Transcript gi bleeding 2013 - University of Yeditepe Faculty of Medicine, 2011

GI BLEEDING IN CHILDREN
SURGICAL PERSPECTIVE
PROF. DR. SELAMI SOZUBIR
YEDITEPE UNIVERSITY HOSPITAL
PEDIATRIC SURGERY DEPARTMENT
BACKGROUND
 Pediatric GI bleeding is a fairly
common, anxiety-provoking chief
complaint.
 Most etiologies are self-limited and
benign, but it is crucial not to miss
conditions that may lead to severe
consequences if undiagnosed.
Types
 Hematemesis
 Melena
 Hematochesia
 Occult bleeding
HISTORY
 Ask both age- and etiology-specific
questions.
 Ask questions that may reveal
underlying but yet undiagnosed organ
dysfunction.
Etiology-specific questions
 Place of the bleeding
 Ask about acuteness or chronicity of bleeding
 Color and quantity of the blood in stool or emesis or
both
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Anorectal disorders, fissures, and distal polyps produce
bright red blood.
Melena rather than bright red blood per rectum is usually a
sign of bleeding that comes from a source proximal to the
ligament of Treitz.
Massive upper GI bleeding, however, can produce bright
red blood per rectum if GI transit time is rapid.
Blood mixed in stool or dark red blood implies a proximal
source with some degree of digestion of the blood.
 history of abdominal pain, or trauma.
Etiology-specific questions
 A history of vomiting, diarrhea, fever, ill
contacts, or travel suggests an infectious
etiology.
 Bloody diarrhea and signs of obstruction
suggest volvulus, intussusception, or
necrotizing enterocolitis
 Recurrent or forceful vomiting is associated
with Mallory-Weiss tears.
Underlying but yet undiagnosed
organ dysfunction
 Recent jaundice, and changes
in stool color may signal liver
disease
 Tendency of bleeding and
hemotoma
Physical examination
 Inspection of the perianal area may
reveal fissures, fistulas, skin
breakdown, or evidence of trauma.
 Gentle digital rectal examination may
reveal polyps, masses, or occult blood.
AGE
 Neonates
 Children aged 1 month to 1
year
 Children aged 1-2 years
 Children older than 2 years
Age Group
Upper Gastrointestinal
Bleeding
Lower Gastrointestinal
Bleeding
Neonates
Swallowed
maternal blood
Hemorrhagic
disease of the
newborn
Stress gastritis
Coagulopathy
Anal fissure
Necrotizing
enterocolitis
Malrotation with
volvulus
Esophagitis
Gastritis
Anal fissure
Intussusception
Gangrenous bowel
Milk protein allergy
Peptic ulcer disease
Gastritis
Polyps
Meckel diverticulum
Esophageal varices
Gastric varices
Polyps
Inflammatory bowel
disease
Infectious diarrhea
Vascular lesions
Infants aged 1 month
to 1 year
Infants aged 1-2
years
Children older than 2
years
Upper gastrointestinal tract
bleeding in neonates
 Swallowed maternal blood
 Stress gastritis
 Hemorrhagic disease of the
newborn
 milk protein allergies
 coagulopathies
Neonates
 Maternal blood ingestion is the most
common cause of suspected GI
bleeding.
 Blood is swallowed during delivery or while
breastfeeding
Swallowed maternal blood
 Infants who swallow maternal blood
during delivery may present with
hematemesis during the first few
days of life.
 Apt test
 1% sodium hydroxide.
 Fetal hemoglobin is resistant to reduction and
remains pink or bright red.
 Absence of fetal hemoglobin eliminates the
diagnosis of acute upper GI bleeding.
Stress gastritis
 Occurs in up to 20% of patients cared for in
the neonatal intensive care unit.
 Prematurity,
 Neonatal distress,
 Mechanical ventilation
 Definitive diagnosis is made with upper
endoscopy.
 Treatment is supportive.Extremely rarely,
continued or massive hematemesis despite
medical therapy leads to operative
interventions.
Hemorrhagic disease of the
newborn
 Hemorrhagic disease of the newborn is a self-limited
bleeding disorder resulting from a deficiency in
vitamin K–dependent coagulation factors.
 In 0.25-0.5% of neonates, severe hemorrhage may
result.
 Prophylactic vitamin K administration in the
newborn period virtually eliminates hemorrhagic
disease of the newborn. If hemorrhagic disease
occurs, administration of 1 mg of vitamin K
intravenously generally stops the hemorrhage within 2
hours.
Lower gastrointestinal tract
bleeding in neonates
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Anal fissures
Necrotizing enterocolitis
Malrotation with volvulus
Arteriovenous malformations
Hirschsprung enterocolitis
Meckel diverticulitis.
NEC
 Necrotizing
enterocolitis (NEC)
in most neonates is
diagnosed from the
history and clinical
presentation.
E
Ö
NEC
NEC
 Aggressive medical resuscitation with bowel
rest, antibiotics, total parenteral nutritional,
and nasogastric decompression is the
standard treatment
 Nonoperative management has a 70-80%
recovery rate, but
 progressive sepsis,
 bowel perforation,
 persistent bleeding,
urgent laparotomy or drain placement
is required.
Malrotation with volvulus
 Malrotation is
suspected with the
sudden onset of
melena in
combination with
bilious emesis in a
previously healthy,
nondistended baby.
 Immediate upper GI contrast study should
be performed to confirm the diagnosis of
malrotation with midgut volvulus.
 Immediate laparotomy reveals the
anomaly and allows derotation of the
bowel, assessment of intestinal viability,
possible bowel resection, and performance
of a Ladd procedure.
Upper gastrointestinal bleeding in
children aged 1 month to 1 year
 Esophagitis
 Gastritis
Esophagitis
 GER
 Peptic esophagitis caused by gastroesophageal
reflux (GER) is the most common cause of
bleeding in this age group.
 Infants present with regurgitation, dysphasia,
odynophagia, and failure to thrive. Diagnostic
workup often begins with a barium swallow.
 Other diagnostic modalities include
pH probes, esophagoscopy,
esophageal manometry, and nuclear
medicine studies.
Lower GI bleeding in children aged
1 month to 1 year
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Anal fissures
Intussusception
Gangrenous bowel
Milk protein allergy
anal fissures
 Anal fissures are the most common
cause of GI bleeding in infants.
 They produce bright red blood that
streaks the stool or causes spots of
blood in the diaper.
 most commonly
located dorsally in
the midline.
 Diagnosis is made by
anal examination,
sometimes
performed with a
nasal speculum.
Intussusception
 Intussusception is
the most likely
cause of lower
GI bleeding in
infants aged 618 months.
 abdominal pain,
mass, currant jelly
stools
 Ultrasonography may
be employed as the
initial diagnostic
study
 a pseudokidney sign
is pathognomonic for
intussusception.
 Successful reduction
is achieved in up to
90% of cases.
 If enema is
unsuccessful, then
laparotomy and
manual reduction or
resection of the
intussusception
becomes necessary.
Meckel diverticulum
 Meckel diverticulum
occurs in 2% of the
population
 GI bleeding is the
most common
presentation of this
congenital anomaly
in children younger
than 4 years (22%).
 The pathogenesis of GI bleeding from a
Meckel diverticulum is ileal ulceration
caused by acid secretion from the ectopic
gastric mucosa. Erosion into small arterioles
leads to painless brisk rectal bleeding.
 Technetium Tc
99m pertechnetate
scanning is used to
identify the Meckel
diverticulum with
90% accuracy..
 Treatment is surgical resection after
preoperative fluid resuscitation and
adequate transfusion.
Upper GI bleeding in children older
than 2 years
 Esophageal and gastric varices
 Esophageal varices result from portal
hypertension regardless of the age
group.
 prehepatic, intrahepatic, and suprahepatic
obstruction,
 The most common causes of portal
hypertension in children are portal vein
thrombosis (prehepatic) and biliary atresia
(intrahepatic).
 Varices secondary to portal vein thrombosis
become apparent when a child is aged 2-3
years, and massive hematemesis may be
the presenting sign. Bleeding from varices
occurs in 80% of children with portal vein
thrombosis by the time they are aged 6
years.
Lower GI bleeding in children older
than 2 years
 Polyps
 The most common cause is
juvenile polyps, and this
remains true until the patients
are teenagers.
 benign hamartomas and may
require no treatment because
they autoamputate.
 Children present with painless
bleeding per rectum, which
often streaks the stool with
fresh blood.
 Colonoscopy is the diagnostic evaluation
of choice because it allows examination
of the entire colon and potential excision
of bleeding polyps when they are
identified.
 Colonoscopy is helpful in diagnosing
other polyposis syndromes such as
familial polyposis and adenomatous
polyps