What is the differential diagnosis (Dx) of life-threatening hematemesis in a 20-month-old child?

Differential Diagnosis of Life-Threatening Hematemesis in a 20-Month-Old

In a 20-month-old child presenting with life-threatening hematemesis, the most critical diagnoses to consider are esophageal varices from portal hypertension, severe gastritis or peptic ulcer disease, Mallory-Weiss tear, coagulopathy (including thrombocytopenia), and ingestion of caustic substances or foreign bodies.

Immediate Life-Threatening Causes

Variceal Bleeding

• Portal hypertension with esophageal varices represents the highest mortality risk in pediatric upper GI bleeding, with mortality rates approaching 30% compared to 10% for non-variceal causes 1
• Consider underlying liver disease, portal vein thrombosis, or congenital portosystemic shunts 2
• Variceal bleeding requires aggressive hemostatic resuscitation with blood products and early endoscopic intervention 2

Coagulopathy and Thrombocytopenia

• Severe thrombocytopenia (platelet count <20,000/mm³) with mucosal bleeding requires immediate hospitalization and intervention 3, 4
• Life-threatening bleeding in thrombocytopenia mandates platelet transfusions, high-dose parenteral glucocorticoids (30 mg/kg methylprednisolone daily for 3 days), and intravenous immunoglobulin 3, 5
• Consider immune thrombocytopenic purpura (ITP), leukemia, aplastic anemia, or disseminated intravascular coagulation 3
• Intracranial hemorrhage occurs in 0.1-0.5% of children with ITP but is rare with platelet counts >20,000/mm³ 6

Peptic Ulcer Disease and Severe Gastritis

• Stress ulceration or Helicobacter pylori-related disease can cause significant bleeding in toddlers 2
• Non-steroidal anti-inflammatory drug exposure should be investigated 2
• Endoscopy with combination therapy (epinephrine injection plus cautery, hemoclips, or hemospray) is the definitive treatment 2

Mallory-Weiss Tear

• Mucosal laceration at the gastroesophageal junction from forceful vomiting or retching 2
• More common in older children but can occur in toddlers with severe vomiting episodes 2
• Usually self-limited but can cause significant hematemesis requiring endoscopic intervention 2

Additional Critical Considerations

Caustic Ingestion

• Accidental ingestion of household cleaners or chemicals causing esophageal or gastric injury 2
• Peak incidence in children aged 1-3 years due to exploratory behavior 2
• Requires urgent endoscopy to assess extent of injury and guide management 2

Foreign Body Ingestion

• Sharp objects or button batteries causing mucosal erosion and bleeding 2
• Button batteries can cause catastrophic vascular injury within hours 2
• Urgent endoscopic removal is mandatory for esophageal button batteries 2

Vascular Malformations

• Dieulafoy lesion or arteriovenous malformations are rare but can cause massive bleeding 2
• Consider in cases without obvious mucosal lesions on endoscopy 2

Trauma-Related Bleeding

• Blunt abdominal trauma or child abuse causing gastric or esophageal injury 7
• Splenic trauma with hemobilia is rare but possible 3
• Traumatic hemorrhage requires hemostatic resuscitation with transfusion threshold of hemoglobin 7 g/dL 2, 7
• Transfusion of >20 mL/kg of blood products within one hour indicates life-threatening hemorrhage requiring massive transfusion protocol activation 8

Initial Stabilization Priorities

Airway and Hemodynamic Management

• Protect the airway immediately in any child with active hematemesis to prevent aspiration 2, 7
• Administer three boluses of 20 mL/kg crystalloid before blood product replacement 3
• Maintain hemoglobin threshold of 7 g/dL for transfusion in non-massive bleeding 2
• For massive hemorrhage (>20 mL/kg products in 1 hour), activate massive transfusion protocol with 1:1:1 ratio of packed red blood cells, plasma, and platelets 3, 8

Diagnostic Approach

• Endoscopy within 36 hours maximizes diagnostic and therapeutic success rates 1
• Endoscopy should be performed urgently in hemodynamically stable patients after resuscitation 2
• Combinations of hemostatic therapies (epinephrine injection plus mechanical or thermal therapy) are superior to monotherapy 2

Common Pitfalls to Avoid

• Delaying endoscopy beyond 36 hours significantly reduces diagnostic yield and therapeutic success 1
• Failing to consider coagulopathy in a bleeding toddler—always check complete blood count with platelet count and coagulation studies 3
• Underestimating blood loss in small children—65% of hemorrhages stop spontaneously, but 25% rebleed within 2 days and 10% have persistent bleeding 1
• Missing child abuse as the underlying cause of trauma-related bleeding 7
• Administering excessive crystalloid leading to hemodilution and worsening coagulopathy—prioritize blood products in massive hemorrhage 7, 9