Hematemesis in Infants

Abstract

Objectives: Infantile acute upper gastrointestinal bleeding involves a decision for therapeutic intervention that most pediatricians first coming into contact with the patient are, not unreasonably, unable to objectively provide. Therefore, some objective tools of individual risk assessment would seem to be crucial. The principal aim of the present study was to investigate the anamnestic and clinical parameters of infants with hematemesis, together with laboratory and instrumental findings, to create a scoring system that may help identify those infants requiring an appropriate and timely application of upper gastrointestinal (GI) endoscopy.Methods: Clinical data of infants admitted for hematemesis to the participating centers over the study period were systematically collected. According to the outcome dealing with rebleeding, need for blood transfusion, mortality, finding of GI bleeding lesions, or need for surgical intervention, patients were blindly divided into a group with major clinical severity and a group with minor clinical severity. Univariate and multivariate logistic regressions were conducted to investigate significant prognostic factors for clinical severity.Results: According to our findings, we drafted a practical diagnostic algorithm and a clinical score able to predict the need for timely upper GI endoscopy (BLOVO infant score). Our clinical scoring system was created by incorporating anamnestic factors, clinical parameters, and laboratory findings that emerged as predictors of a worst outcome. Conclusions:We provided the first objective tool of individual risk assessment for infants with hematemesis, which could be very useful for pediatricians first coming into contact with the patient in the emergency department.

Gastrointestinal bleeding in children: diagnostic approach

“…Rarely, hematemesis can be the result of submucosal masses that, eroding mucosa, can bleed (stromal tumors, gastroduodenal duplications), or hemangiomas and Dieulafoy lesions (aberrant submucosal artery protruding through a minute defect in the mucosa, provoking a massive bleeding) [ 10 , 22 , 28 , 29 ].…”

“…Children who presented with hematemesis but appear in good general conditions, and in which routine exams have turned negative, can be discharged with prescription of oral proton pump inhibitors and followed as outpatients. Conversely, children younger than one year old or children who presented with significant bleeding or physical or biochemical findings suggestive of portal hypertension should be hospitalized to undergo esophagogastroduodenoscopy (EGDS) [ 10 , 22 ]. At the same time, all neonates with hematemesis should be screened for coagulopathy due to vitamin K deficiency, maternal thrombocytopenic purpura, hemophilia, and von Willebrand disease [ 10 ].…”

“…EGDS is the gold standard procedure to evaluate children with hematemesis [ 2 ]. It aims to identify sources of bleeding, diagnose the underlying cause, assess bleeding risk, and potentially administer endoscopic therapy [ 22 ]. Emergency EGDS (as soon as the patient is stable) is necessary only if the bleeding persists and is associated with hemodynamic instability that does not respond to blood transfusion.…”

“…To distinguish between fetal and maternal origin of blood, the Apt-Downey test can be performed. It exploits the different denaturing properties of fetal and maternal hemoglobin in the presence of sodium hydroxide [ 3 , 11 , 16 , 22 ]. Blood is mixed with a small amount of sterile water to cause hemolysis of red blood cells, producing free hemoglobin.…”

“…The sample is then centrifuged, and the supernatant mixed with 1% sodium hydroxide (NaOH). The fluid color, assessed after 2 min, will remain pink in case of fetal hemoglobin, while it will turn yellow- brown in case of adult hemoglobin because the latter one is less stable and will convert to hematin [ 10 , 22 ].…”