What is the likely cause and management of recurrent hematemesis (vomiting blood) in a 15-year-old boy with a history of similar episodes and esophageal injury on endoscopy?

Differential Diagnosis and Management of Recurrent Hematemesis in a 15-Year-Old with Esophageal Injury

In a 15-year-old boy with recurrent hematemesis and documented esophageal injury on endoscopy, the most likely diagnoses are severe erosive esophagitis from gastroesophageal reflux disease (GERD), pill-induced esophageal ulceration, or less commonly, esophageal varices from underlying liver disease—immediate repeat endoscopy with high-dose proton pump inhibitor (PPI) therapy is indicated to assess healing and guide definitive management. 1, 2, 3

Primary Differential Diagnoses

GERD-Related Esophageal Injury (Most Likely)

• Severe erosive esophagitis is the most common cause of esophageal injury with recurrent bleeding in adolescents, accounting for 65.9% of esophageal ulcers in one large series 3
• GERD-induced esophageal ulcers typically measure 2-3 cm in size and are located in the lower thoracic esophagus in 80.3% of cases 3
• Bleeding from reflux esophagitis occurs in 8.2% of patients with GERD, with grade 3-4 esophagitis having an odds ratio of 25.5 for bleeding 4
• Critical pitfall: A history of heartburn or reflux symptoms is present in only 28-37% of patients with bleeding esophagitis, so absence of typical GERD symptoms does not exclude this diagnosis 4

Drug-Induced Esophageal Ulceration (Second Most Common)

• Pill esophagitis accounts for 22.7% of esophageal ulcers and should be strongly considered in adolescents who may take NSAIDs, antibiotics (especially doxycycline), or bisphosphonates 3
• Drug-induced ulcers average 2.92 cm in size but are more commonly located in the mid-esophagus (86.2%) rather than the lower esophagus 3
• Key distinguishing feature: Mid-esophageal ulcers have a greater tendency to hemorrhage compared to gastroesophageal junction ulcers 3

Esophageal Varices (Must Exclude)

• While uncommon in adolescents without known liver disease, variceal bleeding carries 20% mortality at 6 weeks and must be ruled out 1
• Endoscopy should specifically document presence or absence of varices, as management differs completely from non-variceal bleeding 1

Rare but Important Considerations

• Acute necrotizing esophagitis: Presents with upper GI bleeding in elderly or critically ill patients, affects lower two-thirds of esophagus in 59% of cases 5
• Infectious esophagitis: Candidal (3.4%), HSV, or HIV-related in immunocompromised patients 3
• Mallory-Weiss tear: From forceful vomiting, but typically single episode rather than recurrent 1

Immediate Management Algorithm

Step 1: Stabilization and Risk Assessment

• Hemodynamic stabilization is mandatory before endoscopy—restore intravascular volume and stabilize blood pressure 2
• Maintain hemoglobin 7-9 g/dL with restrictive transfusion strategy if variceal bleeding suspected 1, 2
• Place nasogastric tube to assess for active bleeding (prognostic value) 2

Step 2: Pharmacological Therapy (Start Immediately)

• Initiate high-dose PPI therapy immediately: 80 mg omeprazole IV bolus followed by 8 mg/hour continuous infusion for 72 hours 2, 6
• If variceal bleeding is suspected based on history or clinical presentation, start vasoactive agents (octreotide or terlipressin) immediately before endoscopy 1, 2
• Administer erythromycin 250 mg IV 30-60 minutes before endoscopy to improve visualization 2

Step 3: Urgent Endoscopy

• Perform endoscopy within 24 hours to identify bleeding source and provide therapeutic intervention 1, 2
• Endoscopy must document: exact location of injury, size of ulcer/erosion, presence of active bleeding or stigmata of recent hemorrhage, and presence/absence of varices 1
• Endoscopic therapy indications: Active bleeding (spurting or oozing), non-bleeding visible vessel, or adherent clot 1, 2

Step 4: Therapeutic Endoscopic Intervention

For non-variceal bleeding:

• Combination therapy is superior: Mechanical therapy (hemoclips) plus injection therapy (1:10,000 epinephrine) is more effective than injection alone 1, 2
• Inject 4-16 mL of epinephrine solution in quadrants around bleeding point 1
• Apply hemoclips or thermal coagulation (heater probe 20-30 joules) for definitive hemostasis 1

For variceal bleeding (if present):

• Endoscopic variceal ligation (EVL) is the treatment of choice 1
• Continue vasoactive agents for 2-5 days 1
• Initiate short-term antibiotic prophylaxis 1, 2

Follow-Up Management Based on Endoscopic Findings

If Severe Erosive Esophagitis (Grade B or Worse)

• Continue high-dose PPI therapy: Transition to oral omeprazole 40 mg twice daily for 8 weeks 1, 6
• Mandatory repeat endoscopy at 8 weeks to ensure healing and rule out Barrett's esophagus 1
• If healing is incomplete, continue PPI therapy for additional 4 weeks 1
• Long-term maintenance: Once healed, continue once-daily PPI indefinitely to prevent recurrence 1, 6

If Drug-Induced Esophageal Ulcer

• Discontinue offending medication immediately 3
• PPI therapy for 6-8 weeks to allow mucosal healing 2
• Important: Drug-induced ulcers do not typically cause strictures, unlike GERD-induced ulcers 3

If Esophageal Varices Identified

• Combination therapy with EVL plus non-selective beta-blockers (propranolol or carvedilol) to prevent rebleeding 1, 2
• Repeat EVL every 2-8 weeks until variceal eradication 1, 2
• Evaluate for underlying liver disease and portal hypertension 1

Prevention of Rebleeding

For Non-Variceal Causes

• Test for H. pylori in all patients with esophageal or gastric ulcers; eradicate if positive 2, 6
• PPI therapy for minimum 6-8 weeks, then reassess 2
• Avoid NSAIDs, aspirin, and other ulcerogenic medications 3
• Lifestyle modifications: elevate head of bed, avoid late meals, weight loss if overweight 1

For Variceal Bleeding

• Combination EVL plus non-selective beta-blockers reduces rebleeding from 64% to 30% compared to medical therapy alone 1, 2
• Periodic endoscopic surveillance to detect variceal recurrence 1

Red Flags Requiring Escalation

Indications for Rescue Therapy

• Failure of endoscopic hemostasis despite two attempts requires angiographic embolization or surgery 1, 2
• For variceal bleeding uncontrolled by endoscopy plus pharmacotherapy, TIPS placement is indicated 1, 2
• Balloon tamponade can serve as bridge therapy but should not exceed 24 hours due to risk of esophageal rupture 1, 2

Complications Requiring Surgical Consultation

• Esophageal perforation (3.4% risk with ulcers) 3, 7
• Esophageal stricture requiring repeated dilatation (12.5% of ulcer cases) 3
• Refractory bleeding despite optimal medical and endoscopic therapy 2

Special Considerations for Adolescents

• Screening for Barrett's esophagus is not indicated in patients younger than 50 years regardless of GERD symptoms 1
• Esophageal adenocarcinoma incidence is very low in younger patients, so routine cancer screening is not warranted 1
• Consider psychosocial factors: eating disorders, intentional caustic ingestion, or medication non-compliance 3
• Assess for risk factors: obesity, family history of GERD, smoking 1

The recurrent nature of this patient's bleeding mandates aggressive acid suppression, complete endoscopic evaluation with therapeutic intervention, and close follow-up to ensure healing and prevent life-threatening complications. 1, 2, 3