by Katie Donnelly, Children’s National
with Emily Willner, Children’s National

The Case
6 year old male with history of asthma, pneumonia x 2 who presents with hematemesis at 2AM on a Friday night. Challenges of this case include diagnosis/treatment of acute hematemesis with anemia.

Here’s How You Answered Our Questions

Denouement
The case was discussed with GI, and they did not feel that an emergent upper endoscopy was needed.  The patient was started on an IV PPI and admitted to the PICU, where he stabilized over the next two days.  Endoscopy performed shows multiple varices, some of which were banded. Then, the patient had recurrence of GI bleeding and was started on an octreotide drip.  CTA of the abdomen showed numerous esophageal, gastric and rectal varices and a lack of spleen.  Suspicion is splenic vein thrombosis leading to portal hypertension and varices. Patient was discharged with plan for a possible meso-caval shunt in the future.

Teaching Points

–Rarely is GI bleeding emergent enough to require an endoscopy immediately, especially if the patient is or becomes hemodynamically stable.

–NG placement is recommended for diagnosis but most providers have found it less than useful in actual practice.