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I. PROBLEM

Vomiting of bright red blood or active bleeding from the nasogastric (NG) tube is seen in a newborn. Upper gastrointestinal (GI) bleeding is bleeding that occurs proximal to the ligament of Treitz (duodenojejunal flexure) which arises from the esophagus, stomach, or duodenum. It usually presents with hematemesis (vomiting of blood) most commonly bright red or less commonly the color of coffee grounds, or it can present with melena (black tarry stools). Rarely, a brisk upper GI (UGI) bleed has such a short intestinal transit time that it presents with hematochezia (fresh blood through the anus). Coffee ground emesis means the blood has been altered by gastric contents, which indicates slow bleeding from the esophagus and duodenum. Diagnosis is made most commonly by blood-stained aspirates in the NG or orogastric (OG) tube, by hematemesis, or by endoscopy (gastric mucosa shows bleeding). UGI bleeding is more common in sick newborns in the NICU, than in term neonates. The majority of UGI bleeds in neonates are benign, self-limiting, and require minimal workup and treatment, but some can be severe, especially those associated with other underlying conditions.

II. IMMEDIATE QUESTIONS

  1. What are the vital signs? If the blood pressure is dropping and there is active bleeding, urgent crystalloid volume replacement is necessary.

  2. Is the infant ill or well appearing? Is the bleeding mild or severe? If the infant looks well, consider swallowed maternal blood first, mild trauma from nasopharyngeal bleeding, esophagitis, or gastritis (most cases are asymptomatic), clinically relevant mucosal lesions of the upper GI tract (seen in healthy term infants), or milk protein intolerance. If the infant is severely ill (hypovolemia, shock, near death) with significant upper GI bleeding, most of these cases are related to other problems such as hypoxemia, infection, perinatal stress, respiratory failure, congenital heart disease, increased intracranial pressure. Milder bleeding: gastritis, esophagitis, milk protein intolerance. More severe bleeding: coagulopathies (VKDB), NEC, Stress ulcer.

  3. What is the hematocrit? A hematocrit should be done as soon as possible. The result is used as a baseline value and to determine whether blood replacement is needed. With any acute bleeding, the hematocrit may not reflect the blood loss for several hours.

  4. Is blood available in the blood bank should transfusion be necessary? Verify that the infant has been typed and cross-matched so that blood will be quickly available if necessary.

  5. Is there bleeding from other sites? Bleeding from other sites suggests disseminated intravascular coagulation (DIC), vitamin K deficiency bleeding, or other coagulopathy. If bleeding is only from the NG tube, disorders such as stress-related mucosal lesions, NG trauma, and swallowing of maternal blood are likely causes to consider.

  6. How old is the infant? During the first day of life, vomiting of bright red blood or the presence of bright red blood in the NG tube is frequently secondary to swallowing of maternal blood during delivery. Infants with this problem are clinically stable with normal vital signs. ...

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