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An Approach to Managing GI Bleed in Children
1. AN APPROACH TO CHILD WITH
GI BLEED
Syed Awais Ul Hassan Shah
1st year Trainee Pediatrics
2. Background
⢠Gastrointestinal (GI) bleeding in infants and
children is a fairly common problem,
accounting for 10%-20% of referrals to
pediatric gastroenterologists.
3. Definitions
⢠Melena is the passage of black, tarry stools;
suggests bleeding proximal to the ileocecal valve
⢠Hematochezia is passage of bright or dark red
blood per rectum; indicates colonic source or
massive upper GI bleeding
⢠Hematemesis is passage of vomited material that
is black (âcoffee groundsâ) or contains frank
blood; bleeding from above the ligament of Treitz
4. PATHOPHYSIOLOGY OF GI BLEED
⢠1. Consequences of blood loss
⢠2. Risk of hemorrrhagic shock
⢠3. Compensatory mechanism
5. 1. PATHOPHYSIOLOGIC
CONSEQUENCES OF BLOOD LOSS
⢠LOSS OF FLUID(BLOOD) ď DEC. ECF ď
DEHYDRATION ď SHOCK ď DEC GFRď ANURIA
PRE-RENAL A.R.F (INC. BUN AND NITROGEN)
SMALL VOL CONCENTRATED URINE WITH HIGH
SPECIFIC GRAVITY
6. 2. Higher risk for hemorrhagic shock in
children
⢠Age-dependent vital signs ď inaccurate
interpretation of early signs
⢠High ratio surface area to body mass ď
limited thermoregulation ď hypothermia ď
ď pulmonary HT ď hypoxemia acidosis
⢠Smaller total body volume
⢠Lower hematocrit level
7. 3. Sequence of compensatory
mechanism
⢠Loss of less than 15% of BV is compensated
by:
â Contraction of the venous system
â Fluid shift ECFC ď IVFC
â Preferential direction of blood to the brain and the
heartď No hemodynamic changes
8. ⢠Loss 15%-30% BV
â Sympathetic stimulation
â Secretion of aldosterone, ADH, prostaglandins
â Release of catecholamine
â Release of ACTH and corticosteroids
ď ď ď Hemodynamic instability
Tachycardia, O2 consumption, tissue hypoxia
ď ď ď Maintain blood volume
9. ⢠Loss of more than 30%
â Hypotension (Shock), dec. cardiac outputď
ď acidosisď tissue damage
â Acute renal failure
â Liver failure
â Heart failure
10. SYMPTOMS OF UPPER GI BLEED
⢠Symptoms of upper gastrointestinal bleeding
include:
â vomiting bright red blood (hematemesis)
â vomiting dark clots, or coffee ground-like material
â passing black, tar-like stool (melena)
11. SYMPTOMS OF LOWER GI BLEED
⢠Symptoms of lower gastrointestinal bleeding
include:
â passing pure blood (hematochezia) or blood
mixed in stool
â bright red or maroon blood in the stool
12. ⢠Hematemesis : 50% of upper gastrointestinal
bleeding cases
⢠Hematochezia : 80% of all gastrointestinal
bleeding.
⢠Melena
â 70% of upper gastrointestinal bleeding
â 33% of lower gastrointestinal bleeding
â To form black, tarry stools (melena), there must be
150-200 cc of blood and the blood must be in the
gastrointestinal tract for 8 hours to turn black
23. HISTORY
⢠GENERAL QUESTIONS
â Acute or chronic bleeding
â Color and quantity of the blood in stools or vomitus
â Antecedent symptoms
â History of straining
â Abdominal pain
â Trauma
â History of foods consumed or drugs
24. HISTORY
⢠NEONATE
â MILK OR SOY PROTEIN ENTERITIS
â NSAIDs, heparin, indomethacin
â Maternal medications e.g Aspirin and Phenobarbital
â Stress gastritis e.g prematurity, neonatal distress,
and mechanical ventilation
25. HISTORY
⢠CHILDREN AGED 1 MONTH TO 1 YEAR
⢠Episodic abdominal pain that is cramping in nature, vomiting,
and currant jelly stools (intussusception)
⢠Fussiness and increased frequency of bowel movements in
addition to lower gi bleed (milk protein allergy)
26. HISTORY
⢠CHILDREN AGED 1-2 YRS
â Upper GI Bleed
⢠systemic diseases, such as burns (Curling ulcer), head trauma
(Cushing ulcer), malignancy, or sepsis
⢠NSAID
â Lower GI Bleed
⢠Polyps :- painless fresh streaks of blood in stools
27. HISTORY
⢠CHILDREN OLDER THAN 2 YRS
â lower GI bleeding occurs in association with profuse
diarrhea :- Infectious Diarrhea
â Recent antibiotic use : antibiotic-associated colitis
and Clostridium difficile colitis
28. ⢠A history of vomiting, diarrhea, fever, ill contacts, or travel
ď infectious etiology
⢠Sudden onset of melena in combination with bilious emesis in a
previously healthy, nondistended baby ď INTESTINAL
MALROTATION
⢠Bloody diarrhea and signs of obstruction ď VOLVULUS,
INTUSSUSCEPTION or NECROTIZING ENTEROCOLITIS, particularly in
premature infants
⢠Recurrent or forceful vomiting ď Mallory-Weiss tears
⢠Familial history or NSAID use ď ulcer disease
⢠Ingested substances, such as NSAIDs, tetracyclines, steroids,
caustics, and foreign bodies, can irritate the gastric mucosa enough
to cause blood to be mixed with the vomitus
⢠Recent jaundice, easy bruising, and changes in stool colorď liver
disease
⢠Evidence of coagulation abnormalities elicited from the history
ď disorders of the kidney or reticuloendothelial system
29. PHYSICAL EXAMINATION
⢠Signs of shock
⢠Vital signs, including orthostatics
⢠Skin: pallor, jaundice, ecchymoses, abnormal blood vessels,
hydration, cap refill
⢠HEENT: Epistaxis, nasal polyps, oropharyngeal erosions from
caustic ingestions
⢠Abdomen:
â organomegaly, tenderness, ascites, caput medusa
â Abdominal Surgical scars, Hyperactive bowel sounds (upper gi bleeding)
â Abdominal tenderness, with or without a mass(intussusception or
ischemic Bowel disease)
⢠Perineum: fissure, fistula, trauma
⢠Digital Rectum Examination: polyps, mass, occult blood, evidence
of child abuse
30. Substances that deceive
⢠Red discoloration
â candy, fruit punch, beets, watermelon, laxatives,
phenytoin, rifampin
⢠Black discoloration
â bismuth, activated charcoal, iron, spinach,
blueberries, licorice
31. CONSIDERATIONS
⢠Place NG tube to confirm presence of fresh
blood or active bleed. if confirmed
â Esophagogastroduosenoscopy â 90%
â Colonoscopy â 80%
⢠False negative results in 16 % if
duodenopyloric regurgitation is absent
32. FURTHER ASSESSMENT
⢠Is it really blood (haemoccult test)
⢠Apt-Downey test in neonates
â Used to differentiate between maternal and baby blood.
blood placed in test tubeď add sterile water (to hemolye
the RBCs yielding free Hb) ď mix with 1% sodium
hydroxideď if solution turns yellow or brownď maternal
blood
⢠Nasogastric aspiration and lavage
â Clear lavage makes bleeding proximal to ligament of Treitz
unlikely
â Coffee grounds that clear suggest bleeding stopped
â Coffee grounds and fresh blood mean an active upper GI
tract source
33. Laboratory studies
⢠CBC in all cases
â Normal hematocrit ď hypovolemia and hemoconcentration
â Leukocytosis ď infectious etiology
⢠ESR in all cases
⢠BUN, Cr in all cases
⢠PT, PTT in all cases
⢠Others as indicated:
â Type and crossmatch
â AST, ALT, GGTP, bilirubin
â Albumin, total protein
â Stool for culture, ova and parasite examination, Clostridium difficile toxin assay
â Plain abdominal Xray (NEC in neonates)
34. LAB STUDIES (contd..)
⢠Endoscopy
â Identifies site of upper GI bleed in 90 % cases
â FORRESS classification
⢠I â Active hemorrhage
â Ia :- bright red bleeding
â Ib :- slow bleeding
⢠II â Recent hemorrhages
â IIa :- non bleeding visible vessel
â IIb :- adherent clot on base of lesion
â IIc :- flat pigmented spot
⢠III â No evidence of bleeding
35. Endoscopy: indications
⢠EGD: hematemesis, melena
⢠Flexible sigmoidoscopy: hematochezia
⢠Colonoscopy: hematochezia
⢠Enteroscopy: obscure GI blood loss
36. LAB STUDIES (contd..)
⢠Colonoscopy
â Identifies site of lower GI bleed in 80 % cases
â Polyps, FAP syndrome, haemangiomas, vascular
malformations, ulceration, biopsy
38. INITIAL MANAGEMENT
⢠The initial approach to all patients with
significant GI bleed is :
â to establish adequate oxygen delivery.
â to place intravenous line.
â to initiate fluid and blood resuscitation
â to correct any underlying coagulopathies.
39. Therapy
⢠Supportive care: begin promptly
â Bowel Rest and NG decompression (esp in NEC)
â IV fluids
â Blood products (FFPs, RCC)
⢠Specific care
â Barrier agents (sucralfate)
â H2 receptor antagonists (cimetidine, ranitidine, etc.)
â Proton pump inhibitors (omeprazole, lansoprazole)
â Vasoconstrictors (somatostatin analogue[Octreotide], vasopressin,
Beta Blockers)
â Inj Vitamin K (HDN)
â Stool Softeners (Anal Fissure)
â Prokinetics (to reduce vomiting)
â Antibiotics (for enteritis, Cl. Difficile ass. Colitis)
â Withdrawl of offending milk protein (in cases of milk protein allergy)
â H.pylori Eradication ( triple therapy)
40. Therapeutic Procedures
⢠Endoscopy: stabilize and prepare patient first
â Coagulation (injection, cautery, heater probe, laser)
â Variceal injection or band ligation
⢠Colonoscopy :
â To treat colonic polyps, hemangiomas, AV malformations,
⢠Barium or saline enema :
â Intussusception
⢠Arteriography
⢠TIPS (variceal bleeds)
⢠Sengstaken Blakemore balloon tamponade
41. Surgical options
⢠If all medical measures fail
â Laprotomy
â Laproscopy
â Vagotomy
â Pyloroplasty
â Fissurotomy, fistulectomy
â Diverticulectomy