts with oral rehydration therapy, intractable vomiting, hypoglycemia, or electrolyte derangements require intravenous fluid resuscitation, which is often initiated as a 20 mL/kg bolus of 0.9% of sodium chloride in ED. These patients need frequent re-evaluation to review their response to IV hydration. Improvements in mental status, tachycardia, capillary refill time, and urine production are some signs that signal a good response to intravenous resuscitation. After initial resuscitation, patients will need an evaluation of their maintenance fluid needs, which could be either intravenous fluid therapy or ORT, depending on the patient’s clinical status. Maintenance fluids are calculated based on the child’s weight using the 4-2-1 Holliday-Segar Rule.

Holliday-Segar Rule for Maintenance Fluid Calculation

Body Weight

mL/kg/hr

mL/kg/day

First 10 kg

4

100

Second 10 kg

2

50

Each additional kg

1

20

Children who require multiple fluid boluses without signs of improvement should be investigated for other serious conditions such as adrenal insufficiency, cardiogenic or septic shock, etc. It is important to note that rapid correction of serum sodium levels can lead to osmotic demyelination syndrome in hyponatremia and cerebral edema in hypernatremia.

In children with hypoglycemia, glucose can be replaced as per the “rule of 50,” where the percent dextrose multiplied by the number of mL per kilogram equals 50. Neonates often get 10% dextrose solution at 5mL/kg, children between 1 month to 8 years of age (or 25 kg weight) can be given 2mL/kg of 25% dextrose. 50% of dextrose at 1mL/kg can be used safely in older children. The higher tonicity of 25% and 50% dextrose solutions poses a risk of tissue necrosis if extravasation occurs during peripheral IV infusion.
 
Antibiotics are not indicated in viral gastroenteritis and most cases of uncomplicated bacterial gastroenteritis. Considerations can be made for very young infants, immunocompromised, and those with chronic underlying medical conditions. The WHO recommends zinc supplementation for children under 5 years suffering from AGE in developing countries [8]. Studies showing the efficacy of probiotics are inconclusive and further research is needed to establish the safety and efficacy of probiotics in children with AGE [9].

When To Admit This Patient

Most cases of AGE are self-limiting and can be managed on an outpatient basis after a brief period of observation in the ED. Parents and caregivers should be given appropriate discharge instructions emphasizing hygiene and hand-washing techniques to prevent the further spread of the illness. Breastfeeding/routine diet should be continued at home, and supplemental electrolyte solutions may be recommended. Parents and caregivers should be educated to recognize the signs of dehydration and advised to bring the child back to the ED for these. Children with intractable vomiting, severe dehydration, failure to maintain oral hydration, electrolyte derangements, deteriorating clinical status, and those at high risk for complications (very low birth weight infants, < 3 months old, immunosuppressed, and children with chronic medical problems) should be admitted to hospital.

Revisiting Your Patient

History-taking reveals that Zoey has not had much to drink or eat in the past 12 hours, and there has been an outbreak of gastroenteritis in the nursery that she attends. There has been no blood in the stools, and Mum says that Zoey has been very sleepy for the last few hours. Her vaccinations are up to date, and she has no other medical history of note.

On examination, she is irritable when you approach her, and your systematic examination reveals the following:
CNS – Irritable, no signs of meningism, anterior fontanelle closed
HEENT – Dry mucous membranes, slightly sunken eyeballs
Respiratory – Mild tachypnea, bilateral air entry with clear breath sounds
CVS – Central capillary refill 3 seconds, tachycardia, BP 88/50
Abdomen – Soft, lax and non-tender. Bowel sounds ++, no mass palpable
Skin – Slightly reduced skin turgor, no rash

Next steps?

Your examination reveals no red flags of meningitis/sepsis or surgical abdomen. Given the recent outbreak of gastroenteritis in her nursery, you make a provisional diagnosis of acute gastroenteritis for Zoey. Your clinical assessment estimates the degree of dehydration to be moderate (5-10%), and you calculate her fluid depletion to be between 600 to 800 mL (60 to 80 mL/kg). You start the patient on oral rehydration therapy aiming for at least 200 mL to be given slowly over the next hour. You guide the mother in letting the staff know if Zoey vomits or has another episode of diarrhea while in the Emergency Department.

Investigations?

You ask for a random blood sugar to rule out hypoglycemia and a urine dipstick to rule out urinary tract infection.

Review
After an hour, Zoey tolerated 250 mL of oral rehydration solution and had one episode of vomiting but no diarrhea. Her blood sugar was 4 mmol/l. She has perked up significantly and is more alert than before. Her vital signs show improvement, and you decide to give her Ondansetron and continue the ORT.

After two hours, Zoey has tolerated around 400 mL of ORS and is more alert and interactive now. Her vitals are normal, and she has not had any further episodes of diarrhea or vomiting. She has also passed some urine, which has been tested and found to be negative for infection.

Mum was advised to continue oral hydration at home as well as the slow introduction of a regular diet and to come back to ED if Zoey could not tolerate orally, had intractable vomiting, any blood in her stools, high-grade fever, or change from her baseline mental status. Zoey was discharged from the ED and would follow up with her primary physician in the community.

Authors

Picture of Neha Hudlikar

Neha Hudlikar

Emergency Department, Zayed Military Hospital, Abu Dhabi

Picture of Abdulla Alhmoudi

Abdulla Alhmoudi

Dr Abdulla Alhmoudi is a Consultant Emergency Medicine, serving at Zayed Military Hospital and Sheikh Shakhbout Medical City - Abu Dhabi. He pursued his residency training in Emergency Medicine at George Washington University in Washington DC and further enhanced his expertise with a Fellowship in Extreme Environmental Medicine. Dr Alhmoudi's passion for medical education is evident in his professional pursuits. He currently holds the position of Associate Program Director at ZMH EM program and is a lecturer at Khalifa University College of Medicine and Health Sciences. Beyond medical education, he maintains a keen interest in military medicine and wilderness medicine.

Listen to the chapter

References

  1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); August 7, 2018.
  2. Hartman RM, Cohen AL, Antoni S, et al. Risk Factors for Mortality Among Children Younger Than Age 5 Years With Severe Diarrhea in Low- and Middle-income Countries: Findings From the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks [published correction appears in Clin Infect Dis. 2023 Jan 6;76(1):183]. Clin Infect Dis. 2023;76(3):e1047-e1053. doi:10.1093/cid/ciac561
  3. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004;291(22):2746-2754. doi:10.1001/jama.291.22.2746
  4. Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: a systematic review. Arch Dis Child. 2018;103(4):383-388. doi:10.1136/archdischild-2017-313762
  5. Freedman SB, Vandermeer B, Milne A, Hartling L; Pediatric Emergency Research Canada Gastroenteritis Study Group.
  6. Pringle K, Shah SP, Umulisa I, et al. Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea. Int J Emerg Med. 2011;4:58. Published 2011 Sep 9. doi:10.1186/1865-1380-4-58
  7. Tomasik E, Ziółkowska E, Kołodziej M, Szajewska H. Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis. Aliment Pharmacol Ther. 2016;44(5):438-446. doi:10.1111/apt.13728Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr. 2015;166(4):908-16.e166. doi:10.1016/j.jpeds.2014.12.029
  8. Goldman RD. Zinc supplementation for acute gastroenteritis. Can Fam Physician. 2013;59(4):363-364.
  9. Cameron D, Hock QS, Kadim M, et al. Probiotics for gastrointestinal disorders: Proposed recommendations for children of the Asia-Pacific region. World J Gastroenterol. 2017;23(45):7952-7964. doi:10.3748/wjg.v23.i45.7952

Additional Resources

King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

More dehydration content on iem-student.org

Question Of The Day #100

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most appropriate next step in management for this patient’s condition?
  • A) Start 1 Liter of normal saline
  • B) Consult gastroenterology for emergent endoscopy
  • C) Consult surgery for gastrectomy
  • D) Administer 1gm of Ceftriaxone

This patient arrives to the Emergency department with 1 week of melena and fatigue.  His medication list includes an antiplatelet and an anticoagulant medication.  There is tachycardia and melena noted on examination.  This patient likely has an upper GI bleed based on his signs and symptoms with peptic ulcer disease as the most common cause.  The patient’s anticoagulation serves as a risk factor for GI bleeding and is an important contributing factor in this scenario.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Gastroenterology consultation for emergent endoscopy (Choice B) is not necessary as the patient is not acutely unstable.  He may need a diagnostic and therapeutic endoscopy during an inpatient admission, but the GI consultants do not need to be called emergently for this procedure.  An acutely unstable upper GI bleed patient, such as a patient with hemodynamic instability, requiring intubation for airway protection, receiving multiple blood product transfusions, or with brisk (rapid) bleeding on exam should prompt GI consultation for an emergent endoscopy for source control.  Surgery consultation for gastrectomy (Choice C) is not a first-line treatment for upper GI bleeding.  Gastroenterology should first perform a diagnostic and therapeutic endoscopy for most upper GI bleed patients.  Surgical esophageal transection, gastrectomy, colectomy, and other surgical procedures are last resort measures to control GI bleeding.  Administration of IV Ceftriaxone (Choice D) is not needed in this scenario and should not be given routinely in upper GI bleeds.  This patient has no infectious signs or symptoms.  Antibiotics, such as Ceftriaxone or quinolones, should be given to upper GI bleed patients with chronic liver disease (i.e., cirrhosis), or presumed gastroesophageal variceal bleeds.  Antibiotics have been found to have a mortality benefit in this patient population with GI bleeds. 

The best next step in management is to treat the patient’s tachycardia with normal saline (Choice A) for volume resuscitation.  This patient may eventually need blood products, but crystalloid IV fluids are okay to start until the Complete Blood Count results return.  This patient is not in overt hemorrhagic shock, so blood products can be held until there is evidence that the hemoglobin is below 7g/dL.  Reversal of the patient’s anticoagulation with Vitamin K and fresh frozen plasma may also be needed depending on the INR level.  Reversal can wait until coagulation studies are complete since the patient is not acutely unstable. An unstable patient should have their anticoagulant reversed immediately. Correct Answer: A

Want Another Question?

References

 
 
[cite]

Question Of The Day #99

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Complete Blood Count

Result

(Reference Range)

BUN

36.2

5 -18 mg/dL

Creatinine

1.1

0.7 – 1.2 mg/dL

Hemoglobin

9.2

13.0 – 18.0 g/dL

Hematocrit

27.6

39.0 – 54.0 %

Which of the following is the most appropriate advice for this patient’s condition?
  • A) Discharge with gastroenterology follow up in 1 week
  • B) Discharge with instructions to return if repeat hematemesis episodes
  • C) Place a Sengstaken-Blakemore tube
  • D) Admit for monitoring and endoscopy

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Glasgow-Blatchford Score

 

A validated risk stratification tool for patients with upper GIB

Scoring Criteria

Numerical Score

BUN (mg/dL)

<18.2

18.2-22.3

22.4-28

28-70

>70

 

0

+2

+3

+4

+6

Hemoglobin (g/dL) for men

>13

12-13

10-12

<10

 

0

+1

+3

+6

Hemoglobin (g/dL) for women

>12

10-12

<10

 

0

+1

+6

Systolic blood pressure (mmHg)

>110

100-109

90-99

<90

 

0

+1

+2

+3

Other criteria

Pulse >100 beats/min

Melena present

Syncope

Liver disease history

Cardiac failure history

 

+1

+1

+2

+2

+2

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).

Want Another Question?

References

[cite]

Question Of The Day #98

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most likely cause for this patient’s condition?
  • A) Fatty meals
  • B) Bacteremia
  • C) Systemic steroids
  • D) Acetaminophen use

This man presents to the Emergency department with epigastric pain and hematemesis.  His exam shows hypotension, tachycardia, pale conjunctiva, and a tender epigastrium and left upper quadrant.  This patient likely has an upper GI bleed based on his signs and symptoms. 

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Risk factors for GI bleeds include alcohol use, anticoagulant use, NSAID (non-steroidal anti-inflammatory drug) use (i.e., ibuprofen, aspirin, naproxen), recent gastrointestinal surgery or procedures, prior GI bleeds, and a history of conditions that are associated with GI bleeds (i.e., gastritis, peptic ulcers, H. Pylori infection, ulcerative colitis, Chron’s disease, hemorrhoids, diverticulosis, or GI tract cancers).  Fatty meals (Choice A) can trigger gastroesophageal reflux disorder (GERD) symptoms or biliary colic symptoms from cholelithiasis.  However, fatty meals do not increase the risk for GI bleeding.  Physiological stress, such as sepsis or bacteremia (Choice B), can increase the risk for GI bleeding.  This patient does not have any infectious exam signs or symptoms that would support the presence of bacteremia. Acetaminophen use (Choice D) can cause liver failure if taken in excess, but acetaminophen does not cause GI bleeding.  NSAIDs, unlike Tylenol, are associated with GI bleeding. 

Systemic steroid use (Choice C) can increase the risk for GI bleeding and is the likely cause of this patient’s upper GI bleed. Correct Answer: C

Want Another Question?

References

[cite]

Question Of The Day #97

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most appropriate next step in management for this patient’s condition?
  • A) Place Sengstaken-Blakemore tube
  • B) Administer IV Pantoprazole
  • C) Perform endotracheal intubation
  • D) Perform cricothyrotomy

This patient arrives to the Emergency department after multiple episodes of hematemesis.  Her exam shows tachycardia, borderline hypotension, and mild tachypnea.  While in the Emergency department the patient decompensates after more hematemesis episodes and develops altered mental status.  This patient has an upper GI bleed most likely from a gastroesophageal variceal bleed.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

This patient with a depressed mental status needs to have a definitive airway established to prevent aspiration with bloody vomitus.  IV Pantoprazole (Choice B) is used in upper GI bleeds from peptic ulcers but has no role in this acutely ill variceal bleed patient.  The airway should be established prior to medications, such as pantoprazole are considered.  A cricothyrotomy (Choice D) would establish an airway, but this is an invasive approach to airway management and not the best approach in this patient.  A cricothyrotomy involves piercing a needle or scalpel in the anterior neck (cricothyroid membrane) to establish an airway surgically.  This procedure is performed in special situations where a patient cannot be intubated through the trachea (i.e., angioedema of the lips and tongue, facial mass, facial trauma) and cannot ventilate independently (i.e., depressed mental status).  This patient does not meet the criteria for this invasive procedure.  Endotracheal intubation should be attempted first on this patient.  A Sengstaken-Blakemore tube (Choice A) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Once placed correctly, the balloons on the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube should be placed only after intubating a patient and is used as a last resort measure prior to endoscopic treatment.  The best next step in management of this patient is to perform endotracheal intubation (Choice C) for airway protection. Correct Answer: C

Want Another Question?

References

[cite]

Question Of The Day #96

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Which of the following is the most appropriate next step in management for this patient’s condition?
  • A) Abdominal paracentesis
  • B) IV Ceftriaxone
  • C) IV Tranexamic acid
  • D) General surgery consultation

This patient arrives to the Emergency department with upper abdominal pain and hematemesis.  The exam demonstrated hypotension, tachycardia, pale conjunctiva, and abdominal ascites. The patient decompensates during the exam requiring endotracheal intubation for airway protection. This patient has an upper GI bleed most likely from gastro-esophageal varices given her history of liver cirrhosis and stigmata of chronic liver disease.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  First line antibiotics are IV ceftriaxone or IV ciprofloxacin.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  

An abdominal paracentesis (Choice A) is not the best next step in this unstable cirrhotic patient.  Antibiotics are routinely given in gastro-esophageal variceal bleeds due to their mortality benefit, so there is no need for an emergent paracentesis to evaluate for spontaneous bacterial peritonitis (SBP) with an ascitic fluid sample. IV Tranexamic acid (Choice C) is an anti-fibrinolytic agent with pro-coagulative effects.  Its use is recommended in post-partum hemorrhage and traumatic hemorrhages, but it has no utility in the setting of GI bleed.  Early gastroenterology consultation for endoscopy is preferred over general surgery consultation (Choice D).  Surgery consultants can assist in a TIPS procedure (Transjugular intrahepatic portosystemic shunt) to reduce portal hypertension, esophageal resection, or gastrectomy, but less invasive endoscopic therapies with GI specialists are preferred over these procedures.

IV Ceftriaxone (Choice B) is the best next step in this scenario due to the mortality benefit of antibiotics in chronic liver disease patients with variceal bleeds.      

Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

    

Want Another Question?

References

[cite]

Question Of The Day #95

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Complete Blood Count

Result

(Reference Range)

WBC Count

16.2

4.0 – 10.5 X 103/mL

Hemoglobin

10.8

13.0 – 18.0 g/dL

Hematocrit

32.4

39.0 – 54.0 %

Platelets

220

140 – 415 x 103/mL

Which of the following is the most likely diagnosis for this patient’s condition?

  • A) Diverticulosis
  • B) Colon malignancy
  • C) Ischemic colitis
  • D) Ulcerative colitis

This patient arrives to the Emergency department with bright red bloody stools and lower abdominal pain.  The exam shows fever, tachycardia, and left-sided abdominal tenderness.  The laboratory results provided show leukocytosis and anemia.  This patient likely has a lower GI bleed based on her signs and symptoms.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices provided are causes of lower GI bleeding and are possible in this patient.  However, that patient’s signs, symptoms, and risk profile make certain diagnoses less likely than others.  Diverticulosis (Choice A) is the most common cause of lower GI bleeding.  Diverticulosis often occurs in older patients and should not be associated with pain or fever, which support a diagnosis of an inflammatory or infectious etiology (i.e., diverticulitis, Shigellosis, ulcerative colitis, chron’s disease, etc.).  This patient is young and has fever and leukocytosis, making diverticulosis less likely.  Colon malignancy (Choice B) is also possible but is less likely given the patient’s young age, the presence of fever, and the acute onset of symptoms over 2 days.  Colon malignancy tends to cause slow GI bleeding over a longer period of time, rather than acutely over 2 days.  Ischemic colitis (Choice C), such as mesenteric ischemia, is less likely in a young patient without any cardiac risk factors or recent abdominal surgeries. 

Ulcerative colitis (Choice D) is the most likely diagnosis in this scenario.  Peak incidence for ulcerative colitis occurs in the second and third decades of life, and women are more likely than men to have this diagnosis.  Definitive diagnosis requires a biopsy and colonoscopy, but a CT scan of the abdomen and pelvis can show findings consistent with ulcerative colitis for a new diagnosis.  Treatment of an ulcerative colitis flare includes general supportive care, IV steroids, and IV antibiotics if there is concern for a concurrent infectious process.  Intestinal perforation and toxic megacolon also should be evaluated for with CT imaging.    

Want Another Question?

References

[cite]

Question Of The Day #94

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Complete Blood Count

Result

(Reference Range)

WBC Count

4.5

4.0 – 10.5 X 103/mL

Hemoglobin

5.3

13.0 – 18.0 g/dL

Hematocrit

15.9

39.0 – 54.0 %

Platelets

138

140 – 415 x 103/mL

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Administer Platelet transfusion
  • B) IV Vitamin K and IV Fresh Frozen Plasma
  • C) IV Vitamin K only
  • D) Await INR value, and administer IV Vitamin K if INR is greater than 10

This patient arrives to the Emergency Department with bright red bloody stools in the setting of warfarin use.  His exam shows hypotension and tachycardia.  The laboratory results show a low hemoglobin and hematocrit, but no INR or other coagulation studies are provided.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, or other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia and reversal of the patient’s anticoagulation.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

This patient’s platelet level is just below the lower limit of normal, so administration of a platelet transfusion (Choice A) would not be the next best step.  Platelet administration should be considered if the platelet count is below 50,000-100,000, or if a massive transfusion protocol is initiated to prevent coagulopathy.  No INR value is provided in the question stem, but prompt reversal of warfarin should not be delayed for an INR level (Choice D).  Reversal of warfarin should be promptly initiated when a patient is unstable (i.e., hypotensive GI bleed, traumatic wound hemorrhage, intracranial bleed, etc.).  Medication reversal in these settings includes both IV Vitamin K 10mg and IV Fresh Frozen Plasma 10-20cc/kg.  IV Vitamin K helps reverse the Vitamin K antagonistic effect of Warfarin, but it does not acutely provide new Vitamin K-dependent coagulation factors (Factors X, V, II, VII).  IV Vitamin K gives the liver the ‘materials’ needed to regenerate these coagulation factors, but this process takes time.  Fresh frozen plasma contains ‘ready-to-use’ coagulation factors that will help control the hemorrhage acutely.  For this reason, both Vitamin K and FFP are given together in an unstable patient.  An alternative to fresh frozen plasma (FFP) is prothrombin complex concentrate (PCC), which is a concentrated version of coagulation factors.  PCC is not broadly available in all countries, and is generally more expensive than FFP. 

The management of stable patients with a supratherapeutic INR includes holding warfarin doses and sometimes providing PO Vitamin K, depending on the INR level.  Administration of IV Vitamin K only (Choice C) is not the correct treatment in this scenario.  IV Vitamin K and IV Fresh Frozen Plasma (Choice B) is the best next step to reverse this patient’s anticoagulant. 

Want Another Question?

References

[cite]

Question Of The Day #93

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

  • A) CT Angiogram of the abdomen and pelvis
  • B) Consult gastroenterology for colonoscopy
  • C) Start IV Pantoprazole infusion
  • D) Administer Packed Red Blood Cells

This patient arrives to the Emergency Department with bright red bloody stools and generalized abdominal pain.  His exam shows hypotension, tachycardia, a diffusely tender abdomen, and pale conjunctiva.  He also takes warfarin daily for anticoagulation.  This patient is in hemorrhagic shock due to a lower gastrointestinal bleed.  This patient’s condition may be due to coagulopathy from his warfarin (i.e., supratherapeutic INR), diverticulosis, ischemic colitis (i.e., mesenteric ischemia), and other conditions.  Initial management of this unstable patient should include management of the airway, breathing, and circulation (“ABCs”).  This includes aggressive and prompt treatment of the patient’s hypotension and tachycardia.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

A CT Angiogram of the abdomen and pelvis (Choice A) may be helpful in clarifying the etiology and site of the patient’s bleeding, but this is not the best next step in management.  The patient’s shock state first should be managed prior to any imaging studies.  Gastroenterology consultation for colonoscopy (Choice B) may be important later in this patient’s management, but it is not the best next step in management. His shock state should be treated prior to calling any consultants. An IV Pantoprazole infusion (Choice C) is helpful in upper GI bleeds due to peptic ulcer disease.  Proton pump inhibitor medications, like pantoprazole, help reduce findings of ulcer bleeding during endoscopy.  Proton pump inhibitor use has been controversial in upper GI bleeds as there is no evidence that their use decreases mortality, decreases blood product requirements, or ulcer rebleeding, but these medications are often given due to their generally small risk profile.

 

The best next step for this patient in hemorrhagic shock is administration of packed red blood cells (Choice D).  He also should have reversal of his warfarin with IV Vitamin K and fresh frozen plasma to prevent continued bleeding.

Want Another Question?

References

[cite]

Question Of The Day #92

question of the day
~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

  • A) Mesenteric ischemia
  • B) Colon cancer
  • C) Peptic ulcer disease
  • D) Diverticulosis

This elderly patient arrives to the Emergency Department with painless hematochezia.  His exam shows borderline hypotension, tachycardia, and a normal abdominal exam.  This patient most likely has a lower gastrointestinal bleed based on his signs and symptoms.  A brisk (fast) upper GI bleed is also possible but is less likely.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

All choices listed above are potential causes of bright red bloody stools.  Peptic ulcer disease (Choice C) is the most common cause of upper GI bleeding worldwide, not lower GI bleeding.  However, a profusely bleeding peptic ulcer can cause rapid blood transit through the GI tract to form hematochezia rather than melena.  The patient lacks any risk factors or symptoms of peptic ulcer disease, such as upper abdominal pain, hematemesis, NSAID use, or prior H. pylori infection.  Ischemic colitis, or mesenteric ischemia (Choice A), is often associated with abdominal pain and cardiac risk factors (i.e., atrial fibrillation).  Colon cancer (Choice B) is also possible, but typically colon malignancy causes slow, chronic bleeding, rather than acute large volume bloody stools with signs of shock as in this patient.  The most common cause of lower GI bleeding worldwide is diverticulosis (Choice D).  This is the most likely diagnosis in this patient with painless hematochezia.

Want Another Question?

References

[cite]