Transcript Gastrointestinal Hemorrhage

Gastrointestinal Hemorrhage
Carolyn A. Sullivan, MD
Pediatric Gastroenterology
Walter Reed Army Medical Center
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
 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
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

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
Further assessment
 Is
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it really blood?
Hemoccult stool, gastroccult emesis
 Apt-Downey
test in neonates
 Nasogastric aspiration and lavage
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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
Substances that deceive
 Red
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discoloration
candy, fruit punch, Jell-o, beets, watermelon,
laxatives, phenytoin, rifampin
 Black
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discoloration
bismuth, activated charcoal, iron, spinach,
blueberries, licorice
Laboratory studies
 CBC,
ESR; BUN, Cr; PT, PTT in all cases
 Others as indicated:
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Type and crossmatch
AST, ALT, GGTP, bilirubin
Albumin, total protein
Stool for culture, ova and parasite examination,
Clostridium difficile toxin assay
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
Endoscopy: indications
 EGD:
hematemesis, melena
 Flexible sigmoidoscopy: hematochezia
 Colonoscopy: hematochezia
 Enteroscopy: obscure GI blood loss
DDx: neonates
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Upper GI bleeding
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swallowed maternal
blood
stress ulcers, gastritis
duplication cyst
vascular malformations
vitamin K deficiency
hemophilia
maternal ITP
maternal NSAID use
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Lower GI bleeding
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swallowed maternal blood
dietary protein intolerance
infectious colitis
necrotizing enterocolitis
Hirschsprung’s
enterocolitis
duplication cyst
coagulopathy
vascular malformations
Neonatal stress ulcers or gastritis
 Causes
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Shock
Sepsis
Dehydration
Traumatic delivery
Severe respiratory distress
Hypoglycemia
Cardiac condition
DDx: infants
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Hematemesis, melena
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Esophagitis
Gastritis
Duodenitis
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Hematochezia
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Anal fissures
Intussusception
Infectious colitis
Dietary protein intol.
Meckel’s diverticulum
Duplication cyst
Vascular malformation
DDx: children
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Upper GI bleeding
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Esophagitis
Gastritis
Peptic ulcer disease
Mallory-Weiss tears
Esophageal varices
Pill ulcers
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Lower GI bleeding
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Anal fissures
Infectious colitis
Polyps
Lymphoid nodular
hyperplasia
IBD
HSP
Intussusception
Meckel’s diverticulum
HUS
Esophageal varices
Erosive esophagitis
DDx: adolescents
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Hematemesis, melena
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Esophagitis
Gastritis
Peptic ulcer disease
Mallory-Weiss tears
Esophageal varices
Pill ulcers
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Hematochezia
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Infectious colitis
Inflammatory bowel
disease
Anal fissures
Polyps
NSAID induced ulcers
Peptic Ulcer
Mallory-Weiss Tear
Risk of rebleeding of ulcer
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Stigmata of recent
hemorrhage
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Visible vessel
Clot
Spot
Clean base
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Rate of rebleed
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40-50%
25-30%
10%
2-4%
Ulcer with red spot
Therapy
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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
Bleeding Ulcer