Original Article

Upper Gastrointestinal Bleeding in Children in Southern

Iran
Seyed Mohsen Dehghani1, Mahmood Haghighat1, Mohammad Hadi Imanieh1 and Mahmood Reza
Tabebordbar

Departments of Pediatric Gastroenterology, 1Gastroenterohepatology Research Center, Shiraz University of

Medical Sciences, Shiraz, Iran

ABSTRACT
Objective. To find out whether the causes of upper GI bleeding in our center in a developing country differed from developed
countries.

Methods. Children presenting to our center with upper GI bleeding from March 2002 to March 2007, were retrospectively
evaluated. Informations were retrieved from patient’s history and physical examination and results of upper GI endoscopy
regarding etiology of bleeding, managements, use of medications which might predispose patient to bleeding, and the
mortality rate.

Results. From 118 children (67 boys; with age of 7.7±4.7 yrs) who underwent upper GI endoscopies, 50% presented with
hematemesis, 14% had melena and 36% had both. The most common causes of upper GI bleeding among all patients
were gastric erosions (28%), esophageal varices (16%), duodenal erosions (10%), gastric ulcer (8.5%), Mallory Weiss
syndrome tear (7.8%), duodenal ulcer (6.8%), esophagitis (1.7%) and duodenal ulcer with gastric ulcer (0.8%). The causes
of bleeding could not be ascertained in 20.5% of cases. No significant pre-medication or procedure related complications
were observed. Endoscopic therapy was performed in 13.5% of patients. In 14.4% of patients, there was a history of
consumption of medications predisposing them to upper GI bleeding. Two deaths occurred (1.7%) too.

Conclusion. The findings in the present study showed that half of upper GI bleedings in pediatric patients from south of
Iran, were due to gastric and duodenal erosions and ulcers. This study concludes that the causes of upper GI bleeding in
children in our center of a developing country, are not different from those in developed ones. [Indian J Pediatr 2009; 76 (6) :
635-638] E-mail: dehghanism @sums.ac.ir

Key words : Upper gastrointestinal bleeding; Children; Etiology; Empiric therapy

Bleeding may occur anywhere along the GI tract, which
covers a large surface area and is highly vascularized.
While GI bleeding is an alarming symptom for patients
of any age, it can cause panic for children and their care
takers. Early diagnosis and treatment of GI bleeding is
essential. The etiologies of upper GI bleeding in infants
and children include numerous causes ranging from
benign disorders which require little or no treatment, to
serious diseases which require immediate intervention.1
Common sources of upper GI bleeding in children
include mucosal lesions and variceal hemorrhage and
in intensive care settings, infections and drugs are other
possible factors.2 The most common causes of upper GI
bleeding in children are variable in different studies 3-5.
The aim of the present study was to find out the most
common causes of upper GI bleeding in children in
south of Iran and whether the causes of upper GI
bleeding are different between developing and
developed countries.
MATERIALS AND METHODS

This retrospective study was carried out on 118

Correspondence and Reprint requests : Seyed Mohsen
Dehghani, Assistant Professor of Pediatric Gastroenterology,
Department of Pediatrics, Shiraz University of Medical Sciences,
Shiraz-Iran. Tel: +98 711 6261775; Fax: +98 711 6470207,
[DOI--10.1007/s12098--009--0092--3]
[Received January 19, 2008; Accepted May 30, 2008]
consecutive children (age < 18 yrs) who were referred to
pediatric gastroenterology department affiliated to
Shiraz University of Medical Sciences, with upper GI
bleeding and underwent endoscopy from March 2002
to March 2007. The data such as age, sex, type of

Indian Journal of Pediatrics, Volume 76—June, 2009 635

 Seyed Mohsen Dehghani et al

bleeding (hematemesis, melena or both), history of
consumption of medications that predispose the
patients to GI bleeding, history of coagulation disorders,
underlying disease and the therapeutic managements
were recorded. All patients underwent upper GI
endoscopy after receiving a written consent from their
parents.
RESULTS
One hundred and eighteen patients participated in this
study (67 boys and 51 girls) with a mean±SD age of
7.7±4.7 yrs (range, 2 months-17 yrs). The mean interval
between bleeding episodes and presentation to our
center was 21.2±18.4 hrs (range, 4 hours-5 days) and
the mean interval between patients’ arrival and
performing endoscopy was 6.3±4.9 hrs (range, 30
minutes-38 hrs). Clinical presentations included
hematemesis in 50%, melena in 14.4% and both in
35.6%. Three patients had coagulation disorders (2
patients with acute leukemia and thrombocytopenia
and one case of hemophilia A) and 17 cases (14.4%)
had received aspirin (1-5 doses, as antipyretic) before
developing the upper GI bleeding. Twenty-two patients
(18.6%) had previous episodes of upper GI bleeding (2-
8 episodes).
Gastric erosion was the most common cause of
upper GI bleeding in 33(28%), followed by esophageal
varices in 19 cases (16%) (17 patients with cirrhosis
and 2 cases of non-cirrhotic portal hypertension),
duodenal erosions in 12 (10%), gastric ulcer in 10 (8.5%),
Mallory-Weiss syndrome tear in 9 (7.8%), duodenal
ulcer in 8 (6.8%), esophagitis in 2 (1.7%) and combined
gastric and duodenal ulcers in one case. Upper GI
endoscopy was normal in 24 (20.5%) cases. The causes
of upper GI bleeding in different age groups are shown
in table 1.
In 77.2% of patients, bleeding stopped
spontaneously and in 9.3% by medical therapy
(octreotide), and endoscopic therapy was used in 13.5%
(11% sclerotherapy and 2.5% variceal band ligation). In
3 patients with esophageal varices the upper GI
bleedings were mild and stopped spontaneously and
we performed variceal band ligation in an elective
condition. 9 patients (7.6%) needed blood transfusions.
None of the patients needed surgical intervention. Two
patients (1.7%) died due to severe uncontrolled upper
GI bleeding; one case of cryptogenic cirrhosis with
severe bleeding from esophageal varices and the other
was a case of Wilson disease who underwent liver
transplantation about one month before the onset of
upper GI bleeding, due to erosive gastritis.
DISCUSSION
Upper GI bleeding (bleeding arising proximal to the
ligament of Treitz) commonly presents with
hematemesis, and/or melena. A nasogastric tube

TABLE 1. Causes of Upper Gastrointestinal Bleeding in Different Age Groups

[Age group] (yrs)

Causes <1 (n=7) 1-6 (n=25) 6-12 (n=53) 12-18 (n=33)

Gastric erosions 5 (71.4%) 7 (28%) 14 (26.6%) 8 (24%)

Esophageal varices – 4 (16%) 7 (13.3%) 8 (24%)
Duodenal erosions – 1 (4%) 4 (7.5%) 6 (18%)
GU – 1 (4%) 6 (11.1%) 3 (9.5%)
Mallory-Weiss syndrome tear 1 (14.3%) 4 (16%) 4 (7.5%) –
DU – 1 (4%) 2 (3.8%) 5 (15.5%)
Esophagitis – – 1 (1.9%) 1 (3%)
GU + DU – – – 1 (3%)
Undetermined 1 (14.3%) 7 (28%) 15 (28.3%) 1 (3%)

GU: Gastric ulcer; DU: Duodenal ulcer

TABLE 2. Comparison of Results of the Present Study with Other Studies

Cause EL Mouzan Mittal SK Huang IF Present study

Saudi Arabia India Taiwan Iran

Esophagitis and Mallory-Weiss 36% 23.7% 30.4% 9.5%

syndrome tear
Esophageal varices 4.3% 39.4% 10.7% 16%
Gastric erosions 44% 7.2% 44.6% 28%
Gastric ulcer 7% 1.3% 9.8% 8.5%
Duodenal erosions – — 2.7% 10%
Duodenal ulcer – 0.4% 15.2% 6.8%
Normal 25% 25% 9.8% 20.5%

636 Indian Journal of Pediatrics, Volume 76—June, 2009

 Upper Gastrointesinal Bleeding in Children in Southern Iran
lavage that yields blood or coffee ground materials
confirms this clinical diagnosis. However, lavage may
not be positive, if bleeding has ceased or arises beyond
a closed pylorus.
The incidence of upper GI hemorrhage is not well
established in children. The most detailed studies have
been in the critical care settings.6-8 In one of the largest
prospective studies, upper GI bleeding was observed in
63 (6.4%) of 984 pediatric ICU admissions. 7 The most
common causes of upper GI bleeding in children vary
depending upon age and the geographic setting. In
western countries, the most common reported causes
are gastric and duodenal ulcers, esophagitis, gastritis
and varices, while in India, variceal bleeding
predominates.4,9-13 In this study, the most common cause
of upper GI bleeding in children was gastric erosions
which is similar to other studies.3,5 (Table 2) There are
only two reports from India in which the main cause of
upper GI bleeding in pediatric patients was esophageal
varices and thus they concluded that the cause of
upper GI bleeding is different between developed and
developing countries4,11, but the present study showed
that this conclusion is not a fact in every developing
country, because the causes of upper GI bleeding in
present study are similar to developed countries.
The present study observed cases of gastric and
duodenal ulcers with lesser frequency than Cox and
Stav series.10, 14 This difference may be due to lower age
of our patients as with increasing the age, the causes of
upper GI bleeding became more similar to adult.3, 5, 15, 16
Upper endoscopy is the diagnostic modality of
choice for upper GI bleeding. It identifies the source of
bleeding, allows for risk stratification regarding the
likelihood of continuous bleeding, and permits
therapeutic intervention. Multiple reports have
established its safety norms in children. 4, 12, 17-19 In the
present study, the cause of bleeding could not be
ascertained in 20.5% of cases. This may be due to some
delay in performing endoscopy or some cases of
esophageal or gastric erosions which got healed up
rapidly before being confirmed by endoscopy. The
overall yield of endoscopy to identify the source of
upper GI bleeding in our series is similar to the most
previous reports2-4 (Table 2). In this study, the highest
yield of endoscopy was in children older than 12 years
(97%), in contrast to El Mouzan study3 which reported a
higher yield in children below 12 yrs of age.
In this study, the causes of upper GI bleeding in
about half of the patients were gastric and duodenal
erosions and ulcers. Endoscopic therapy was used in a
small group of children with upper GI bleeding as
reported in other studies too. 20 This means that most
episodes of the upper GI bleeding in children stopped
spontaneously without any need to endoscopic or
surgical interventions. 14.4% of patients received
Indian Journal of Pediatrics, Volume 76—June, 2009
aspirin before developing upper GI bleeding. It means
that more public education and awareness about the
side effects of this medication in children is needed. The
present study concludes that the causes of upper GI
bleeding in our pediatric age group are not different
from those in developed countries.
Acknowledgements
We would like to thank Dr. Davood Mehrabani at Center for
Development of Clinical Research of Nemazee Hospital for
editorial assistance.
Contributions: Seyed Mohsen Dehghani, Research idea,
preparing proposal, collecting and analysis the data, writing and
submitting the manuscript. Mahmood Haghighat, Preparing
proposal, collecting and analysis the data, writing the
manuscript. Mohammad Hadi Imanieh, Preparing proposal,
collecting and analysis the data, writing the manuscript.
Mahmood Reza Tabebordbar, Preparing proposal, collecting and
analysis the data, writing the manuscript.
Conflict of Interest: None
Role of Funding Source: This study was supported financially
by Vice Chancellor for Research Affairs of Shiraz University of
Medical Sciences No. 85-3123.
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