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Approach to a child with
hematemesis or melena
Avijeet k. Mishra
1st year Resident
Guide – Dr Surya Bahadur Thapa
DOCH
Contents
 Introduction
 Etiology
 Initial assessment and stabilization
 History
 Physical examination
 Investigation...
Case
A 32 months old male presented to us with a history of 2 days of
abdominal pain , 3 episodes of black colored stool a...
Introduction
Upper gastrointestinal bleeding-
Bleeding from a site proximal to the ligament of Treitz
Hematemesis is the ...
Contd..
 Hematemesis-
Vomiting of blood which may be red or coffee grounds
 Melena-
Passage of black tarry stools
Action...
Etiology
Neonate
 Swallowed maternal blood
- During delivery
- From mother’s nipple
 Coagulopathy
- Hemorrhagic disease ...
Contd…
 Stress ulcers/ gastritis – critically ill newborns
 Drug intake
-by mother: warfarin, aspirin
-by neonate: indom...
Contd…..
Infant
 Mucosal erosion :
-Reflux esophagitis
-Pyloric stenosis
 Coagulation disorders
 Bacterial/amoebic ente...
Contd..
Children
 Swallowed epistaxis
 Reflux esophagitis
 Gastric erosion/ gastritis/ peptic ulcer
 Esophageal varice...
Contd..
Adolescents
 Swallowed epistaxis
 Gastric erosion/ gastritis/ peptic ulcer (drugs, H. pylori infection, stress-
...
Contd….
At our center out of 83 patients with gastrointestinal bleeds
undergoing endoscopy, 40 were found to have esophag...
Initial assessment and stabilization
 As for any other emergency the first priority should be to assess the circulation,
...
contd..
1. Whether actual blood loss or ingested substances
• Hematemesis
food coloring
red candy
colored gelatin
beets
to...
Contd…
- For detecting blood in vomitus or nasogastric aspirate
Gastroccult test is used
2. In neonate –
Whether patients ...
Contd…
3. Is there a pulmonary, oral or ENT source of bleed?
- Epistaxis, sore throat, dental procedures or tonsillectomy
...
Focused history
 Age of patient
 Magnitude and duration
 Color and amount of hematemesis/ melenous stool
 Associated G...
Contd..
 Sudden onset of bright color hematemesis and melena
of large amount: Esophageal varices
 Gradual onset chronic,...
Contd..
 Acid regurgitation, nausea, vomiting, water brash, retrosternal pain: Reflux
esophagitis
 Anorexia, nausea, vom...
Contd..
 History of drug intake: NSAIDS, corticosteroids, Mucosal irritants, iron
preparation: Gastritis.
 Poisoning : P...
Contd…
 Review of Systems
GI disorders
Liver disease
Bleeding diathesis
 Family History
GI disorders (polyps, ulcers, co...
Physical examination
 Vital signs :- PR, BP, RR, CRT
 Pallor, diaphoresis, confusion, obtundation, tachycardia,
tachypne...
Contd..
Pallor- Increased paleness will point towards ongoing blood
loss
Icterus- chronic liver disease
Skin- petechiae...
Contd…..
 Gastrointestinal examination
1. Epigastric tenderness – acute gastritis or peptic ulcer disease
2. Protruding a...
Investigations
 In an emergency setting only a few tests are essential in the beginning to
evaluate UGIB
CBC
PT/INR
APTT
...
Contd..
2. Endoscopy-
- UGI endoscopy is the gold standard for diagnosis and treatment of UGIB
- Procedure of choice for a...
Contd..
4. Nuclear scintigraphy-
- In persistent bleeding in whom endoscopy fail
- Useful only if the rate of bleeding exc...
Management
 The initial steps in the management of severe UGIB include assessment,
resuscitation, re- evaluation, identif...
Contd….
Blood transfusion-
- Rate depends on severity, continuing active bleeding and co-morbidities
- BT not needed in he...
Contd..
Reassessment and monitoring-
-Vitals should be monitor every 10- 15 minutes till stabilized
-Then hourly for 24 h...
Contd…
Correction of coagulopathies-
- Vitamin k given empirically
- Coagulopathy with INR >1.5 or abnormal aPTT- FFP
Ph...
Contd….
 Endoscopic techniques
1. Variceal bleed-
Endoscopic sclerotherapy is the mainstay of treatment in this group
End...
Case
Our case presented to us in the ER. At presentation he was an
average build child with pallor and vitals of T-98*F, ...
Contd…
 USG abdomen- splenomegaly, N hepatic echotexture, thickened wall of
extrahepatic portal vein
 CT portogram- port...
Summary
UGI bleeding is a potentially life threatening emergency requiring
an appropriate diagnostic and therapeutic appr...
Reference
Indian journal of pediatrics
Pediatric in review
Nelson textbook of pediatrics
www.Wikipedia.com
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Approach to a child with hematemesis or melena

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Approach to a child with hematemesis or melena

  1. 1. Approach to a child with hematemesis or melena Avijeet k. Mishra 1st year Resident Guide – Dr Surya Bahadur Thapa DOCH
  2. 2. Contents  Introduction  Etiology  Initial assessment and stabilization  History  Physical examination  Investigations  Management  summary
  3. 3. Case A 32 months old male presented to us with a history of 2 days of abdominal pain , 3 episodes of black colored stool and 1 episode of fresh blood mixed with feces small in quantity without any similar past history. He had uneventful neonatal period and no history of rashes or bleeding from other sites.
  4. 4. Introduction Upper gastrointestinal bleeding- Bleeding from a site proximal to the ligament of Treitz Hematemesis is the cardinal sign Some may present with melena Lower gastrointestinal bleed- Bleeding from site distal to the ligament of Treitz Hematochezia is the usual presentation
  5. 5. Contd..  Hematemesis- Vomiting of blood which may be red or coffee grounds  Melena- Passage of black tarry stools Action of digestive enzymes and bacteria change the color of stool to black tarry and foul smelling  Hematochezia – Passage of fresh blood per anus, usually in or with stool
  6. 6. Etiology Neonate  Swallowed maternal blood - During delivery - From mother’s nipple  Coagulopathy - Hemorrhagic disease of the newborn - Septicemia, DIC - Hemophilia
  7. 7. Contd…  Stress ulcers/ gastritis – critically ill newborns  Drug intake -by mother: warfarin, aspirin -by neonate: indomethacin, steroids  Vascular malformation- hemangioma, AV-malformation Duplication cyst  Gastrointestinal polyposis syndrome
  8. 8. Contd….. Infant  Mucosal erosion : -Reflux esophagitis -Pyloric stenosis  Coagulation disorders  Bacterial/amoebic enteritis, Intussusception, Mid gut volvulus, Meckel's diverticulum, Milk protein allergy, AV malformation
  9. 9. Contd.. Children  Swallowed epistaxis  Reflux esophagitis  Gastric erosion/ gastritis/ peptic ulcer  Esophageal varices  Mallory-Weiss syndrome  Coagulopathy  Dysentery, intussusception, volvulus, Meckel’s diverticulum, colonic polyps, HSP
  10. 10. Contd.. Adolescents  Swallowed epistaxis  Gastric erosion/ gastritis/ peptic ulcer (drugs, H. pylori infection, stress- severe systemic disease, burn, raised ICP)  Mallory Weiss tear  Esophageal varices  Inflammatory bowel disease, dysentery, colonic polyps  Vascular lesions- telangeictasia, angiodysplasia, hemangioma, AV malformation
  11. 11. Contd…. At our center out of 83 patients with gastrointestinal bleeds undergoing endoscopy, 40 were found to have esophageal varices, 8 had gastric erosion , 1 had polyp and 34 had normal endoscopy
  12. 12. Initial assessment and stabilization  As for any other emergency the first priority should be to assess the circulation, breathing and airway of a patient presenting with UGIB  Most important aspect of evaluation is to determine the degree and rapidity of blood loss  Orthostatic changes in BP(more than 10 mm Hg) suggest a moderate bleed(15-20% blood loss) and warrant a more aggressive approach to management  Presence of signs of shock (tachycardia, prolonged CRT, cold clammy skin, supine hypotension) indicates severe bleed of more than 25-30% of blood loss and a need for immediate volume expansion and stabilization before proceeding to a diagnostic algorithm
  13. 13. contd.. 1. Whether actual blood loss or ingested substances • Hematemesis food coloring red candy colored gelatin beets tomato skin rifampin phenytoin • Melena bismuth iron preparations licorice spinach grapes blueberries charcoal
  14. 14. Contd… - For detecting blood in vomitus or nasogastric aspirate Gastroccult test is used 2. In neonate – Whether patients own blood or swallowed blood Apt-Downey test is used to differentiate
  15. 15. Contd… 3. Is there a pulmonary, oral or ENT source of bleed? - Epistaxis, sore throat, dental procedures or tonsillectomy - Hence these areas must be explored to rule out in cases of doubt 4. Level of bleeding - Acute onset hematochezia or melena- level of bleeding can be confirmed by the passage of a nasogastric tube - Presence of blood in stomach and clearing of nasogastric aspirate with lavage are diagnostic of UGIB
  16. 16. Focused history  Age of patient  Magnitude and duration  Color and amount of hematemesis/ melenous stool  Associated GI symptoms :- vomiting, diarrhea, pain  Associated systemic symptoms :- fever, rash, joint pains, dizziness, palpitations
  17. 17. Contd..  Sudden onset of bright color hematemesis and melena of large amount: Esophageal varices  Gradual onset chronic, mild hematemesis and melena: Acid peptic disease  Preceding repeated forceful vomiting and retching: Mallory Weiss syndrome
  18. 18. Contd..  Acid regurgitation, nausea, vomiting, water brash, retrosternal pain: Reflux esophagitis  Anorexia, nausea, vomiting and epigastric pain with relation to food: Peptic ulcer  Bloody diarrhea, vomiting, abdominal pain, fever: Dysentery  History of easy bruising or bleeding: coagulation, platelet dysfunction or thrombocytopenia
  19. 19. Contd..  History of drug intake: NSAIDS, corticosteroids, Mucosal irritants, iron preparation: Gastritis.  Poisoning : Paracetamol, iron.  Risk factors for portal HTN: umbilical sepsis / catheterization, jaundice, liver disease- Esophageal varices  H/o chronic cough, recurrent lung infections: Cystic fibrosis, Bronchiectasis.
  20. 20. Contd…  Review of Systems GI disorders Liver disease Bleeding diathesis  Family History GI disorders (polyps, ulcers, colitis) Liver disease Bleeding diathesis
  21. 21. Physical examination  Vital signs :- PR, BP, RR, CRT  Pallor, diaphoresis, confusion, obtundation, tachycardia, tachypnea → Shock.  Acute losses of 10-25% of blood volume cause tachycardia, narrow pulse pressure and postural hypotension.  Earliest sign to increase is HR
  22. 22. Contd.. Pallor- Increased paleness will point towards ongoing blood loss Icterus- chronic liver disease Skin- petechiae, Purpura, ecchymoses, vascular malformations, stigmata for chronic liver disease like spider angioma, palmar erythema Examination of nose, oral cavity and throat
  23. 23. Contd…..  Gastrointestinal examination 1. Epigastric tenderness – acute gastritis or peptic ulcer disease 2. Protruding abdomen, prominent blood vessels and Hepatosplenomegaly – portal hypertension and bleeding from esophageal varices 3. Splenomegaly- Extrahepatic portal vein obstruction(EHPVO) 4. Examination of perineum and rectum
  24. 24. Investigations  In an emergency setting only a few tests are essential in the beginning to evaluate UGIB CBC PT/INR APTT LFT Blood grouping and Cross matching  Further investigations 1. abdominal USG- EHPVO, portal hypertension due to liver disease, large vessel anomalies, splenic artery aneurysm
  25. 25. Contd.. 2. Endoscopy- - UGI endoscopy is the gold standard for diagnosis and treatment of UGIB - Procedure of choice for all patients with UGIB. - In the skilled hands diagnosis of etiology in 85-90% of cases - Contraindicated in in hemodynamically unstable patients 3. CT angiography - Vascular malformations beyond the duodenum , in areas not accessed by routine UGI endoscopy
  26. 26. Contd.. 4. Nuclear scintigraphy- - In persistent bleeding in whom endoscopy fail - Useful only if the rate of bleeding exceeds 0.1 ml/min 5. Angiography- - Celiac/ superior mesenteric artery angiography is used selectively in children with non-variceal bleeding eg from peptic ulcer, that obscures endoscopic evaluation and therapy - Also important in hemobilia, splenic artery aneurysm and some types of vascular malformation - Bleeding must be 0.5 ml/min to be detected by angiography
  27. 27. Management  The initial steps in the management of severe UGIB include assessment, resuscitation, re- evaluation, identification of the cause and source of bleeding and commencing appropriate treatment  Resuscitation and stabilization 1. Circulation- large bore venous access to restore blood volume crystalloids initially blood transfusion
  28. 28. Contd…. Blood transfusion- - Rate depends on severity, continuing active bleeding and co-morbidities - BT not needed in hemodynamically stable patient that has hematocrit above 24% - Overtansfusion should be avoided in variceal bleed 2. Airway – -Intubation in uncontrolled massive hematemesis to prevent aspiration and facilitate endoscopy if necessary 3. Breathing – Supplemental oxygen
  29. 29. Contd.. Reassessment and monitoring- -Vitals should be monitor every 10- 15 minutes till stabilized -Then hourly for 24 hours after bleeding stops Nasogastric aspiration- Aspiration and saline lavage indicated in all patients with UGIB to confirm - Presence of intragastric blood - Rate of gross bleeding - Check for ongoing or recurrent bleeding - Clear gastric field for endoscopic visualization - Prevent aspiration - Prevent hepatic encephalopathy in patients of cirrhosis
  30. 30. Contd… Correction of coagulopathies- - Vitamin k given empirically - Coagulopathy with INR >1.5 or abnormal aPTT- FFP Pharmacotherapy 1. Variceal bleed- Octeotride- Drug of choice for variceal bleed Acts by decreasing splanchnic blood flow Vasopressin, Terlipressin Somatostatin 2. Prokinetic agents- Erythromycin, Metoclopramide 3. Mucosal bleed- PPI, H2 blocker
  31. 31. Contd….  Endoscopic techniques 1. Variceal bleed- Endoscopic sclerotherapy is the mainstay of treatment in this group Endoscopic variceal ligation 2. Nonvariceal bleed Injection adrenaline and saline Endoclip devices  Balloon tamponade Sengstaken-blakemore tube Used in whom bleeding continues despite pharmacotherapy and endoscopic methods
  32. 32. Case Our case presented to us in the ER. At presentation he was an average build child with pallor and vitals of T-98*F, PR- 170, BP- 90/60, RR- 36. He was pale and anicteric. On per abdomen he had splenomegaly of about 3 cm. Rest of the exam was normal. Lab investigations- Hb- 5.7, TLC – 13,000, platelets 17,600 LFT-N , RFT- N PT/INR- N, aPTT- N
  33. 33. Contd…  USG abdomen- splenomegaly, N hepatic echotexture, thickened wall of extrahepatic portal vein  CT portogram- portal cavernoma with multiple collaterals at splenic hilum, peri-cholecystic, peri-pancreatic region  UGI endoscopy- grade 3 varices
  34. 34. Summary UGI bleeding is a potentially life threatening emergency requiring an appropriate diagnostic and therapeutic approach Therefore primary focus in a child with UGI bleed is resuscitation and stabilization followed by a diagnostic evaluation In infants and toddlers mucosal erosion is the most common cause while in older children variceal bleeding due to EHPVO is most common UGI endoscopy is the most accurate and useful diagnostic tool to evaluate UGI bleed Treatment depends on the cause
  35. 35. Reference Indian journal of pediatrics Pediatric in review Nelson textbook of pediatrics www.Wikipedia.com

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