? Gastrointestinal (GI) bleeding in infants and
children is a fairly common problem,
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accounting for 10%-20% of referrals to
pediatric gastroenterologists.
Definitions
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? Melena is the passage of black, tarry stools;
suggests bleeding proximal to the ileocecal valve
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? Hematochezia is passage of bright or dark redblood per rectum; indicates colonic source or
massive upper GI bleeding
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? Hematemesis is passage of vomited material that
is black ("coffee grounds") or contains frank
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blood; bleeding from above the ligament of TreitzPATHOPHYSIOLOGY OF GI BLEED
? 1. Consequences of blood loss
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? 2. Risk of hemorrrhagic shock? 3. Compensatory mechanism
1. PATHOPHYSIOLOGIC
CONSEQUENCES OF BLOOD LOSS
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? LOSS OF FLUID(BLOOD) DEC. ECF
DEHYDRATION SHOCK DEC GFRANURIA
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PRE-RENAL A.R.F (INC. BUN AND NITROGEN)SMALL VOL CONCENTRATED URINE WITH HIGH
SPECIFIC GRAVITY
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2. Higher risk for hemorrhagic shock in
children
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?Age-dependent vital signs inaccurate
interpretation of early signs
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? High ratio surface area to body mass
limited thermoregulation hypothermia
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pulmonary HT hypoxemia acidosis? Smal er total body volume
? Lower hematocrit level
3. Sequence of compensatory
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mechanism
? Loss of less than 15% of BV is compensated
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by:? Contraction of the venous system
? Fluid shift ECFC IVFC
? Preferential direction of blood to the brain and the
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heart No hemodynamic changes
? Loss 15%-30% BV
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? Sympathetic stimulation? Secretion of aldosterone, ADH, prostaglandins
? Release of catecholamine
? Release of ACTH and corticosteroids
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Hemodynamic instabilityTachycardia, O2 consumption, tissue hypoxia
Maintain blood volume
? Loss of more than 30%
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? Hypotension (Shock), dec. cardiac output
acidosis tissue damage
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? Acute renal failure? Liver failure
? Heart failure
SYMPTOMS OF UPPER GI BLEED
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? Symptoms of upper gastrointestinal bleeding
include:
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? vomiting bright red blood (hematemesis)? vomiting dark clots, or coffee ground-like material
? passing black, tar-like stool (melena)
SYMPTOMS OF LOWER GI BLEED
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? Symptoms of lower gastrointestinal bleedinginclude:
? passing pure blood (hematochezia) or blood
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mixed in stool
? bright red or maroon blood in the stool
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? Hematemesis : 50% of upper gastrointestinalbleeding cases
? Hematochezia : 80% of all gastrointestinal
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bleeding.
? Melena
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? 70% of upper gastrointestinal bleeding? 33% of lower gastrointestinal bleeding
? To form black, tarry stools (melena), there must be
150-200 cc of blood and the blood must be in the
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gastrointestinal tract for 8 hours to turn black
CAUSES
Causes of GI bleed in neonates
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? Upper GI bleeding
? Lower GI bleeding
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? swallowed maternal? swallowed maternal blood
blood
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? dietary protein intolerance
? stress ulcers, gastritis
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? infectious colitis/enteritis? vascular malformations
? necrotizing enterocolitis
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? HDN
? Hirschsprung's enterocolitis
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? hemophilia? coagulopathy
? maternal ITP
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? vascular malformations
? maternal NSAID use
Causes of GI bleed in infants
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? Hematemesis, melena
? Hematochezia
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? Esophagitis? Anal fissures
? Gastritis
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? Intussusception
? Duodenitis
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? Infectious colitis/enteritis? Coagulopathy
? Dietary protein intol.
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? Meckel's diverticulum? Vascular malformation
? Coagulopathy
Causes of GI Bleed in Children 1 -12 yrs
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? Upper GI bleeding
? Lower GI bleeding
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? Esophagitis? Anal fissures
? Gastritis
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? Infectious colitis
? Polyps
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? Peptic ulcer disease? Lymphoid nodular
? Mallory-Weiss tears
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hyperplasia
? Esophageal varices
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? IBD? Pill ulcers
? HSP
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? Intussusception
? Swallowed epistaxis
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? Meckel's diverticulum? Foreign body
? HUS
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? Coagulopathy
? Sexual abuse
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? CoagulopathyCauses of GI Bleed in Adolescents
? Hematemesis, melena
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? Hematochezia? Esophagitis
? Infectious colitis
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? Gastritis
? Inflammatory bowel
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? Peptic ulcer diseasedisease
? Mallory-Weiss tears
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? Anal fissures
? Esophageal varices
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? Polyps? Pill ulcers
Esophageal varices
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Erosive esophagitisNSAID induced ulcers
Peptic Ulcer
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HISTORY? GENERAL QUESTIONS
? Acute or chronic bleeding
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? Color and quantity of the blood in stools or vomitus? Antecedent symptoms
? History of straining
? Abdominal pain
? Trauma
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? History of foods consumed or drugsHISTORY
? NEONATE
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? MILK OR SOY PROTEIN ENTERITIS? NSAIDs, heparin, indomethacin
? Maternal medications e.g Aspirin and Phenobarbital
? Stress gastritis e.g prematurity, neonatal distress,
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and mechanical ventilationHISTORY
? CHILDREN AGED 1 MONTH TO 1 YEAR
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? Episodic abdominal pain that is cramping in nature, vomiting,
and currant jel y stools (intussusception)
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? Fussiness and increased frequency of bowel movements inaddition to lower gi bleed (milk protein al ergy)
HISTORY
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? CHILDREN AGED 1-2 YRS? Upper GI Bleed
? systemic diseases, such as burns (Curling ulcer), head trauma
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(Cushing ulcer), malignancy, or sepsis
? NSAID
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? Lower GI Bleed? Polyps :- painless fresh streaks of blood in stools
HISTORY
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? CHILDREN OLDER THAN 2 YRS
? lower GI bleeding occurs in association with profuse
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diarrhea :- Infectious Diarrhea? Recent antibiotic use : antibiotic-associated colitis
and Clostridium difficile colitis
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? A history of vomiting, diarrhea, fever, ill contacts, or travelinfectious etiology
? Sudden onset of melena in combination with bilious emesis in a
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previously healthy, nondistended baby INTESTINAL
MALROTATION
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? Bloody diarrhea and signs of obstruction VOLVULUS,INTUSSUSCEPTION or NECROTIZING ENTEROCOLITIS, particularly in
premature infants
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? Recurrent or forceful vomiting Mallory-Weiss tears
? Familial history or NSAID use ulcer disease
? Ingested substances, such as NSAIDs, tetracyclines, steroids,
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caustics, and foreign bodies, can irritate the gastric mucosa enoughto cause blood to be mixed with the vomitus
? Recent jaundice, easy bruising, and changes in stool color liver
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disease
? Evidence of coagulation abnormalities elicited from the history
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disorders of the kidney or reticuloendothelial systemPHYSICAL EXAMINATION
? Signs of shock
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? Vital signs, including orthostatics
? Skin: pallor, jaundice, ecchymoses, abnormal blood vessels,
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hydration, cap refil? Abdomen:
? organomegaly, tenderness, ascites, caput medusa
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? Abdominal Surgical scars, Hyperactive bowel sounds (upper gi bleeding)
? Abdominal tenderness, with or without a mass(intussusception or
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ischemic Bowel disease)? Perineum: fissure, fistula, trauma
? Digital Rectum Examination: polyps, mass, occult blood, evidence
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of child abuse
Substances that deceive
? Red discoloration
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? candy, fruit punch, beets, watermelon, laxatives,
phenytoin, rifampin
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? Black discoloration? bismuth, activated charcoal, iron, spinach,
blueberries, licorice
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CONSIDERATIONS
? Place NG tube to confirm presence of fresh
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blood or active bleed. if confirmed? Esophagogastroduosenoscopy ? 90%
? Colonoscopy ? 80%
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? False negative results in 16 % ifduodenopyloric regurgitation is absent
FURTHER ASSESSMENT
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? Is it real y blood (haemoccult test)? Apt-Downey test in neonates
? Used to differentiate between maternal and baby blood.
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blood placed in test tubeadd sterile water (to hemolye
the RBCs yielding free Hb) mix with 1% sodium
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hydroxide if solution turns yellow or brownmaternalblood
? Nasogastric aspiration and lavage
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? Clear lavage makes bleeding proximal to ligament of Treitz
unlikely
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? Coffee grounds that clear suggest bleeding stopped? Coffee grounds and fresh blood mean an active upper GI
tract source
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Laboratory studies
? CBC in al cases
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? Normal hematocrit hypovolemia and hemoconcentration? Leukocytosis infectious etiology
? ESR in all cases
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? BUN, Cr in all cases
? PT, PTT in all cases
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? Others as indicated:? Type and crossmatch
? AST, ALT, GGTP, bilirubin
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? Albumin, total protein
? Stool for culture, ova and parasite examination, Clostridium difficile toxin assay
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? Plain abdominal Xray (NEC in neonates)LAB STUDIES (contd..)
? Endoscopy
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? Identifies site of upper GI bleed in 90 % cases? FORREST classification
? I ? Active hemorrhage
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? Ia :- bright red bleeding
? Ib :- slow bleeding
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? I ? Recent hemorrhages? I a :- non bleeding visible vessel
? I b :- adherent clot on base of lesion
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? I c :- flat pigmented spot
? I I ? No evidence of bleeding
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Endoscopy: indications? EGD: hematemesis, melena
? Flexible sigmoidoscopy: hematochezia
? Colonoscopy: hematochezia
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? Enteroscopy: obscure GI blood lossLAB STUDIES (contd..)
? Colonoscopy
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? Identifies site of lower GI bleed in 80 % cases? Polyps, FAP syndrome, haemangiomas, vascular
malformations, ulceration, biopsy
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LAB STUDIES (contd..)? Barium contrast studies
? GER, FB, esophagitis, IBD, Polyps, malrotation, volvulus
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? Doppler USG (Intussusception)
? Barium enema (IBD, polyps, intussusception)
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? H.pylori stool antigen, IgG levels, rapid urease test ormucosal biopsy
? Ultrasound abdomen (intussusception)
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? Fasting plasma gastrin level (Z-E syndrome)
? Technetium scan (Meckel's diverticulum)
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? Enteroscopy? Arteriography (helpful when endoscopy has failed)
INITIAL MANAGEMENT
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? The initial approach to all patients withsignificant GI bleed is :
? to establish adequate oxygen delivery.
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? to place intravenous line.? to initiate fluid and blood resuscitation
? to correct any underlying coagulopathies.
Therapy
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? Supportive care: begin promptly
? Bowel Rest and NG decompression (esp in NEC)
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? IV fluids? Blood products (FFPs, RCC)
? Specific care
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? Barrier agents (sucralfate)
? H2 receptor antagonists (cimetidine, ranitidine, etc.)
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? Proton pump inhibitors (omeprazole, lansoprazole)? Vasoconstrictors (somatostatin analogue[Octreotide], vasopressin,
Beta Blockers)
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? Inj Vitamin K
? Stool Softeners (Anal Fissure)
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? Prokinetics (to reduce vomiting)? Antibiotics (for enteritis, Cl. Difficile ass. Colitis)
? Withdrawl of offending milk protein (in cases of milk protein allergy)
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? H.pylori Eradication ( triple therapy)
Therapeutic Procedures
? Endoscopy: stabilize and prepare patient first
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? Coagulation (injection, cautery, heater probe, laser)
? Variceal injection or band ligation
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? Colonoscopy :? To treat colonic polyps, hemangiomas, AV malformations,
? Barium or saline enema :
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? Intussusception
? Arteriography
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? TIPS (variceal bleeds)? Sengstaken Blakemore bal oon tamponade
Surgical options
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? If all medical measures fail
? Laprotomy
? Laproscopy
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? Vagotomy? Pyloroplasty
? Fissurotomy, fistulectomy
? Diverticulectomy
Summary
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Definitions: Hematemesis, Malena and Hematochezia
Pathophysiology
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Causes: In Infant, Children 1-12 yrs, Adolescents > 12 yrsHistory/ Presentation
Physical examination
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Initial Management- Blood investigations/IVF/Blood
products/O2/Medications/PPI/NG washes/ Specific investigations(USG)
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Role of endoscopy- Upper GI/Lower GICause specific treatment
Surgical Options
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