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Long B, Gottlieb M. Emergency medicine updates: Upper gastrointestinal bleeding. Am J Emerg Med 2024; 81:116-123. [PMID: 38723362 DOI: 10.1016/j.ajem.2024.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/20/2024] [Accepted: 04/27/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician. DISCUSSION UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with UGIB.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Reddy SM, Lander AD, Stumper O, Botha P, Khan N, Pachl M. Esophago-Vascular Fistulae in Children: Five Survivors, Literature Review, and Proposal for Management. J Pediatr Surg 2023; 58:1969-1975. [PMID: 37208288 DOI: 10.1016/j.jpedsurg.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Esophago-vascular fistulae in children are almost uniformly fatal with death occurring by exsanguination. We present a single centre series of five surviving patients, a proposal for management and literature review. MATERIALS AND METHODS Patients were identified from surgical logbooks, surgeon recollection and discharge coding data. Demographics, symptoms, co-morbidities, radiology, management and follow up details were recorded. RESULTS Five patients (1M, 4F) were identified. Four were aorto-esophageal and one caroto-esophageal. Median age at initial presentation was 44 (8-177) months. Four patients had cross sectional imaging prior to surgery. Median time from presentation to combined entero-vascular surgery was 15 (0-419) days. Four patients required repair on cardio-pulmonary bypass with four undergoing staged surgical procedures. All required combined esophageal and cardio-vascular surgery. Length of PICU stay following combined surgery was 4 (2-60) days and overall hospital stay was 53 (15-84) days. Median follow up was 51 (17-61) months. Two patients had esophageal atresia and trachea-esophageal fistula managed as neonates. Three had no co-morbidities. Four had esophageal foreign bodies:1 esophageal stent, 2 button batteries, 1 chicken bone. One patient had a complication following colonic interposition. Four patients required an esophagostomy at the time of definitive surgery. All patients were alive and well at last follow up with one having successful reconnection surgery. CONCLUSION In this series, outcomes were favourable. Multidisciplinary discussion and surgery are mandatory. If hemorrhage is controlled at presentation, then survival to discharge is possible but the magnitude of surgical intervention is both significant and very high risk. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Snighda M Reddy
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Anthony D Lander
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Oliver Stumper
- Department of Cardiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Phil Botha
- Department of Cardiac Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Natasha Khan
- Department of Cardiac Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Max Pachl
- Department of Paediatric Surgery, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK.
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Tafoya LA, McGee JC, Kaisler S, Gottula AL, Lauria MJ, Braude DA. Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport. Air Med J 2023; 42:110-118. [PMID: 36958874 DOI: 10.1016/j.amj.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/31/2023]
Abstract
Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.
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Affiliation(s)
- Louis A Tafoya
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM
| | - John C McGee
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Sean Kaisler
- University of New Mexico School of Medicine, Albuquerque, NM; 306th Rescue Squadron, Davis-Monthan Air Force Base, Tucson, AZ
| | - Adam L Gottula
- Department of Emergency Medicine and Anesthesiology, The Harry Max Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Michael J Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM.
| | - Darren A Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
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Al-Taie B, Rosvall O, Larsson M, Edholm D. Button battery injury causing an aorto-oesophageal fistula in a 1-year-old child - Sengstaken-Blakemore tube, a life-saving bridge during surgery. Paediatr Int Child Health 2023; 43:19-22. [PMID: 38018156 DOI: 10.1080/20469047.2023.2277506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 10/26/2023] [Indexed: 11/30/2023]
Abstract
ABBREVIATION AEF: aorto-oesophageal fistula;BB: button battery;CTA: computed tomography angiography;ER: emergency room;GI: gastro-intestinal;SBT: Sengstaken-Blakemore tube.
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Affiliation(s)
- Baraa Al-Taie
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Oda Rosvall
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Magnus Larsson
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - David Edholm
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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A Model for Early Endoscopic Detection of High-Risk Gastroesophageal Varices in Children With Biliary Atresia. J Pediatr Gastroenterol Nutr 2022; 74:643-650. [PMID: 34984987 DOI: 10.1097/mpg.0000000000003375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE In children with biliary atresia and portal hypertension, progression to gastroesophageal varices carrying a risk of bleeding depends on age, total serum bilirubin concentration and initial endoscopic features. We report an attempt to use these factors for early detection of high-risk varices (HRVs). METHODS Based on different combinations of these factors, a model was set to estimate the probabilities of emergence of HRVs at various time intervals. A 10% probability was chosen to set the date of the next endoscopy in children who did not display HRVs initially. A total of 113 children without HRVs who underwent their first endoscopy before age 8 in 2013-2020 were included. A comparison was made with children seen during the period 1990-2012 when this model was not used. RESULTS In all, 65 of the 113 children underwent one to five additional endoscopies at dates set according to the model. The emergence of HRVs was recorded in 22 children after a mean interval of 14 months and was managed by endoscopic primary prophylaxis in all but one who underwent liver transplantation. Three other children bled before the next planned endoscopy. Compared with 175 children of the same age ranges without HRVs in the period 1990-2012, the use of the model was associated with a faster detection of HRVs with a lower number of endoscopic procedures (P = 0.0022 and P = 0.023, respectively). CONCLUSION The results suggest that the model reported may be a useful tool for the early detection of HRVs to allow primary prophylaxis of bleeding.
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Bridwell RE, Long B, Ramzy M, Gottlieb M. Balloon Tamponade for the Management of Gastrointestinal Bleeding. J Emerg Med 2022; 62:545-558. [PMID: 35065859 DOI: 10.1016/j.jemermed.2021.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/26/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid intervention. In critically ill patients who are refractory to other therapies, balloon tamponade devices can be lifesaving. OBJECTIVE We provide a review of balloon tamponade devices for gastric and esophageal variceal bleeding for emergency clinicians. DISCUSSION Balloon tamponade is intended for hemodynamically unstable patients with massive gastrointestinal bleeding and inability to perform endoscopy, failed endoscopy, delay in endoscopy, or the need to stabilize before transfer. There are 3 main tamponade devices: the Linton-Nachlas tube, the Sengstaken-Blakemore tube, and the Minnesota tube. Each tamponade device has some unique features including the number of balloons and ports. We describe the technique with pearls and pitfalls for placement. CONCLUSIONS It is essential for emergency physicians to be familiar with balloon tamponade for acute gastrointestinal bleeding. We review the common balloon tamponade devices, and this article is intended to serve as a resource for those interested in expanding their knowledge of balloon tamponade. © 2022 Elsevier Inc.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Mark Ramzy
- Department of Emergency Medicine and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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There Is No Excuse for Mortality Due to Lack of Competency and Training of Paediatric Endoscopists in Gastrointestinal Bleeding Therapy in 2018. J Pediatr Gastroenterol Nutr 2018; 67:684-688. [PMID: 30211844 DOI: 10.1097/mpg.0000000000002148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute upper gastrointestinal bleeding in children is possibly the last medical emergency which continues to lead to the death of a child due to the lack of competency/clinical judgement of the doctor, as opposed to the disease itself, leading to mortality despite optimum medical intervention. This is unacceptable in any circumstances in 2018. It occurs due to a number of conspiring factors including lack of appreciation of the clinical presentation requiring urgent endoscopic intervention; misapprehension of the urgency of timing required of such an intervention predicated on the severity of the gastrointestinal (GI) bleed; lack of application of a paediatric-specific validated score predicting for such endoscopic intervention; lack of skill in endo-haemostatic intervention techniques by paediatric endoscopists; poor training in such techniques among paediatric endoscopists; paucity of cases with lack of exposure of the paediatric endoscopist regularly to enable skills to be maintained, once acquired; reluctance of adult endoscopists in many centres to support paediatric GI bleeding services. In essence then the paediatric GI community urgently needs to identify centres of excellence to whom these children should be transferred. Transfer is safe in all but the most critical cases once stabilised with transfusion, octreotide/terlipressin and iv proton pump inhibitors. The resources are country-dependent but this is really no excuse. We must not let this parlous state of affairs continue. Solutions are explored in this article and please let this serve as a call to action for all those involved in this continuing debacle in order to save "save-able" lives.
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Sengstaken-Blakemore Tube: an extra mile. Int J Pediatr Adolesc Med 2017; 4:141-143. [PMID: 30805519 PMCID: PMC6372569 DOI: 10.1016/j.ijpam.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 09/25/2017] [Accepted: 10/11/2017] [Indexed: 12/22/2022]
Abstract
Upper gastrointestinal bleeding (UGIB) in children has multiple etiologies but fortunately is not encountered commonly by pediatricians. Aorto-esophageal fistula (AEF) in children is a rare cause of UGIB and it is mainly secondary to accidental ingestion of foreign bodies, particularly disc batteries, or after cardiothoracic surgery. In this study, we report a case of a 3-year-old child who developed de novo AEF with no prior injury to the esophagus. The child presented with massive UGIB leading to hypovolemic shock, acute kidney injury, and cardiac arrest. The torrential bleed was controlled using a Sengstaken–Blakemore Tube (SBT), which allowed urgent chest CT angiography as well as subsequent thoracotomy and repair of the fistula Unfortunately, the child succumbed to repeated cardiac arrests secondary to the renal injury and severe acidosis. This case highlights the need for the early recognition of massive UGIB in children and the requirement to make appropriately sized SBTs available in all pediatric gastroenterology units.
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Thomson M, Belsha D. Endoscopic management of acute gastrointestinal bleeding in children: Time for a radical rethink. J Pediatr Surg 2016; 51:206-10. [PMID: 26703435 DOI: 10.1016/j.jpedsurg.2015.10.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 10/30/2015] [Indexed: 12/13/2022]
Abstract
Currently we are no nearer than 10 or 20years ago providing a safe, adequate, and effective round-the-clock endoscopic services for acute life-threatening gastrointestinal bleeding in children. Preventable deaths are occurring still, and it is a tragedy. This is owing to a number of factors which require urgent attention. Skill-mix and the ability of available endoscopists in the UK are woeful. Manpower is spread too thinly and not concentrated in centers of excellence, which is necessary given the relative rarity of the presentation. Adult gastroenterologists are increasingly reticent regarding their help in increasingly litigious times. Recent work on identification of those children likely to require urgent endoscopic intervention has mirrored scoring systems that have been present in adult circles for many years and may allow appropriate and timely intervention. Recent technical developments such as that of Hemospray® may lower the threshold of competency in dealing with this problem endoscopically, thus allowing lives to be saved. Educational courses, mannequin and animal model training are important but so will be appropriate credentialing of individuals for this skill-set. Assessment of competency will become the norm and guidelines on a national level in each country mandatory if we are to move this problem from the "too difficult" to the "achieved". It is an urgent problem and is one of the last emergencies in pediatrics that is conducted poorly. This cannot and should not be allowed to continue unchallenged.
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Affiliation(s)
- Mike Thomson
- Centre for Paediatric Gastreonterology, Sheffield Children's Hospital, UK.
| | - Dalia Belsha
- Pediatric Gastroenterology Registrar, Sheffield Children's Hospital, UK
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