GASTROINTESTINA BLEEDING in paediatrics.

Excerpts
On Gastrointestinal bleeding in paediatrics

1. GASTROINTESTINA BLEEDING DR DAUDA DAMINA SENIOR REGISTRAR DEPARTMENT OF PAEDIATRICS UMTH 16/08/2024 1

2. OUTLINE. Introduction Epidemiology Relevant anatomy Definitions Aetiology Management Resuscitation History Examintation Treatment Conclusion 16/08/2024 2

3. INTRODUCTION Gastrointestinal (GI) bleeding is a relatively common and potentially serious problem in paediatrics. Bloody emesis or bloody stools are very anxiety provoking for parents Fortunately, many cases do not result in serious health consequences and haemodynamically significant bleeding is uncommon. Broadly classified into upper and lower GI bleeding. The spectrum of causes ranges from a small amount of bleeding as seen in an infant with an anal fissure to severe bleeding that may be present in a child with varices from underlying chronic liver disease. The initial approach to patients with significant GI bleeding should be to ensure patient stability. It is important to quickly to determine the site and severity of bleeding in order to institute prompt treatment. 16/08/2024 3

4. EPIDEMIOLOGY. Severe GI bleeds are rare in the general paediatric population and are therefore not well documented. Incidence of upper GI bleeds in PICU – 6-20%. The incidence of lower GI bleeding has not been well established. In one report, rectal bleeding alone accounted for 0.3% of the chief complaints in more than 40,000 patients presenting to a major urban emergency department. An investigation into the epidemiology of GI bleeding in hospitalized children in the United States reported 23,383 pediatric discharges with a diagnosis of GI bleeding accounting for 0.5% of all discharges. 16/08/2024 4

5. RELEVANT ANATOMY GIT divided into 2 by the ligament of Treitz. Found at the duodenojejunal junction. Connects the fourth portion of the duodenum to the diaphragm near the splenic flexure. Upper GI  proximal to the ligament Lower GI  distal to the ligament 16/08/2024 5

6. DEFINITIONS. Hematemesis Vomitus of frank red blood Usually indicates a more rapidly bleeding lesion Coffee ground emesis Due to the coagulative effect of gastric acid on blood It is usually a slower bleed therefore allowing acid and blood to interact 16/08/2024 6

7. DEFINITIONS… Hematochezia the passage of gross blood. Results from lower GI bleeding Rarely due to blood from the upper GI tract may appear unchanged in the stool due to rapid intestinal transit. Melena Black, tarry stools Can be produced by relatively small amounts of blood (50-100 cc) in the stomach Can persist for 3-5 days following an acute bleed Black color most likely due to hematin, the oxidative product of heme following interaction with intestinal bacteria. 16/08/2024 7

8. AETIOLOGY. Numerous Varies based on; Age Site of bleeding. 16/08/2024 8

9. Age Group Upper Gastrointestinal Bleeding Lower Gastrointestinal Bleeding Neonates Hemorrhagic disease of the newborn Swallowed maternal blood Stress gastritis Coagulopathy Anal fissure Necrotizing enterocolitis Malrotation with volvulus Infants aged 1 month to 1 year Esophagitis Gastritis Anal fissure Intussusception Gangrenous bowel Milk protein allergy Infants aged 1-2 years Peptic ulcer disease Gastritis Polyps Meckel diverticulum Children older than 2 years Esophageal varices Gastric varices Polyps Inflammatory bowel disease Infectious diarrhea Vascular lesions 16/08/2024 9

10. UPPER GI BLEEDING. 16/08/2024 10

11. NEONATE. Swallowed maternal blood may be ingested during birth or during nursing. Esophagitis from underlying gastroesophageal reflux may lead to ulcerations and subsequent bleeding. The amount of blood seen from esophagitis is generally relatively small. Stress ulcers Gastric stress ulcerations are more common than duodenal ulcers in this age group. The amount of bleeding may be significant. Haemorrhagic disease of the newborn . may be seen if vitamin K has not been administered. 16/08/2024 11

12. CHILDREN Stress gastritis and ulceration. Causes include: Surgery Burns Infections (both viral and bacterial) Medications Ischemia Mechanical trauma from foreign bodies or enteral feeding tubes Tumors Vascular anomalies are seen less often in the GI tract than the skin and soft tissues Symptomatic hemangiomas of the gut GI system are rare and can present with significant bleeding Large lesions that do not respond to prednisone may be treated with Interferon alfa-2b 16/08/2024 12

13. ADOLESCENTS AND OLDER CHILDREN Mallory-Weiss tear can occur as a result of forceful vomiting and is the most common cause of minor UGI bleeding in children Peptic mucosal injury can occur via several mechanisms including NSAID use, infection with Helicobacter pylori, and stressors listed before Variceal bleeding Most common cause of severe UGI bleeding in children Most common location is the esophagus Due to high-pressure, turbulent flow in the thin-walled superficial vessels of the distal oesophagus Bleeding spontaneously stops in 50% with re-bleeding in 40% Nonspecific abdominal pain may precede variceal bleeding for up to 48 hours May present as either hematemesis or melena 16/08/2024 13

14. LOW ER GI BLEEDING. 16/08/2024 14

15. NEONATES Cow’s milk protein sensitivity Milk protein may be associated with a proctocolitis. Melena or hematochezia may also be signs of this problem. Blood in the stool is generally the presenting symptom and is seen most commonly in the first 3 months of life. Necrotizing enterocolitis (NEC) may present as blood in the stool. Commonly occurs in premature infants who have begun enteral feedings, usually after 2 to 3 weeks of life. Volvulus A serious yet less common cause of GI bleeding. The occurrence of bilious vomiting should always initiate evaluation for a volvulus or other serious cause of intestinal obstruction. Can also present with hematemesis along with abdominal distention; such a presentation suggests bowel ischemia and is a surgical emergency 16/08/2024 15

16. CHILDREN Anal fissures produce bright red blood that streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline. I ntussusception Episodic abdominal pain that is cramping in nature, vomiting, and currant jelly stools are findings in children with intussusception. M ilk protein allergy, fussiness and increased frequency of bowel movements; frank diarrhea is atypical Polyps painless bleeding per rectum, which often streaks the stool with fresh blood. Infectious diarrhea lower GI bleeding occurs in association with profuse diarrhea . Recent antibiotic use raises suspicion for antibiotic-associated colitis and  Clostridium difficile  colitis. 16/08/2024 16

17. CHILDREN Meckel diverticulum often summarized by clinicians by "The Rule of Twos": it occurs in 2% of the population, it usually presents prior to 2 years of age, it usually is located within 2 feet of the ileocecal valve, is 2 inches in length has 2 types of heterotrophic mucosa 16/08/2024 17

18. MANAGEMENT 16/08/2024 18

19. Rx – RESUSCITATION. The initial evaluation of a child after presenting with GI bleeding should focus on stabilizing the patient and determining the severity of the bleed. Vital signs should be measured and reviewed. Signs of a significant bleeding episode may include symptoms of hypovolemia, such as tachycardia and hypotension, Orthostatic changes and prolonged capillary refill. Children with signs and symptoms of significant bleeding and children with active blood loss should be hospitalized in a paediatric intensive care unit if possible. Stabilizing the patient should generally take precedence over evaluation and therapeutic considerations. Large bore venous access should be instituted, and fluid resuscitation initiated with Ringer’s lactate or normal saline. Transfusion with packed red blood cells may be indicated, and coagulation factors or platelets may need to be administered in specific cases. 16/08/2024 19

20. HISTORY A focused history should be quickly obtained when feasible because it may provide clues to the cause of bleeding. Upper Vs Lower GI bleeding? Age of the child? Well or ill child? Ask about acuteness or chronicity of bleeding Colour and quantity of the blood Presence or absence of pain. For complaints of bloody stool, ask history of foods consumed or drugs used that may give a stool bloody appearance. 16/08/2024 20

21. HISTORY Associated symptoms Reflux esophagitis or peptic ulcer disease  chronic heartburn, chest pain, epigastric abdominal pain, vomiting, oral regurgitation, or dysphagia. Mallory-Weiss tear  Hematemesis following repeated forceful retching, vomiting, or coughing. Abdominal pain is uncommon and, if present, more likely to be musculoskeletal in origin due to forceful emesis. Intestinal malrotation  with the sudden onset of melena in combination with bilious emesis in a previously healthy, nondistended baby. Infectious etiology  history of vomiting, diarrhea , fever, ill contacts, or travel. Liver disease  r ecent jaundice, easy bruising, and changes in stool colour. Intussusception  Episodic abdominal pain that is cramping in nature, vomiting, and currant jelly stools. 16/08/2024 21

22. HISTORY Drug history NSAID use may suggest ulcer disease Indomethacin, which is used for patent ductus arteriosus in neonates, may cause GI bleeding through intestinal vasoconstriction and platelet dysfunction Recent antibiotic use raises suspicion for antibiotic-associated colitis and Clostridium difficile colitis. 16/08/2024 22

23. EXAMINATION. An initial focused physical examination may be helpful in determining the cause of the bleeding. The presence of hepatomegaly and splenomegaly may point to variceal bleeding from liver disease. Scleral icterus, palmer erythema, spider telangiectasias and hepatosplenomegaly may be noted with chronic liver disease. Perianal disease may point to the presence of Crohn disease. Careful nasal examination may determine epistaxis or nasal polyps as the cause of bleeding. Oropharyngeal erosions from caustics and other ingestions may be seen. 16/08/2024 23

24. EXAMINATION. Symptoms of intussusception include a palpable, sausage-shaped mass. Children with a gangrenous bowel present with evidence of bowel obstruction, abdominal distension, dehydration, and peritonitis. Inspection of the perianal area may reveal fissures, fistulas, skin breakdown, or evidence of trauma. Gentle digital rectal examination may reveal polyps, masses, or occult blood 16/08/2024 24

25. Dermatological Clues Skin findings in liver disease include caput madusa (black arrows), spider angiomata (red arrow), and jaundice Other skin lesions include: hemangiomas (green arrow) and telangiectasias (blue arrow) which can also be present in the GI tract 16/08/2024 25

26. Patient comes in with an Upper GI bleed… Gastric aspiration is a useful indicator of UGI bleeding Saline at room temperature is best used for gastric lavage Bloody aspirate indicates active bleed Clear aspirate does not eliminate bleeding from the duodenum 16/08/2024 26

27. INVESTIGATIONS. These help elicit the cause and define the extent of bleeding. A complete blood cell count: the hemoglobin level and hematocrit . platelet count. M ean corpuscular volume – low in chronic blood loss, denotes iron-deficiency anemia . C oagulation studies – abnormal in underlying liver disease or malabsorption. 16/08/2024 27

28. INVESTIGATIONS. Liver function Test – may point to the presence of liver disease. Alanine aminotransferase, aspartate aminotransferase, and Bilirubin. S erum albumin – low in liver disease or protein losing enteropathy. Blood urea nitrogen and creatinine – help determine fluid status and the presence of renal insufficiency. Blood grouping and cross-match. 16/08/2024 28

29. Apt-Downey test Used to differentiate between maternal and fetal blood. The blood is placed in a test tube; sterile water is added to hemolyze the RBCs, yielding free hemoglobin . This solution then is mixed with 1% sodium hydroxide. If the solution turns yellow-brown, the hemoglobin is maternal or adult hemoglobin , which is less stable than fetal hemoglobin . If the solution remains the same color , it is the more stable fetal hemoglobin ; therefore, the newborn is the source of the bleeding. 16/08/2024 29

30. Endoscopy Preferred method to evaluate the GI tract to determine the etiology of bleeding Can determine the cause of UGI bleed in 90% of cases and KGI bleed in 80% 5 most common findings of UGI bleed via endoscopy are duodenal ulcer (20%), gastric ulcer (18%), esophagitis (15%), gastritis (13%), and varices (10%) 7 Most UGI bleeds in children will resolve spontaneously Indicated when it will influence clinical decision making and therapeutic intervention Contraindicated if patient is clinically unstable Cox K, Ament ME. Upper gastrointestinal bleeding in children and adolescents. Pediatrics . 1979; 63:408-413. 16/08/2024 30

31. Mallory-Weiss tear Diffuse nodular gastritis from H. Pylori infection Esophageal varices 16/08/2024 31

32. Radiographic Studies Radiographic studies have limited use in diagnosing GI bleeding in children Abdominal U/S with Doppler may be useful to evaluate portal hypertension Intususception Abdominal Xrays Obstruction NEC Angiography useful only if bleeding is occurring at a rate of 0.5 cc/min or more Localizes site of bleeding Place “coils” for embolization of a bleeding vessel Can be useful over upper endoscopy in patients with hemobilia Radionuclear imaging with technetium- labeled red blood cells can be used to detect bleeding at a rate as low as 0.1 mL per minute Meckel diverticulum 16/08/2024 32

33. Treatment ABC’s always important initially! Definitive treatment depends on the cause of GI bleeding. For acid-peptic disease treat with acid suppression medications Antacids H2 receptor antagonists Proton pump inhibitors Octreotide and vasopressin can be useful to reduce splanchnic blood flow in patients with severe UGI bleeding 16/08/2024 33

34. Treatment Endoscopic treatment includes electrocoagulation, laser photocoagulation, argon plasma coagulation, injection of epinephrine and sclerosants, band ligation, and mechanical clipping Endoscopic treatment of variceal bleeding includes either injection sclerotherapy or variceal banding Exploratory laparotomy may be required in patients with uncontrolled bleeding for both diagnostic and therapeutic intervention. 16/08/2024 34

35. Treatment Heamorrhagic disease of the newborn IV administration of 1 mg of vitamin K generally stops the hemorrhage within 2 hours. If the clinical condition warrants, fresh frozen plasma and packed red blood cells are administered in addition to the vitamin K. NEC – NPO, antibiotics, total parenteral nutritional, and nasogastric decompression. H. pylori infection – Treatment is a combination of H2 blockage, antibiotic therapy, and bismuth. 16/08/2024 35

36. CONCLUSION. Practitioners caring for children should be familiar with the diagnosis and treatment of gastrointestinal bleeding. The initial goals are to establish the extent and severity of the bleeding and, when indicated, to hospitalize and stabilize the patient as quickly as possible. Once stabilized, diagnostic testing with a variety of modalities is indicated to establish the cause of bleeding. Endoscopic studies are often used to help determine the site of bleeding and for therapeutic intervention in specific cases. Newer diagnostic modalities, such as video capsule endoscopy and small intestinal endoscopy, may be useful when bleeding sites are unable to be detected. Treatment is directed at the specific cause. 16/08/2024 36

37. THANK YOU QUESTIONS? 16/08/2024 37

38. References 16/08/2024 38