Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Pediatric Surgery 4 An Approach To Child With GI Bleed PPT-Powerpoint Presentations and lecture notes
AN APPROACH TO CHILD WITH
GI BLEED
Background
? Gastrointestinal (GI) bleeding in infants and
children is a fairly common problem,
accounting for 10%-20% of referrals to
pediatric gastroenterologists.
Definitions
? Melena is the passage of black, tarry stools;
suggests bleeding proximal to the ileocecal valve
? Hematochezia is passage of bright or dark red
blood per rectum; indicates colonic source or
massive upper GI bleeding
? Hematemesis is passage of vomited material that
is black ("coffee grounds") or contains frank
blood; bleeding from above the ligament of Treitz
PATHOPHYSIOLOGY OF GI BLEED
? 1. Consequences of blood loss
? 2. Risk of hemorrrhagic shock
? 3. Compensatory mechanism
1. PATHOPHYSIOLOGIC
CONSEQUENCES OF BLOOD LOSS
? LOSS OF FLUID(BLOOD) DEC. ECF
DEHYDRATION SHOCK DEC GFRANURIA
PRE-RENAL A.R.F (INC. BUN AND NITROGEN)
SMALL VOL CONCENTRATED URINE WITH HIGH
SPECIFIC GRAVITY
2. Higher risk for hemorrhagic shock in
children
?
Age-dependent vital signs inaccurate
interpretation of early signs
? High ratio surface area to body mass
limited thermoregulation hypothermia
pulmonary HT hypoxemia acidosis
? Smal er total body volume
? Lower hematocrit level
3. Sequence of compensatory
mechanism
? Loss of less than 15% of BV is compensated
by:
? Contraction of the venous system
? Fluid shift ECFC IVFC
? Preferential direction of blood to the brain and the
heart No hemodynamic changes
? Loss 15%-30% BV
? Sympathetic stimulation
? Secretion of aldosterone, ADH, prostaglandins
? Release of catecholamine
? Release of ACTH and corticosteroids
Hemodynamic instability
Tachycardia, O2 consumption, tissue hypoxia
Maintain blood volume
? Loss of more than 30%
? Hypotension (Shock), dec. cardiac output
acidosis tissue damage
? Acute renal failure
? Liver failure
? Heart failure
SYMPTOMS OF UPPER GI BLEED
? Symptoms of upper gastrointestinal bleeding
include:
? vomiting bright red blood (hematemesis)
? vomiting dark clots, or coffee ground-like material
? passing black, tar-like stool (melena)
SYMPTOMS OF LOWER GI BLEED
? Symptoms of lower gastrointestinal bleeding
include:
? passing pure blood (hematochezia) or blood
mixed in stool
? bright red or maroon blood in the stool
? Hematemesis : 50% of upper gastrointestinal
bleeding cases
? Hematochezia : 80% of all gastrointestinal
bleeding.
? Melena
? 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
gastrointestinal tract for 8 hours to turn black
CAUSES
Causes of GI bleed in neonates
? Upper GI bleeding
? Lower GI bleeding
? swallowed maternal
? swallowed maternal blood
blood
? dietary protein intolerance
? stress ulcers, gastritis
? infectious colitis/enteritis
? vascular malformations
? necrotizing enterocolitis
? HDN
? Hirschsprung's enterocolitis
? hemophilia
? coagulopathy
? maternal ITP
? vascular malformations
? maternal NSAID use
Causes of GI bleed in infants
? Hematemesis, melena
? Hematochezia
? Esophagitis
? Anal fissures
? Gastritis
? Intussusception
? Duodenitis
? Infectious colitis/enteritis
? Coagulopathy
? Dietary protein intol.
? Meckel's diverticulum
? Vascular malformation
? Coagulopathy
Causes of GI Bleed in Children 1 -12 yrs
? Upper GI bleeding
? Lower GI bleeding
? Esophagitis
? Anal fissures
? Gastritis
? Infectious colitis
? Polyps
? Peptic ulcer disease
? Lymphoid nodular
? Mallory-Weiss tears
hyperplasia
? Esophageal varices
? IBD
? Pill ulcers
? HSP
? Intussusception
? Swallowed epistaxis
? Meckel's diverticulum
? Foreign body
? HUS
? Coagulopathy
? Sexual abuse
? Coagulopathy
Causes of GI Bleed in Adolescents
? Hematemesis, melena
? Hematochezia
? Esophagitis
? Infectious colitis
? Gastritis
? Inflammatory bowel
? Peptic ulcer disease
disease
? Mallory-Weiss tears
? Anal fissures
? Esophageal varices
? Polyps
? Pill ulcers
Esophageal varices
Erosive esophagitis
NSAID induced ulcers
Peptic Ulcer
HISTORY
? GENERAL QUESTIONS
? Acute or chronic bleeding
? Color and quantity of the blood in stools or vomitus
? Antecedent symptoms
? History of straining
? Abdominal pain
? Trauma
? History of foods consumed or drugs
HISTORY
? NEONATE
? MILK OR SOY PROTEIN ENTERITIS
? NSAIDs, heparin, indomethacin
? Maternal medications e.g Aspirin and Phenobarbital
? Stress gastritis e.g prematurity, neonatal distress,
and mechanical ventilation
HISTORY
? CHILDREN AGED 1 MONTH TO 1 YEAR
? Episodic abdominal pain that is cramping in nature, vomiting,
and currant jel y stools (intussusception)
? Fussiness and increased frequency of bowel movements in
addition to lower gi bleed (milk protein al ergy)
HISTORY
? CHILDREN AGED 1-2 YRS
? Upper GI Bleed
? systemic diseases, such as burns (Curling ulcer), head trauma
(Cushing ulcer), malignancy, or sepsis
? NSAID
? Lower GI Bleed
? Polyps :- painless fresh streaks of blood in stools
HISTORY
? CHILDREN OLDER THAN 2 YRS
? lower GI bleeding occurs in association with profuse
diarrhea :- Infectious Diarrhea
? Recent antibiotic use : antibiotic-associated colitis
and Clostridium difficile colitis
? A history of vomiting, diarrhea, fever, ill contacts, or travel
infectious etiology
? Sudden onset of melena in combination with bilious emesis in a
previously healthy, nondistended baby INTESTINAL
MALROTATION
? Bloody diarrhea and signs of obstruction VOLVULUS,
INTUSSUSCEPTION or NECROTIZING ENTEROCOLITIS, particularly in
premature infants
? Recurrent or forceful vomiting Mallory-Weiss tears
? Familial history or NSAID use ulcer disease
? Ingested substances, such as NSAIDs, tetracyclines, steroids,
caustics, and foreign bodies, can irritate the gastric mucosa enough
to cause blood to be mixed with the vomitus
? Recent jaundice, easy bruising, and changes in stool color liver
disease
? Evidence of coagulation abnormalities elicited from the history
disorders of the kidney or reticuloendothelial system
PHYSICAL EXAMINATION
? Signs of shock
? Vital signs, including orthostatics
? Skin: pallor, jaundice, ecchymoses, abnormal blood vessels,
hydration, cap refil
? Abdomen:
? organomegaly, tenderness, ascites, caput medusa
? Abdominal Surgical scars, Hyperactive bowel sounds (upper gi bleeding)
? Abdominal tenderness, with or without a mass(intussusception or
ischemic Bowel disease)
? Perineum: fissure, fistula, trauma
? Digital Rectum Examination: polyps, mass, occult blood, evidence
of child abuse
Substances that deceive
? Red discoloration
? candy, fruit punch, beets, watermelon, laxatives,
phenytoin, rifampin
? Black discoloration
? bismuth, activated charcoal, iron, spinach,
blueberries, licorice
CONSIDERATIONS
? Place NG tube to confirm presence of fresh
blood or active bleed. if confirmed
? Esophagogastroduosenoscopy ? 90%
? Colonoscopy ? 80%
? False negative results in 16 % if
duodenopyloric regurgitation is absent
FURTHER ASSESSMENT
? Is it real y blood (haemoccult test)
? Apt-Downey test in neonates
? Used to differentiate between maternal and baby blood.
blood placed in test tubeadd sterile water (to hemolye
the RBCs yielding free Hb) mix with 1% sodium
hydroxide if solution turns yellow or brownmaternal
blood
? Nasogastric aspiration and lavage
? Clear lavage makes bleeding proximal to ligament of Treitz
unlikely
? Coffee grounds that clear suggest bleeding stopped
? Coffee grounds and fresh blood mean an active upper GI
tract source
Laboratory studies
? CBC in al cases
? Normal hematocrit hypovolemia and hemoconcentration
? Leukocytosis infectious etiology
? ESR in all cases
? BUN, Cr in all cases
? PT, PTT in all cases
? Others as indicated:
? Type and crossmatch
? AST, ALT, GGTP, bilirubin
? Albumin, total protein
? Stool for culture, ova and parasite examination, Clostridium difficile toxin assay
? Plain abdominal Xray (NEC in neonates)
LAB STUDIES (contd..)
? Endoscopy
? Identifies site of upper GI bleed in 90 % cases
? FORREST classification
? I ? Active hemorrhage
? Ia :- bright red bleeding
? Ib :- slow bleeding
? I ? Recent hemorrhages
? I a :- non bleeding visible vessel
? I b :- adherent clot on base of lesion
? I c :- flat pigmented spot
? I I ? No evidence of bleeding
Endoscopy: indications
? EGD: hematemesis, melena
? Flexible sigmoidoscopy: hematochezia
? Colonoscopy: hematochezia
? Enteroscopy: obscure GI blood loss
LAB STUDIES (contd..)
? Colonoscopy
? Identifies site of lower GI bleed in 80 % cases
? Polyps, FAP syndrome, haemangiomas, vascular
malformations, ulceration, biopsy
LAB STUDIES (contd..)
? Barium contrast studies
? GER, FB, esophagitis, IBD, Polyps, malrotation, volvulus
? Doppler USG (Intussusception)
? Barium enema (IBD, polyps, intussusception)
? H.pylori stool antigen, IgG levels, rapid urease test or
mucosal biopsy
? Ultrasound abdomen (intussusception)
? Fasting plasma gastrin level (Z-E syndrome)
? Technetium scan (Meckel's diverticulum)
? Enteroscopy
? Arteriography (helpful when endoscopy has failed)
INITIAL MANAGEMENT
? The initial approach to all patients with
significant GI bleed is :
? to establish adequate oxygen delivery.
? to place intravenous line.
? to initiate fluid and blood resuscitation
? to correct any underlying coagulopathies.
Therapy
? Supportive care: begin promptly
? Bowel Rest and NG decompression (esp in NEC)
? IV fluids
? Blood products (FFPs, RCC)
? Specific care
? Barrier agents (sucralfate)
? H2 receptor antagonists (cimetidine, ranitidine, etc.)
? Proton pump inhibitors (omeprazole, lansoprazole)
? Vasoconstrictors (somatostatin analogue[Octreotide], vasopressin,
Beta Blockers)
? Inj Vitamin K
? Stool Softeners (Anal Fissure)
? Prokinetics (to reduce vomiting)
? Antibiotics (for enteritis, Cl. Difficile ass. Colitis)
? Withdrawl of offending milk protein (in cases of milk protein allergy)
? H.pylori Eradication ( triple therapy)
Therapeutic Procedures
? Endoscopy: stabilize and prepare patient first
? Coagulation (injection, cautery, heater probe, laser)
? Variceal injection or band ligation
? Colonoscopy :
? To treat colonic polyps, hemangiomas, AV malformations,
? Barium or saline enema :
? Intussusception
? Arteriography
? TIPS (variceal bleeds)
? Sengstaken Blakemore bal oon tamponade
Surgical options
? If all medical measures fail
? Laprotomy
? Laproscopy
? Vagotomy
? Pyloroplasty
? Fissurotomy, fistulectomy
? Diverticulectomy
Summary
Definitions: Hematemesis, Malena and Hematochezia
Pathophysiology
Causes: In Infant, Children 1-12 yrs, Adolescents > 12 yrs
History/ Presentation
Physical examination
Initial Management- Blood investigations/IVF/Blood
products/O2/Medications/PPI/NG washes/ Specific investigations(USG)
Role of endoscopy- Upper GI/Lower GI
Cause specific treatment
Surgical Options
This post was last modified on 08 April 2022