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<< Gastrointestinal Bleeding: An Evidence-Based ED Approach To Risk Stratification

Special Circumstances

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Special Circumstances

Special Circumstances

Chronic Alcoholics And Cirrhotic Patients

Cirrhotic patients with GI bleeding represent a group at much higher risk for mortality and, as such, warrant special attention.90,121,122 Variceal bleeding in cirrhotic patients can be massive and very difficult to control. Hence, urgent endoscopy is usually indicated in any cirrhotic patient presenting with suspected GI bleeding. The presence of encephalopathy, the severity of the bleeding, and the time between clinically overt bleeding and treatment have been identified as the main predictive factors of failure to control bleeding.123

In addition to the control of variceal bleeding, subsequent bacterial infections are a major cause of
morbidity in these patients. Empiric antibiotic prophylaxis with ciprofloxacin has been shown to be effective in increasing short-term survival in cirrhotic patients with variceal bleeding.124-126

HIV Disease

Although patients with HIV disease may experience GI bleeding from the typical causes, these patients may have conditions that are rare in patients without HIV.34 It appears that the most common causes of upper GI bleeding in patients with HIV disease are peptic ulcers and Kaposi's sarcoma.127 Although much less common than upper GI bleeding, lower GI bleeding in HIV patients is most commonly due to cytomegalovirus colitis, idiopathic colitis, colonic ulcers, lymphoma, and intestinal Kaposi's sarcoma.128,129 Besides anemia, thrombocytopenia, endoscopic stigmata of hemorrhage, and comorbid illnesses (see Table 1), the presence of lymphoma, in particular, has been identified as an independent risk factor for rebleeding and mortality in patients with HIV disease.127,129



Pediatric Gastrointestinal Bleeding

Pediatric GI bleeding is, in many ways, a different clinical entity than GI bleeding in adults. A clinically useful discussion of GI bleeding in infants and young children is beyond the scope of this review. The differences primarily revolve around the etiology of GI bleeding in the different age groups. Ulcers may be seen in children in the community, but they are more commonly seen in children already in an intensive care setting for other major physiologic derangements (e.g., burns, trauma, sepsis).130 Esophageal varices are seen in young children but are typically due to biliary atresia, neonatal hepatitis, congenital hepatic fibrosis, and cystic fibrosis, as opposed to adult varices, which are often due to the chronic effects of alcoholism.130 Lower GI bleeding in young children also exists, but this is due to a different set of conditions than in adults. In neonates who have been born outside of the hospital (home births), vitamin K deficiency may cause a coagulopathy that reveals itself as ecchymosis, petechiae, and bloody stools.130 Whereas diverticular disease and colon malignancies are relatively common in older adults, these conditions are just not seen in children. Much more common conditions in infants and young children include anal fissures, milk allergy, Meckel's diverticulum, intussusception, juvenile polyps, and infectious diarrhea.130

The different etiologies seen in adults with GI bleeding and children with GI bleeding strongly suggests that the approach is different. It is probably prudent for emergency physicians unfamiliar with pediatric GI bleeding to obtain phone consultation with a pediatric gastroenterologist or pediatric emergency physician to assist with management when confronted with these cases.

Publication Information
Authors

John L. Westhoff; Kurtis R. Holt

Publication Date

March 1, 2004

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