Lower GI Bleeding in Children

Lower GI Bleeding in Children PowerPoint PPT Presentation


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Definition. Originates from the intestine distal to the ligament of Treitz, which is located at the junction of the duodenum and jejunum. Definition. Melena: passage per rectum of black tarry stools; usually indicates upper GI bleedHematochezia: passage of bright red blood per rectum; usually indicated lower GI bleed, but can occur with massive upper GI bleed.

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Lower GI Bleeding in Children

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1. Lower GI Bleeding in Children Fairly common chief complaint Rectal bleeding accounts for up to 0.3% of visits to major urban ERs Provokes alarm and anxiety in parents and physicians Differential diagnosis is extensive and varies according to age Most etiologies are self-limited and benign

3. Definition Melena: passage per rectum of black tarry stools; usually indicates upper GI bleed Hematochezia: passage of bright red blood per rectum; usually indicated lower GI bleed, but can occur with massive upper GI bleed

4. Differential Diagnosis: Neonate Anorectal fissures (***most common***) Swallowed maternal blood Necrotizing enterocolitis Malrotation with midgut volvulus Hirschsprung disease

5. Differential Diagnosis: Infant Anorectal fissures (***most common***) Allergic enterocolitis Intussusception Meckel diverticulum Hemolytic uremic syndrome Henoch-Schonlein purpura Lymphonodular hyperplasia Gastrointestinal duplication Infectious colitis

6. Differential Diagnosis: Preschooler Juvenile Polyps Infectious colitis Intussusception Meckel diverticulum Hemolytic uremic syndrome Henoch-Schonlein purpura

7. Differential Diagnosis: Schoolage and Adolscence Juvenile Polyps Infectious colitis Inflammatory bowel disease Hemorrhoids Vaginal bleeding

8. Don't forget! Upper GI bleed-->Lower GI bleed Coagulopathy Trauma False positives

9. False Positive Visible “Blood” Antibiotics (Ampicillin, Rifampin) Bismuth preparations (Pepto-Bismol) Beets Chocolate Flavored gelatin Iron Kool-aid Red licorice

10. What does this look like?

11. Anal Fissure Most common cause in the first 2 years of life Blood is generally bright red and present on the outside of the stool Results from superficial tear of the squamous lining of the anal canal Usually caused by passage of large, constipated stool Painful, leads to with-holding (initiates a vicious cycle)

12. Food Allergy Can present with postprandial nausea, vomiting, abdominal pain, and diarrhea, +/- iron deficiency anemia May exhibit malabsorption, protein-losing enteropathy, and failure to thrive May see infiltration of GI tract with eosinophils and/or peripheral eosinophilia The most common allergens are-->???

13. Food Allergy Can present with postprandial nausea, vomiting, abdominal pain, and diarrhea, +/- iron deficiency anemia May exhibit malabsorption, protein-losing enteropathy, and failure to thrive May see infiltration of GI tract with eosinophils and/or peripheral eosinophilia The most common allergens are--> Cow's milk and soy protein

14. Meckel Diverticulum Results from incomplete obliteration of the omphalomesenteric duct Ulceration of adjacent ileal mucosa by heterotopic gastric mucosa in the diverticulum Painless passage of large amount of blood “Rule of Twos”

15. What could this be?

16. Intussusception Most common in children under 2 years Colicky abdominal pain, vomiting, palpable sausage-shaped abdominal mass, passage of “currant jelly stool”

17. Infectious Enteritis Diagnosed based on stool culture Bacterial: Shigella, Salmonella, Campylobacter, E. coli, Yersinia, C. diff Viral: Rotavirus, Norwalk virus Parasitic: Entameoba histolytica Consider sexual abuse: Gonorrhea, Chlamydia, HSV

18. Juvenile Polyps Most common source of lower GI bleeding beyond infancy Occur between 2 and 8 years Peak at 3 to 4 years Benign hamartomas (arise from normal tissue) Painless rectal bleeding Majority located in the rectosigmoid region Bright red blood on the outside of the stool Bleed after autoamputation or injury by fecal passage

19. Hemorrhoids Rare in infants and children If present, portal HTN should be suspected Not uncommon in constipated adolescents Usually present with bleeding upon defecation Blood may be on the surface of the stool, on the toilet paper, or in the toilet bowl

21. Now what are you thinking?

22. Inflammatory Bowel Disease Approximately 25% of patients present before age 20years Rectal bleeding is seen in almost all of UC patients and 25% of CD patients

23. History Duration of bleeding Amount of bleeding Color of blood Relationship to stool Consistency of accompanying stool Presence of blood on toilet paper Associated symptoms Past episodes of GI bleeding Recent use of medications, including NSAIDs

24. Physical Exam Vitals: Febrile, tachycardia, hypotension General: Pallor, distress, nutritional status HEENT: Posterior nose (to r/o epistaxis) Skin: Ecchymoses, jaundice, eczema Abdomen: Caput medusa, ascites, bowel sounds, masses, tenderness Rectal: Fissures, hemorrhoids, skin tags GU: Vaginal bleeding

25. Management Treatment should be directed at the underlying cause Don't forget your ABCs Have a low threshold for volume replacement and possible blood transfusion in a severe acute GI bleed In the majority of patients, supportive therapy remains the mainstay of treatment

26. Laboratory Evaluation CBC Coags LFTs Chem-10 Stool cultures (bacterial, viral, O&P) Confirmatory occult blood test False +: red meat, iron supplements, turnips, horseradish, broccoli, cauliflower, cantaloupe

27. Diagnostic Studies Supine and upright AXRs Small bowel series Air-contrast barium enema Technitium-99 pertechnetate scan Technitium-99 labelled erythrocyte scan Angiography Anoscopy Proctosigmoidoscopy vs. colonoscopy

28. Red arrows point to linear bands of radiolucency which parallel the wall of the bowel indicating the presence of pneumatosis intestinalis in NEC

29. Technetium-99m pertechnetate has affinity for oxyntic cells (gastric mucosa) which will identify the location of a Meckel diverticulum

30. Anoscopes (disposable)

31. Juvenile polyps

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