Approach to GI Bleeding

1. Approach to GI Bleeding Simon Lam October 13, 2011 ACH Resident Academic Half Day

2. Overview • Case 1 and Case 2 • Presentation • History • Physical • Labs • Classification • DDx – UGIB • Case 1 – Cont’d • Initial Management • DDx –LGIB • Case 2 – Cont’d • Case 3

3. Case 1 • A. S. - 23 mo male with GDD presents with “a cup” of bright red hematemsis • ABC stable • S – No other symptx, no melena/hematochezia. • A – No allergies • M – Vit D and Iron supplements • P – Ex 32 wk, had a UVC placed as neonate and 1 episode of CONS sepsis in NICU. • L – Last meal 2 hours ago • E – “Just happened all of a sudden”

4. Case 2 • 2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting • ABC stable • S – 2 day history of periumbilical pain • A – No allergies • M – Vit D • P – Had severe reflux as an infant, resolved by 12 mos • L – Last meal 2 hours ago • E – Has had about 3 BM today, all full of blood.

5. Presentation • Hematemesis • Coffee ground emesis • Melena stool • Hematochezia • Normal stools with blood • Bloody Diarrhea

6. History • Onset, duration, volume and associated symptoms • Colour of blood/emesis/stool • Consistency of accompanying stool • Blood coating or mixed into stool • Hx of dyspepsia, heartburn, abdominal pain, constipation, diarrhea or weight loss • Hx of jaundice, easy bruising may suggest liver disease • Hx of NSAID use

7. On Exam • ABC • Vitals • HEENT • CVS • RESP • ABD • Must include DRE! • GU • Worrisome Signs • Pallor • Diaphoresis • Restlessness • Increased HR • Decreased BP • Orthostatic changes • Increase HR 20 bpm • Decrease BP 10 mmHg

8. Labs • CBC • Hct • MCV • Plts • Iron studies • Creatinine • Alb • CRP/ESR • ALT/AST • INR/PTT • Stool WBC, C+S, O+P

9. Guaiac Test • Used to confirm the presence of hemoglobin • False positives • Ascrobic acid (Vit C) • Animal myoglobin/hemoglobin

10. Apt Test • Differentiates maternal vs infant blood • Maternal = 2α2β • Fetal/infant = 2α2γ • NaOH will denature maternal blood and not fetal/infant • Positive test = Pink • Negative test = Yellow/Brown

11. Classification • Commonly classified based on location • Above Ligament of Treitz = UGBI • Below Ligament of Treitz = LGIB

12. May try to pass NG into stomach and aspirate. If + blood, likely UGBI. However if negative, does not exclude UGBI

13. Upper Gastrointestinal Bleed • DDx • Swallowed blood • Mallory-Weiss tear • Variceals • Gastritis* • Peptic ulcer • AV malformations • Hemangiomas • Angiodysplasia • Dieulafoy lesion • Hemobilia • Vitamin K deficiency • Thrombocytopenia

14. Case 1 • A. S. - 23 mo male with GDD presents with “a cup” of bright red hematemsis • ABC stable • S – No other symptx, no melena/hematochezia. • A – No allergies • M – Vit D and Iron supplements • P – Ex 32 wk, had a UVC placed as neonate and 1 episode of CONS sepsis in NICU. • L – Last meal 2 hours ago • E – “Just happened all of a sudden”

15. On Exam • HR 150 BP 80/62 • HEENT – No scleral icterus, mild conjunctival pallor • CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT = 3 • Resp – N • Abd – Soft non tender. Spleen ~14cm below CM on MCL. No hepatomegaly, No sigmata of chronic liver diease • MSK N • CNS – Playful during exam

16. Labs • Hb – 80 MCV 90 Plts -150 • INR – 1.0 • Alb – 35 • ALT/AST – N • ESR/CRP - N

17. DDx? • Sounds like UGBI • Esophagel varicies • Congestive gastropathy • Dieulafoy lesion • Peptic ucler

18. Initial Management • ABCs • 2 large bore IV • O2 and monitors • Type + Screen • Crossmatch • May consider Blood, FFP, Cryoprecipitate • Proton Pump Inhibitors • Octreotide

19. PPI • Helpful for gastric mucosal bleeds • Thought to decrease the activation of pepsinogen to pepsin which may degrade the fibrin clot • pH greater than 6 allow for better platelet aggregation • CHILDREN <40 kg: 2 mg/kg IV loading dose over 15 minutes • 0.2 mg/kg/hour for 72 hours • CHILDREN ≥40 kg: 80 mg IV loading dose over 15 minutes • 8 mg/hour for 72 hours

20. Octreotide • Decreases splanchnic blood flow • Decreases bleeding from esophageal and gastric varices • S/E is hyperglycemia, angina, arrhythmias, and headache • 1-2 mcg/kg (Max 50mcg) initial I.V. bolus followed by 1-2 mcg/kg/hour (max 50mcg/hr) one hour after loading dose continuous infusion

21. Endoscopy • Bleeding varicies • Banding • Sclerotherapy – small percentage will have esophageal ulcerations leading to strictures

22. Sengstaken-Blakemore tube • If unable to stablize, may need to use in PICU setting • Patient will to be sedated • ETT to secure airway • Stabilize before going into endoscopy • Consider angiography

23. Swallowed Blood • Infant – Maternal blood • Apt test • Child – epitaxis, recent dental extraction or tonsillectomy

24. Mallory – Weiss Tear • Repeated vomiting or retching • Acute mucosal laceration of the gastroesophageal junction • Tx – Up to 50 – 80% stop before time of endoscopy • Electrocoagulation, heater-probe application, or sclerotherapy

25. Gastritis • Diffuse • Trauma • Burn • Surgery • Severe medical problems • Locailzed • NSAID • H. pylori • EtOH • Bezoar Tx – Proton Pump Inhbitors, may need antibiotics in certain situations

26. AV Malformation • Hemangiomas • Angiodysplasia • Dieulafoy lesion • Tx – Endoscopy • Thermal ablation

27. Lower Gastrointestinal Bleed • DDx • Anal fissure • Sloughed polyp • Meckel’s Diverticulum • Vasculitis • Vascular malformation • UGBI • Don’t want to miss • Necrotizing entercolitis • Malrotation/Volvulus • Intussusception • Incarcerated hernia • Hirschsprung entercolitis

28. Case 2 • 2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting • ABC stable • S – 2 day history of periumbilical pain • A – No allergies • M – Vit D • P – Had severe reflux as an infant, resolved by 12 mos • L – Last meal 2 hours ago • E – Has had about 3 BM today, all full of blood.

29. On Exam • HR 150 BP 80/62 • HEENT – No scleral icterus, mild conjunctival pallor • CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT = 3 • Resp – N • Abd – Soft, slightly tender in RLQ with deep palpation. No masses. BRBPR on DRE • MSK N • CNS – responsive to exam

30. DDx? • Meckel’s Diverticulum • Massive UGIB • Malrotation with Volvulus • Intussusception

31. Initial Management • ABCs • 2 large bore IV • O2 and monitors • Type + Screen • Crossmatch • May consider Blood, FFP, Cryoprecipitate

32. Labs • Hb – 80 MCV 90 Plts -150 • INR – 1.0 • Alb – 35 • ALT/AST – N • ESR/CRP - N • Normal AXR • Normal Abd Ultrasound • Previously normal barium swallow (done for reflux as infant)

33. Meckel’s Diverticulum • Remnant of the omphalomesteric duct • Rule of 2s – 2% of population, 2% of affected become symptomatic, 50% present before the age of 2, 2 inches long and 2 feet from ileocecal valve • May contain acid secreting cells which erode the mesenteric side of lumen causing profuse bleeding • Tx – Surgical excision Technetium 99 absorbed by gastric mucosa

34. Anal Fissure • Usually associated with constipation or recent history of passing large stool • Painful defecation • Spotting on toilet paper • Resolves with regular soft stooling

35. Sloughed Juvenile Polyp • Intermittant painless rectal bleeding • Ages 1 – 10 • Maybe bright red, streaked on stools or mixed in • May get intermittent abdominal pain, colocolonic intussusception and prolapse through anal canal • Often out grow their vascular supply and will auto-amputate • May be seen in stool

36. Vasculitis • HenochSchonleinPurpura (HSP) • IgA mediated small vessel vasculitis affecting skin, kidney, GI tract and joints • May have guaiacpostive stools • Tx - Supportive

37. Bloody Diarrhea - DDx • Infectious • Ulcerative colitis • Crohn’s disease • Allergic colitis

38. Infectious • Salmonella • EHEC (O157:H7) • Campylobacter • Shigella • Yersinia • C. Diff • Amox, TMP-SMX • Supportive • Erythromycin • TMP - SMX • Supportive, TMP-SMX, aminoglycosides • Metronidazole or PO Vancomycin

39. Inflammatory Bowel Disease • Crohn’s Disease • Insidious, may present with abdo pain, growth delay, delayed puberty • ASCA • Transmural inflammation • Skip lesions, Terminal Ileum involved 60% • Ulcerative colitis • Presents with bloody diarrhea and tenesmus • p-ANCA • Mucosa inflammation • Continuous • Rectum involved and progresses proximally

40. Allergic Colitis • Inflammatory enteropathy caused by the ingestions of cow milk protein • Stools often loose with occult or frank blood present • Tx – Elimination diet • Soy formula may have up to 50% cross reactivity • Usually resolves by 1 year of age

41. When to consult GI? • True UGBI bleed • r/o swallowed blood • Mallory Weis tear may not need consult • LGIB • r/o Meckel’s • r/o Infectious • r/o CMPA

42. Case 3 • 14 year old male with recurrent blood mixed in with stool x 1 year. Feeling tired all of the time. Occasional dark stools, no hematemesis. +FOBT by GP. Negative celiac screen • A – No allergies • M – Ventolin • P – Epitaxis, exercise induced asthma • FHx – Dad also gets lots of nose bleeds and ‘lung problems’, paternal grandfather died of stroke • no IBD, no celiac, no FHx of hemophilia • L – This morning at 08:00 • E – GP referred to GI

43. On Exam • See 5mm red/purple stains on skin over face, upper trunk, arms. Also noted on buccal mucosa and tongue. • Lesions blanch with pressure • Some look like they branch out from centre • DRE revealed some frank blood • Exam otherwise normal

44. Labs • Hb – 90 MCV 70 Plts -200 • Retics 5% • INR – 1.0 • Alb – 35 • ALT/AST – N • ESR/CRP – N • Ferritin – Low • TIBC - High Hypochromic microcytic

45. Endoscopy finding

46. Hereditary Hemorrhagic Telangiectasia • Also known as Osler-Weber-RenduDiease • Autosomal dominant mutation in transforming growth factor beta signalling pathway • Important for vascular growth and repair • Triad = Telangiectasia, affected first degree relative and epitaxis • Dx – 3 of 4 Criteria • Epistaxis - Spontaneous, recurrent nosebleeds • Telangiectases - Multiple at characteristic sites (lips, oral cavity, fingers, nose) • Visceral lesions - Such as gastrointestinal (GI) telangiectasia (with or without bleeding), pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM • Family history - A first-degree relative with HHT

47. Treatment – GI standpoint • Estrogen-progesterone therapy • Transfusion • Aminocaproic acid • Endoscopic photoablation or electrocautery

48. Boyle 2008

49. References • JT Boyle. 2008. Gastrointestinal Bleeding in Children and Infants. Pediatrics in Review. (2) 39 – 51 • C Ramsook and EE Endom. 2011. Diagnostic approach to lower gastrointestinal bleeding in children. Up to date. http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/diagnostic-approach-to-lower-gastrointestinal-bleeding-in-children?source=search_result&search=lower+gi+bleed&selectedTitle=3%7E102. Accessed October 12, 2011 • Soares et al 2010. J Port Gastrenterol. v.17 n.5 Lisboa set • A. Panigrahi. 2011. Pediatric Osler-Weber-Rendu Syndrome. Medscape reference. http://emedicine.medscape.com/article/957067-overview. Accessed October 12, 2011 • X Villa. 2011. Approach to upper gastrointestinal bleeding in children. Up to date. http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/approach-to-upper-gastrointestinal-bleeding-in-children?source=search_result&search=upper+gi+bleed&selectedTitle=2%7E150. Accessed October 12, 2011

50. Thanks! Special Thank You to Dr. C. Waterhouse