Hot Seat #60: 6yo M with acute onset hematemesis
Posted on: August 31, 2015, by : Katie Donnelly MD
by Katie Donnelly, Children’s National
with Emily Willner, Children’s National
The Case
Previously healthy 6 year old male with history of asthma, pneumonia x 2 who presents with hematemesis at 2AM on a Friday night. Was in his normal state of health until this evening. Woke up from sleep and stated he felt unwell. Went to the bathroom and vomited dark red blood and “coffee grounds”, then slumped over in parents arms for 1-2 minutes, stated he felt weak and dizzy. Was brought in by ambulance to the ED. No recent travel. Denies any foreign body ingestion.
ROS: No nosebleeds, no history of easy bruising or bleeding, no history of significant abdominal pain. No fevers.
PMHx: asthma, pneumonia x 2
FHx: no liver disease, no hematologic disease or coagulopathy
Surgical Hx: none
Allergies: NKDA
PE: HR 131 BP 84/44 RR 20 T 36.4 O2 100%
GEN: Tired appearing but alert and interactive, no acute distress
HEENT: pale but moist mucus membranes, no blood at nares or in mouth, pharynx not erythematous without signs of bleeding
CV: 2+ pulses throughout, normal S1, S2, no murmur
LUNGS: CTA bilaterally
ABD: soft, NTND, normoactive bowel sounds, unable to palpate liver or spleen
SKIN: pale palms but no bruises, petechiae or purpura
You obtain IV access and labs.
Questions for you:
You elect to place an NG tube, lavage with 100 ml Normal saline. There is return of dark red blood, then the NG clots off. The patient has not had any further episode of emesis. He receives a normal saline bolus, BP improves to 100/62 with heart rate down to 110.
Your labs and X-rays are complete:
CBC: WBC 11.8 HGB 6 HCT 17.8 Plts 215 differential N 25% L 64% m 7% E 2%
COAGS: PT 20 INR 1.7 PTT 29
CHEM: Na 140 K 3.8 Cl 106 CO2 23 BUN 23 Cr 0.4 Pr 5.2 Alb 2.6 ALT 33 AST 23 Alk Phos 233 Bili 0.2
Abdominal XR: nonspecific bowel gas pattern, no free air, no foreign body
With these labs, you decide to discuss the patient with GI.
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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Hmm, extrapolating from my general EM training, low Hb, history of syncope vs near-syncope, dark red NG return, relatively short onset of symptoms concern me for UGI bleed from a significant ulcer (insert further differential here including AVM, portal HTN). After fluid resuscitation one could predict the Hb will fall. I would arrange PICU admission, transfusion and octreotide, and urgent GI consult- meaning they need to evaluate the patient in a timely fashion (though they could elect to wait till later AM to endoscope, as long as the patient remains hemodynamically stable).
Don’t forget the coagulopathy. This is NOT a simple bleeding ulcer with a PT of 20 and albumin of 2.5. This patient has a chronic disease and liver insufficiency. Normal liver enzymes argue against an auto-immune or infectious etiology.
Initially–Two large bore IVs and get an epoc/Istat so you can see the Hb and order blood. would prioritize getting the patient cryoprecipitate and prbcs. May be able to stop the bleeding with ffp/cryo. I forget if there is indication for vit k with elevated pt and normal ptt. Watch the BP and for signs of encephalopathy. Get an NH3. XR is fine but not as helpful as other things here. You know patient doesn’t have free air. I’d be surprised if this patient doesn’t have massive splenomegaly. An US wouldn’t hurt and I’d imagine if this patient did have varices that a GI doc would want evidence of portal hypertension before putting a scope in a kid with Hb of 6 and coagulopathy.
I’d guess this patient has something anatomic like a splenic artery narrowing with resultant massive splenomegaly and portal hypertension. So banding and a surgical correction +/- TIPS might be the way to go once stabilized.
Kid still capable of ingestions with unexplained hematemesis–though he denies any foreign body ingestion, I’d still have asked specifically about availability of medications and gotten an iron level with my initial set of labs. I agree with Dave, however, my money is on liver disease leading to poor synthetic function.
Even with mild coagulopathy, there ought to be some insult leading to bleed. Maybe variceal, so yes octreotide, but common things being common would drip a PPI as well. +/- antibiotics. Don’t expect to get much better corrected with products though- INR of FFP is about 1.5-1.7 to begin with- so would encourage GI not to wait for improved coags before scoping as that can be a source of unnecessary delay.