Age-specific causes of upper gastrointestinal bleeding in children

Abstract

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Keywords: Age-specific; Epidemiology; Pediatric; Unusual cause; Upper gastrointestinal bleeding.

Figure 1

Anatomic locations of upper gastrointestinal bleeding in children, with corresponding common causes. CMPA: Cow’s milk protein allergy; NSAIDs: Non-steroidal anti-inflammatory drugs; PGS: Prolapse gastropathy syndrome.

Figure 2

The most common causes of upper gastrointestinal bleeding in children from 1-year-old to 3-years-old. A: Gastric ulcer in a 3-year-old boy who presented with hematemesis; B: Mallory-Weiss tear in a 3-year-old boy; C: Esophageal varices grade II in a 2-year-old boy with extrahepatic portal vein obstruction after cardiac surgery.

Figure 3

Causes of upper gastrointestinal bleeding in children older than 3-years-old. A: Erosive gastritis in a 14-year-old girl with cerebral palsy; B: Gastroesophageal varices type 2 in a 6-year-old girl with chronic liver disease due to extrahepatic portal vein obstruction; C: Macronodular gastritis in a 16-year-old girl due to Helicobacter pylori infection; D: Eosinophilic esophagitis in a 16-year-old boy; E: Gastric trichobezoar in a 9-year-old boy; F: Traumatic perforation of the duodenum as a consequence of a handlebar injury in a 6-year-old boy. The patient was referred to the hospital two days after injury and the surgery was performed on the day of admission.

Figure 4

Clinical approach to children with upper gastrointestinal bleeding. BS: Blakemore-Sengstaken; EST: Endoscopic sclerotherapy; EVL: Esophageal varices ligation; GI: Gastrointestinal; PPI: Proton pump inhibitor; TIPS: Transjugular intrahepatic portosystemic shunt; UGIB: Upper gastrointestinal bleeding; VS: Vital signs; NSAIDs: Non-steroidal anti-inflammatory drugs.