Lower GI Bleed

1. SameerLapsia, MD AnupamaChawla, MD Stony Brook Children’s Hospital Reviewed by Christine WaasdorpHurtado, MD of the Professional Education Committee Lower GI Bleed

2. Definition • Lower GI (LGI) bleeding is defined as bleeding in the gastrointestinal tract distal to the ligament of Treitz Ligament of Treitz

3. Stool Characteristics of LGI bleed • Melenais described as black, tarry stools • Dark black color thought to be due to hematin • Can be produced by relatively small amounts of blood (50-100 cc) • Usually occurs from a source above the ileocecal valve but can be seen from sources in the proximal small bowel if the colonic transit time is slow http://www.medicalassessment.com/terms.php?R=642&L=B

4. Stool characteristics defining LGI bleed • Hematochezia refers to the passage of bright red blood from the rectum • Usually from a colonic source • Massive upper GI bleed can present as hematochezia due to rapid transit time • In infants hematochezia may be due to an upper GI source owing to shorter intestinal transit time http://blog.naver.com/PostView.nhn?blogId=siasia29&logNo=110084804249&categoryNo=135&viewDate=&currentPage=1&listtype=0

5. Stool characteristics defining LGI bleed • Maroon colored stoolsmay be indicative of a Meckel’s diverticulum http://www.felipedia.org/~felipedi/wiki/images/1/1d/Hematochezia.jpg

6. Blood or not blood?: That is the question • Many items can appear as blood in the stools such as foods containing red food coloring (Jell-O, Kool Aid), syrup medications, beets, tomato and peach skins • Many items can appear as melena such as spinach, licorice, grape juice and certain medications such as Pepto-Bismol (due to bismuth) and Iron • Question is best answered by performing a guaiac test

7. Guaiac • Guaiac is a colorless compound that turns blue when placed in contact with substances (such as heme portion of hemoglobin) that have peroxidase activity and are then exposed to hydrogen peroxide = +

8. Guaiac • “False-positives” can occur in foods containing peroxidase activity such as red meat, melons, grapes, radishes, turnips, cauliflower, and broccoli • “False-negative” can occur in patients taking Vitamin C due to anti-oxidant properties

9. Source of Blood :GI tract or not? That is another question • Melena may be seen in patients who have swallowed blood posttonsillectomy, or from epistaxis or traumatic nasopharayngeal lesions due to passage of a NG-tube • Swallowed maternal blood • Females who are menstruating may appear to have hematochezia and often their stool occult blood is positive • Hematuria may be mistaken for hematochezia • Munchausen syndrome by proxy should also be considered

10. Blood from the Lower or Upper GI tract?: • Upper GI bleed can mimic a lower GI bleed • Placement of a NG-tube and aspiration and guaiac of gastric contents can help • If negative guaiac may indicate bleeding from a distal source • However, a bleeding duodenal ulcer may not necessarily yield a positive guaiac. • If suspicion is high of an Upper GI source then an upper endoscopy is warranted

11. History 101

12. Potential Etiologies of Lower GI Bleed based on History From Walker – Lower Gastrointestinal Bleed

13. Common Etiologies of Lower GI Bleed based on Age From Walker – Lower Gastrointestinal Bleed

14. Common etiologies in the newborn period • Anorectal fissures • Can present with streaks or bright red blood on the surface of stools • History is usually of a patient who strains, grunts, stiffens his/her leg or arches their back when having a bowel movement • Diagnosed easily by physical examination by spreading the perineal skin http://www.homeouniverse.com/category/diseases/stomach-diseases/

15. Common etiologies in the newborn period • Milk- or soy-induced colitis • Caused by ingestion of milk or soy protein which causes an inflammatory enteropathy in susceptible newborns • 25% - 50% of patients with cow’s milk protein intolerance will have a cross-reaction to soy protein • Treatment is with elimination of milk and soy protein from the mother’s diet if the infant is exclusively breastfed • Can challenge by adding milk or soy protein back in diet • Treatment is with elimination of milk and soy formula in formula fed infants • Casein-hydrolysateformula • Amino acid formula • Usually resolves by 1 year of age

16. Common etiologies in the newborn period • Necrotizing enterocolitis(NEC) • Intestinal pneumatosis of unclear etiology • Associated with prematurity, low birth weight, asphyxia, and sepsis (10% of NEC occurs in full-term patients) • Correlation with PRBC transfusion • Symptoms include systemic instability, apnea, lethargy, poor feeding, abdominal distention, bilious emesis, and bloody stools • Medical and/or surgical management depends on the severity and course of the disease

17. Necrotizing enterocolitis • X-ray findings: • Radiographic hallmark is pneumatosisintestinalis(ie gas in the bowel wall) • In early stages may see dilated loops of bowel • May also seen pneumoperitoneum in cases of perforation

18. Common etiologies in the newborn period • Malrotation with midgut volvulus • Incidence of 1 in 6000 live births • Symptoms include abdominal distention, bilious emesis, and melena • Surgical emergency! • UGI series may show the that duodenum does not cross the midline and the rest of the small intestine lies to the right of the midline http://radiologysigns.tumblr.com/post/35676542893/corkscrew-sign

19. Common etiologies in infancy • Hirschsprung Disease Enterocolitis • Typical presentation is that of severe constipation, abdominal distention, vomiting, and feeding intolerance. • 10-30% of patients have Lower GI bleeding • Gold standard for diagnoses is via rectal biopsy demonstrating absence of ganglion cells in the Meissner and the Auerbach plexus • Treatment is via either a diverting colostomy followed by a second-stage intestinal pull-through of intestine containing nerves or a primary pull-through

20. Common etiologies in infancy Infectious colitis

21. Common etiologies in infancy • Meckel diverticulum – Rule of 2s: • 2% of the population • 2:1 male:female ratio • 2 feet from the ileocecal valve (usual location) • 2 inches in diameter • 2% of patients develop complications • 2 types of tissue are usual (gastric mucosa – most common; can also have pancreatic tissue) • Presentation: • The lower GI bleed is often brisk and painless • Stool often described as maroon colored • Diagnosis can be made by radionuclide 99m pertechnetate scan showing the presence of heterotopic gastric mucosa; occasionally laparoscopy/laparotomy may be necessary • Rx via surgical excision

22. Meckel Diverticulum Arrow shows presence of Meckel Diverticulum Radionuclide 99m pertechnetate scan http://www.ajronline.org/content/189/1/81/F7.large.jpg

23. Common etiologies in infancy • Intussusception • Most common cause of intestinal obstruction in infants between 6 and 36 months of age • Usually idiopathic and most common location is ileocecal region in infancy • Usual presentation is severe abdominal pain, irritability and patients often draw up their legs • Patients may pass a bloody, mucoid stool(currant jelly) Contrast enema can be used to reduce the intussusception in 75-90% of children http://radiologyinthai.blogspot.com/2011/10/intussusception-reduction.html

24. Common etiologies in infancy • Lymphonodular hyperplasia • Characterized by multiple yellowish nodules that are enlarged lymphoid follicles • Etiology is not well established • Mucosal thinning, ulceration of the follicles leads to abdominal pain and bleeding • It resorbs slowly as patients enter adolescence http://davisbabies.blogspot.com/2009/06/lymphonodular-hyperplasia.html

25. Common etiologies during Preschool Age • Polyps • Intestinal polyps can cause isolated, recurrent, and painless hematochezia • Juvenile polyps account for more than 95% of all polyps found in children and have low malignancy potential • They are hamartomatous • Vast majority are solitary and occur mostly on the left side of the colon • Recurrent or multiple polyps can be seen in juvenile polyposis coli or generalized juvenile polyposis • Adenomatous polyps are more frequently found in adults and have high malignancy potential • Both are treated with excision via colonoscopy or if too numerous or malignant potential via surgery

26. Polyps Juvenile polyps usually are smooth, bright red, have a friable surface and surrounding colonic chicken skin mucosa Adenomatous polyp in the colon which is pedunculated with a head with a cobblestone or lobulated red-brown surface http://www.standardofcare.com/mwiki/index.php?title=Adenomatous_polyp http://www.sciencedirect.com/science/article/pii/S1096288307001076

27. Common etiologies during Preschool Age • Henoch-SchönleinPurpura • Systemic vasculitis involving the skin, GI tract, joints and kidneys • Typical presentation is an urticarial rash on the buttocks and lower extremities with peak onset from 3-7 years followed by large joint arthralgias and papularpurpuric lesions • GI manifestions occur in 45-75% of patients • Include: vomiting, colicky abdominal pain, melena, and/or bloody stools due to diffuse mucosal hemorrhage • Intussusception associated with HSP can also cause melena or hematochezia

28. Common etiologies during School Age • Inflammatory bowel disease • 90-95% of patients with Ulcerative Colitis and 25% of patients with Crohn’s disease present with rectal bleeding and/or bloody diarrhea • The peak incidence of IBD occurs in patients between the ages of 15 and 25 years. • Approximately 25 to 30 percent of patients with CD and 20 percent of patients with UC present before the age of 20 years

29. Inflammatory bowel disease Modified from: Das KM. Relationship of extraintestinal involvements in inflammatory bowel disease: New insights into autoimmune pathogenesis. Dig Dis Sci 1999; 44:1.

30. Rare causes of Lower GI Bleeding

31. So a patient comes in with an Lower GI bleed… • ABCs are always important (Airway Breathing Circulation) • If hemodynamically unstable immediate management includes fluid resuscitation and possible blood transfusions • If the patient remains unstable after receiving a blood transfusion of >85 cc/kg then emergency exploratory surgery is indicated • Note that over expansion of blood volume can worsen variceal bleeding

32. So a patient comes in with an Lower GI bleed… • Initial approach depends on patient’s age and clinical history • Workup may include lab studies, stool studies, or imaging depending on the suspected etiology or to rule out possibilities • Invasive procedures such as endoscopy and colonoscopy should be considered if clinical decisions will be affected by performing the procedures

33. Interventional endoscopy to attain homeostasis • Endoscopic treatment includes: • Electrocoagulation, laser photocoagulation, argon plasma coagulation, injection of epinephrine and sclerosants, band ligation, and mechanical clipping Band Ligation Clipping

34. References • Turck D & Michaud L. Lower Gastrointestinal Bleeding. In Walker’s Pediatric Gastrointestinal Disease 5 Volume 2. Shelton, CT: People’s Medical Publishing House. • Abdullah BA, Gupta SK, & Croffie JM. The role of esophagogastroduodenoscopy in the initial evaluation of childhood inflammatory bowel disease: a 7-year study. Journal of Pediatric Gastroenterology & Nutrition 2002; 35:636.