Gastro-Intestinal Haemorrhage

GI haemorrhage require prompt diagnosis and treatment, which can eventually include surgical interventions. Haemorrhage in immunocompromised patients may result from different aetiologies. 

Mucosal ulceration, gastritis or esophagitis are frequent causes of bleeding, provoked by oesophageal varices associated with portal hypertension or Mallory-Weiss caused by repeated emesis.  Necrotizing pancreatitis can also explain bleeding.

Primary GI tumors can cause haemorrhage by vascular infiltration or indirect damage due to infarctions or lacerations. Radiation therapies can induce inflammatory and vascular changes that may lead to haemorrhage.

Certain infections are associated with GI bleeding, including: Candida spp., viruses like herpes virus, C. difficile and Cryptosporidium (all of them infections related to the immunocompromised state associated with the underlying disease and its treatment).

Entities frequently present in certain malignancies, like DIC, coagulopathy and thrombocytopenia, contributes to GI bleeding. Some drugs commonly used for managing symptoms, like nonsteroidal anti- inflammatory drugs (NSAIDs) increase the risk of bleeding.

The indication for proton pump inhibitors or H2 blockers plays a role in the prevention of GI bleeding due to specific local causes.

Clinical picture

Symptoms include pain, hematemesis, melena or haematochezia, and anaemia-induced symptoms and signs such as fatigue, headache, dizziness, syncope, dyspnoea, pallor, and oliguria. The patient might present in shock, thus considered as medical emergency that prompt immediate action and management.

Oesophageal varices

Initial management

• CBC, PT, PTT ,Blood type and cross matching
• Bed elevation 30-40 degrees
• Volume expansion with normal saline
• Correction of anemia
• Febrile patients should receive broad spectrum Abs
• NGT and Gastric lavage

Emergent treatment

• Systemic infusion of vasopressin.
• Endoscopic variceal ligation or sclerotherapy.
• Balloon tamponade with a sengstaken-blakmore tube.

Upper gastrointestinal haemorrhage

Children with cancers are prone to multiple shallow gastric and duodenal ulcers.

• High dose steroids
• High dose irradiation
• Chemotherapy induced emesis can cause Mallory-Weiss tears (mucosal laceration at gastro-oesophageal junction)

Management

Prophylactic antacids, H2 blockers, proton pump inhibitors are recommended.

• H2 blockers, proton pump inhibitors, lavage, correction of thrombocytopenia & coagulopathy.
• Endoscopy for uncontrolled bleeding.
• Surgery for persistent bleeding should be individualized.

Lower gastrointestinal haemorrhage

References

• Kaste SC, Rodriguez-Galindo C, Furman WL (1999) Pictorial essay: imaging pediatric oncologic emergencies of the abdomen. AJR Am J Roentgenol 173:729–736
• Pizzo PA (2021) Management of oncologic emergencies. In: Lanzkowsky P (ed) Manual of pediatric hematology and oncology, 8th edn. Elsevier, San Francisco
• Fisher MJ, Rheingold SR (2011) Oncologic emergencies. In: Pizzo PA, Poplack DG (eds) Principles and practice of pediatric oncology, 6th edn. Lippincott Williams & Wilkins, Pennsylvania