manegement of lower GIT bleeding in children.pptx

to detect causes, epidemiology, key clinical features of different causes, diagnosis, manegement

1. Lower GIT bleeding BY Prof. DR. Mohamed Elsayed Hamed Professor of pediatric gastroenterology & endoscopy – Zagazig university

2. Objectives • Define lower GI bleeding in children • Review epidemiology and age-specific causes • Understand clinical presentation • Outline diagnostic approach • Discuss management strategies • Highlight referral and follow-up considerations

3. Definitions Hematemesis : emission of bright red blood from the mouth, in case of active bleeding, or “coffee- ground” colored material, in case of non-recent bleeding. Melena: black and foul-smelling stool emission from the anus. These characteristics are due to the hemoglobin oxidation to hematin by intestinal enzymes and floral bacteria. Hematochezia : passage of bright red or dark (due to the presence of clots) blood via rectum, isolated or mixed to stool or mucus. Overt bleeding : passage of visible blood whose origin has not been identified by endoscopic or radiological investigations. Occult bleeding : passage of not visible blood suggested by laboratory tests (e.g. iron deficiency anemia) and confirmed by positive fecal occult blood t

4. Epidemiology prevelance of approximately 6.4 % Less common than upper GI bleeding. The mortality of LGIB is estimated around 0.9%

5. Common and rare Causes of lower GI bleed in children by age   Neonate Swallowed maternal blood , Necrotising enterocolitis Hirschsprung’s disease with enterocolitis, Malrotation with midgut volvulus, Coagulopathy Vascular malformations, Brisk upper GI bleeding, GI duplication cyst, Allergic colitis ,Anal fissure Infancy (1 month-2 years) Meckel’s diverticulum, Intussusception, Infantile/very early onset inflammatory bowel disease (VEO-IBD) Infectious colitis ,Foreign body Malrotation, Vascular malformation Hirschsprung’s disease enterocolitis, Anal fissure Allergic colitis

6. Preschool (2-5 years) Juvenile polyps, vasculitis (Henoch- Schonlein Purpura/HSP) Haemolytic - Uraemic -Syndrome (HUS), Solitary rectal ulcer syndrome Anal fissure, Infectious colitis ,Vascular malformation, VEO-IBD Intussusception, Meckel’s Diverticulum, Foreign body School age (5-16 years) Inflammatory bowel disease , Haemorrhoids Anal fissure, Infectious colitis, HSP ,HUS, ,Meckel’s diverticulum, Juvenile polyps , Foreign body

7. Key clinical features of diagnoses Swallowed maternal blood Occurs secondary to cracked/sore nipples in breast fed babies Necrotising enterocolitis (NEC) Bowel ischaemia and necrosis causing LGIB Aetiology poorly understood but more common in preterm/low birth weight babies Can present with various symptoms – poor feeding, bilious vomiting, abdominal distension Hirschsprung’s disease with enterocolitis Hirschsprung’s disease is a congenital malformation resulting in  aganglionic   portions of bowel which are unable to undergo peristalsis Hirschsprung associated enterocolitis is a form of toxic megacolon, which is a medical emergency, and can present with lower GI bleeding

8. Malrotation with midgut volvulus During gestation the midgut rotates within the abdominal cavity, in malrotation this does not occur in the normal way, giving rise to the potential for the midgut to form a volvulus. The volvulus can cause an obstruction which can lead to bowel ischaemia and therefore bleeding A pathognomonic sign of the volvulus is the so-called “Whirlpool Sign”, a spiraling of the superior mesenteric vein around the superior mesenteric axis, easily recognizable on CT Coagulopathy These include: Vitamin K deficiency Von Willebrand disease Haemophilia

9. Anal fissures Can occur at any age, starting in the neonatal period Associated with difficult defecation or straining Commonly suggests underlying constipation. In older children, recurrent anal fissures should raise suspicion of sexual abuse Allergic colitis Occurs in 5-15% babies Can be triggered by a cow’s milk protein, or soy protein allergy which results in an inflammatory colitis which can present with diarrhoea , faltering growth and LGIB Occurs in bottle fed and breast-fed babies , due to dairy or soy milk which can be found in the breast-feeding adult’s diet Frequently resolves around 18 months of age and dairy/soy can be gradually reintroduced into the baby’s diet

10. GI duplication cysts Congenital malformations commonly found in the jejunum and ileum Case study reports suggest they can contain ectopic GI mucosa which can cause LGIB More frequently present with obstruction , can be a lead point for intussusception Vascular Malformations Congenital telangiectasias can occur in children with certain congenital diseases e.g. Hereditary Haemorrhagic Telangiectasia (Osler-Weber- Rendu ) Klippel- Trenaunay Syndrome Turner’s Syndrome These can all produce GI telangiectasias which can produce significant lower GI bleeding Meckel’s Diverticulum Bleeding can result from acid production by ectopic mucosa found within the diverticulum The severity and chronicity of the bleeding can vary 60% of patients who present with LGIB secondary to Meckel’s diverticulum are younger than 2 years old

11. Diagnosed by Meckel’s scan ((99Tc-pertechnetate nuclear scan) a false positive result is gastrointestinal duplication , since it contains internal gastric heterotopic mucosa that can concentrate the Tc-pertechnetate , Vascular malformation, False negative results can also occur from small amounts of ectopic gastric mucosa in the diverticulum or technical problem. Single Photon Emission Computed Tomography (SPECT) or SPECT-CT can overcome Meckel scan

12. Intussusception This occurs when a portion of bowel ‘telescopes’ within itself In children under 2 years it is commonly idiopathic but in older children the lead point is more commonly a duplication cyst or a Meckel’s diverticulum Presents with  paroxysmal abdominal pain  which can  transiently improve  following a vomit or a bowel movement The child sometimes has a sausage shaped abdominal mass and is having ‘red current jelly’ stools Infectious colitis Signs of colitis are bloody diarrhea, tenesmus, urgence to defecate, nighttime stooling and abdominal pain. Commonly shigella, salmonella, campylobacter and Escherichia coli O157:H7 Giardia and Entamoeba histolytica if there is a travel history

13. The  target sign  of  intestinal intussusception , also known as the  doughnut sign  or  bull's eye sign .

14. inflammatory bowel disease chronic, immune-mediated disorders  interplay between host genotype, environment, microbiome, and immune system. use of anti-tumor necrosis factor therapy for patients at high risk for complicated disease. . In treating patients with IBD, biochemical or endoscopic remission, rather than clinical remission , is the therapeutic goal because intestinal inflammation often persists despite resolution of abdominal symptoms.

15. Pediatric IBD: common patterns of inflammation and endoscopic images. A: UC. Pancolitis . Diffuse inflammation with erythema, exudates, and loss of vascular pattern. B: CD. Skipped lesions in upper and lower GI tract. Deep longitudinal ulcers in the terminal ileum. Multiple aphtoid ulcers in the descending colon

16. Algorithm for high suspicion of IBD

17. Single Juvenile polyp These are submucosal growths with a prevalence of 7-12%, most commonly found in boys below 10 years old Produce haematochezia and occasional abdominal pain Rarely malignant , more commonly an inflammatory process Foreign body This could have been swallowed or inserted into the rectum Beware button batteries or “super strong ” magnets which can erode through gut mucosa causing bleeding, or objects with sharp edges which can cause trauma Immunoglobulin A deficiency, or Henoch Schonlein Purpura (HSP) A systemic vasculitis which most commonly presents between the ages of 3-15y Presents with cutaneous purpura, arthralgia and abdominal pain Can also produce LGIB

18. Juvenile polyposis syndrome AD genetic condition A mutation of the BMPR1A and SMAD4 genes There are three types : Juvenile polyposis of infancy (JPI) : The most severe type   Generalized juvenile polyposis : The most common type Juvenile polyposis coli : polyps to form only in the colon. Presented by bleeding per rectum, diarrhea, abdominal pain, constipation  juvenile polyposis syndrome are benign  should schedule a screening every year unless no polyps are found , then screenings should be done every three years ..

19. Haemolytic Uraemic Syndrome A complication of  E.coli 0157:H7  which produces a toxin that can result in HUS A triad of microangiopathic haemolytic anaemia , thrombocytopaenia and acute renal injury Develops 5-10 days after the onset of diarrhoea Solitary rectal ulcer syndrome uncommon in children . typically linked to constipation and excessive straining during bowel movements This strain can result in the prolapse of rectal mucosa into the anal canal , leading to congestion, edema, and ulceration resulting in bright red blood in the stool and pain on defecation Haemorrhoids More common in older adolescents Frequently associated with constipation retroflexion maneuver in rectum is fundamental to better evaluate the internal anal region

20. Clinical assessment Firstly, assess the child for signs of haemodynamic instability History 1 find any clues which could suggest the cause of the bleeding . Colour of stool – bright red/black or tarry Is it definitely blood ? – discolouration of stool by ingested substances e.g. liquorice , beetroot. Is it definitely from the GI tract ? – consider haemoptysis or epistaxis as causes for blood passing through the GI tract Quantity of blood Any other GI symptoms – diarrhoea , vomiting, abdominal pain

21. Any systemic upset – lethargy, weight loss Any other evidence of bleeding disorder – bruising easily/petechiae Recent travel Other medications – NSAIDs, anticoagulants Potential ingestion of harmful substances which could cause bleeding Trauma Co-morbidities e.g . liver disease Family history of GI disorders which could cause LGIB e.g. inflammatory bowel disease

22. Examination checking cardiovascular stability considering hypotension/tachycardia/prolonged CRT  Check skin for pallor, abnormal bruising or petechiae and jaundice telangiectasias, bluish nodules, and hemangioma, that can be clue for multisystem vascular diseases such as hereditary hemorrhagic telangiectasia, blue nevus syndrome, and visceral cutaneous angiomatosis with thrombocytopenia ENT examination for evidence of bleeding, check oral mucosa for ulceration During the head and neck examination, search for pigmented macules (freckles ) on the lips or buccal mucosa, typically observed in Peutz-Jeghers Syndrome

23. Abdominal examination for any distension, pain on palpation, masses (think sausage shaped mass for intussusception) or organomegaly Perianal examination, assessing for anal fissures, external haemorrhoids or abscesses, evidence of nappy rash which could result in blood being found in the nappy Anal inspection may reveal the presence of anal skin tags or perianal fistulae suspicious for Crohn’s disease A per rectum examination is rarely indicated in children in the emergency department

24. Red Flag Signs ⚠️ Persistent bleeding with hemodynamic instability Severe anemi a Abdominal distension or severe pain Signs of shock Bloody diarrhea with fever

25. Proposed algorithm for the approach to children with moderate-severe melena or hematochezia

26. Proposed algorithm for the approach to children with obscure gastrointestinal bleeding

27. Diagnostic Flowchart Start / ABC Stabilization Hemodynamic Assessment CBC / Coagulation / Stool Culture

28. Colonoscopy is indicated for patients with clinical or laboratory evidence of chronic inflammation ( more than 5 bloody stools per day, nighttime stooling, anemia, hypoalbuminemia ) or in well-appearing patients with persistent bloody diarrhea for more than two weeks or with fecal calprotectin high levels

29. Management Initial priorities include stabilizing the patient’s hemodynamic status. if the child is in hypovolaemic shock with a lower GI bleed then resuscitation will be required

30. Insert 2 large bore cannulae and take bloods: FBC, U&E, CRP, Coagulation, LFTs, blood group, and a VBG Initial fluid bolus of 10ml/kg, consider resuscitating with blood if available Reassess and repeat fluid bolus as indicated If they remain shocked, give 5ml/kg packed red cells as boluses alongside FFP at a 1:1 ratio If still shocked after 20ml/kg blood products then give 10ml/kg platelets and 0.1 ml/kg 10% calcium chloride. clinical assessment and appropriate diagnostic procedures.

31. Specific therapy based on cause: e.g., polypectomy for juvenile polyp, treatment of IBD, surgical for Meckel’s diverticulum, treatment of anal fissure (conservative). Refer to paediatric gastroenterology/surgery. Considerations for children : smaller blood volume, rapid decompensation, need for specialist paediatric care.

32. Prognosis and Follow-up Many mild cases resolve spontaneously; e.g., some series show >80% of LGIB in children may resolve without major intervention . Risk of recurrence depends on cause (e.g., polyps may recur, IBD requires long-term therapy) Importance of monitoring for anemia, growth, nutritional status.

33. Take-Home Messages Recognise that LGIB in children is uncommon but important Colour /characteristics of the stool/blood can guide localization Age-specific causes differ significantly from adults. Early stabilization + appropriate referral = key to good outcomes . Provide a checklist for clinicians.