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Gastrointestinal Hemorrhage

Gastrointestinal Hemorrhage. Carolyn A. Sullivan, MD Pediatric Gastroenterology. Objectives. Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding Review the most common etiologies for GI bleeding in pediatric patients in various age groups. Definitions.

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Gastrointestinal Hemorrhage

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  1. Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology

  2. Objectives • Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding • Review the most common etiologies for GI bleeding in pediatric patients in various age groups

  3. Definitions • Melena: passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve • Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding • Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz

  4. History • Present illness • source, magnitude, duration of bleeding • associated GI symptoms (vomiting, diarrhea, pain) • associated systemic symptoms (fever, rash, joint pains) • Review of systems • GI disorders, liver disease, bleeding diatheses • Anesthesia reactions • medications (NSAID’s, warfarin) • Family history

  5. Physical examination • Vital signs, including orthostatics • Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill • HEENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding • Abdomen: organomegaly, tenderness, ascites, caput medusa • Perineum: fissure, fistula, induration • Rectum: gross blood, melena, tenderness

  6. Further assessment • Is it really blood? • Hemoccult stool, gastroccult emesis • Apt-Downey test in neonates • 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

  7. Substances that deceive • Red discoloration • candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin • Black discoloration • bismuth, activated charcoal, iron, spinach, blueberries, licorice

  8. Laboratory studies • CBC, ESR; BUN, Cr; 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

  9. Imaging studies and indications • Upper GI series: dysphagia, odynophagia, drooling • Barium enema: intussusception, stricture • Abdominal US: portal hypertension • Meckel’s scan: Meckel’s diverticulum • Sulfur colloid scan, labeled RBC scan, angiography : obscure GI bleeding

  10. Endoscopy: indications • EGD: hematemesis, melena • Flexible sigmoidoscopy: hematochezia • Colonoscopy: hematochezia • Enteroscopy: obscure GI blood loss

  11. Upper GI bleeding swallowed maternal blood stress ulcers, gastritis duplication cyst vascular malformations vitamin K deficiency hemophilia maternal ITP maternal NSAID use Lower GI bleeding swallowed maternal blood dietary protein intolerance infectious colitis necrotizing enterocolitis Hirschsprung’s enterocolitis duplication cyst coagulopathy vascular malformations DDx: neonates

  12. Neonatal stress ulcers or gastritis • Causes • Shock • Sepsis • Dehydration • Traumatic delivery • Severe respiratory distress • Hypoglycemia • Cardiac condition

  13. Hematemesis, melena Esophagitis Gastritis Duodenitis Hematochezia Anal fissures Intussusception Infectious colitis Dietary protein intol. Meckel’s diverticulum Duplication cyst Vascular malformation DDx: infants

  14. Upper GI bleeding Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers Lower GI bleeding Anal fissures Infectious colitis Polyps Lymphoid nodular hyperplasia IBD HSP Intussusception Meckel’s diverticulum HUS DDx: children

  15. Esophageal varices

  16. Erosive esophagitis

  17. Hematemesis, melena Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers Hematochezia Infectious colitis Inflammatory bowel disease Anal fissures Polyps DDx: adolescents

  18. NSAID induced ulcers

  19. Peptic Ulcer

  20. Mallory-Weiss Tear

  21. Stigmata of recent hemorrhage Visible vessel Clot Spot Clean base Rate of rebleed 40-50% 25-30% 10% 2-4% Risk of rebleeding of ulcer

  22. Ulcer with red spot

  23. Therapy • Supportive care: begin promptly • IV fluids, blood products, pressors • Specific care • Barrier agents (sucralfate) • H2 receptor antagonists (cimetidine, ranitidine, etc.) • Proton pump inhibitors (omeprazole, lansoprazole) • Vasoconstrictors (somatostatin analogue, vasopressin) • Endoscopic therapy: stabilize and prepare patient first • Coagulation (injection, cautery, heater probe, laser) • Variceal injection or band ligation • Polypectomy

  24. Bleeding Ulcer

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