FIGURE 91.1 Emergency management of severe UGI bleeding The management involves a multidisciplinary approach from resuscitation, to consultation, to medications, to endoscopy if indicated Therapies for acute variceal hemorrhage include both pharmacologic and endoscopic therapy Multiple pharmacologic agents have been studied, including vasopressin, somatostatin, and octreotide While robust data is lacking in children, octreotide is the preferred initial pharmacotherapy It may be given as an initial IV loading dose of to µg/kg, followed by a to µg/kg/hr continuous IV infusion Emergency flexible esophagogastroduodenoscopy should be arranged if the patient remains hemodynamically unstable after initial pharmacologic therapies Endoscopic techniques used for acute management of variceal bleeding include endoscopic variceal sclerotherapy and band ligation Ideally, endoscopy will be performed within 24 hours ( Fig 91.1 ) PEPTIC ULCER DISEASE Goals of Treatment Peptic ulcer disease (PUD) often presents with nonspecific symptoms of abdominal pain, dyspepsia, and heartburn to varying degrees of severity In rare cases, children present with GI hemorrhage, GI perforation, or gastric outlet obstruction The primary goal of ED management is to identify the rare child with a significant complication from PUD that requires further stabilization and management (see Chapter 33 Gastrointestinal Bleeding ) In the majority of cases, once PUD is identified as a potential cause of abdominal pain, it is appropriate to initiate outpatient diagnostic testing, start a gastric antisecretory regimen, and ensure close follow-up CLINICAL PEARLS AND PITFALLS Stress-related ulcers are common causes of PUD in early infancy The most common causes of PUD in older children are Helicobacter pylori (H pylori ) and nonsteroidal anti-inflammatory drug (NSAID) usage Gastric outlet obstruction from PUD should be considered in the child with chronic nonspecific abdominal symptoms and frequent nonbilious emesis of both liquids and solids at time of presentation Proton pump inhibitors (PPIs), if discontinued abruptly, may result in rebound hypersecretion and exacerbation of symptoms Clinical Evidence While the term PUD describes a group of disorders which involves changes to the mucosal lining of the upper GI tract (esophagus, stomach, and duodenum), this section will focus on diseases of the stomach and duodenum PUD has various levels of severity with the most common causes of ulcers in stomach and duodenum being H pylori infection followed by NSAIDs and corticosteroids Less common etiologies include stress-induced gastropathy, portal gastropathy, caustic ingestion, inflammatory bowel disease (IBD), eosinophilic gastritis, Zollinger–Ellison syndrome, and other infectious (e.g., cytomegalovirus) agents Ulcer disease occurs when there is an imbalance between cytotoxic factors (e.g., acid, pepsin, NSAIDs, H pylori ) and cytoprotective factors, including the secretion of mucus and bicarbonate by superficial epithelial and mucous cells in the upper GI tract Local blood flow, delayed gastric emptying, duodenal reflux, and other factors have been suggested as important factors in the development of gastric ulceration H pylori produces a localized inflammatory reaction that contributes to epithelial damage either by direct toxic effect or via immunopathologic means H pylori infection usually occurs in childhood with earlier acquisition and higher prevalence with increasing age noted in developing countries There are higher prevalence rates among family members and institutionalized populations, suggesting person-to-person transmission via either an oral route or a fecal-to-oral route A family history of ulcer disease is typically present in 50% or more of children with duodenal ulcers Clinical Considerations Clinical Recognition Symptoms of PUD vary with the patient’s age Stress ulcers account for 80% of peptic disease in early infancy, and often present as medical emergencies Infants may present either with nonspecific feeding difficulties and vomiting, or with upper GI bleeding or perforation Nonspecific signs and symptoms predominate among older infants and preschool-aged children, with boys and girls affected equally Preschool-aged children often complain of poorly localized abdominal pain, vomiting, or GI hemorrhage, which can manifest as either hematemesis or melena Among teenagers with ulcer disease, a male predominance is seen, with boys outnumbering girls nearly 4:1 Older children and adolescents generally present with abdominal pain, which is classically described as waxing and waning, sharp or gnawing, and localized to the epigastrium It may awaken the child at night or in the early hours of the morning Other historical clues include a family history of ulcer disease and the presence of predisposing factors such as smoking or use of NSAIDs Initial Assessment/H&P History should focus on the presence of hematemesis and whether melanotic stools have been passed Identifying if risk factors (e.g., NSAID usage or personal/family history of H pylori ) or chronic GI symptoms (e.g., pain with meals) are present may also help If a gastrostomy tube is present, determining the color of any material emanating from the tube when accessed may help Physical examination may reveal orthostasis, pallor, as well as abdominal tenderness, which is poorly localized in young children, but localized to the epigastrium or to the right of the midline in older children and adolescents Stool should be tested for occult blood The remainder of the physical examination should include an oral examination looking for dental enamel erosion, which would suggest chronic gastroesophageal reflux (GER) or recurrent emesis, and an examination of the lungs for wheezing, which also might suggest bronchospasm due to or exacerbated by reflux Weight loss may be noted Management/Diagnostic Testing A CBC and fecal occult blood test are good screening tests when one is considering the possibility of significant PUD If a gastrostomy tube is present then material can be suctioned from the stomach If a gastrostomy tube is not present and there is a high suspicion without overt hematemesis then an NG ...FIGURE 91.1 Emergency management of severe UGI bleeding The management involves a multidisciplinary approach... given as an initial IV loading dose of to µg/kg, followed by a to µg/kg/hr continuous IV infusion Emergency flexible esophagogastroduodenoscopy should be arranged if the patient remains hemodynamically