Lower gastrointestinal bleeding in newborn infant

Lower GI bleeding in newborn infant

1. Case Presentation
Lower GI bleeding

2. Lower GI bleeding

3. Definition: LGIB
Bleeding distal to the ligament of Treitz
Present with hematochezia

4. Diagnosis
Detection of blood in the stool
guaiac (Hemoccult II)
fecal hemoglobin measurement by
immunodiffusion
fecal alpha-1 antitrypsin measurement
Locate the site of bleeding
colonoscopy-sigmoidoscopy
Identify the cause of bleeding

5. Major causes of lower GI bleeding in children by
age group

6. Causes of LGIB: neonatal period
Swallowed maternal blood
Anorectal fissures
Necrotizing enterocolitis
Malrotation with midgut volvulus
Hirschsprung disease
Coagulopathy (Hemorrhagic disease of the
newborn, hemophilia, or other bleeding disorders
eg. liver disease)

7. Causes of LGIB: infancy period
Anorectal fissures
Milk or soy-induced enterocolitis (allergic colitis)
Meckel's diverticulum
Hemolytic uremic syndrome and Henoch -
Schönlein purpura
Lymphonodular hyperplasia
Gastrointestinal duplication
Intussusception

8. Juvenile polyps—Juvenile polyps are benign hamartomas, which occur between the ages of 2 and
8 years, with a peak at three to four years. Patients usually present with painless rectal bleeding,
although a few may have lower abdominal pain from traction on the polyp. More than 60 percent of
patients have a palpable polyp by rectal examination [36].
Polyps are confined to the rectosigmoid region in 80 to 90 percent of cases, with almost 75 percent
being in the rectum [37]. Juvenile polyps in the rectum tend to autoamputate or on occasion
present as prolapsed tissue. Polyps usually bleed after injury by fecal passage and usually result in
bright red blood on the outside of the stool; if the polyp is located proximally, the blood will be
darker and found in the core of the stool.
Diagnostic methods that have been used include double-contrast enemas following bowel
preparation, hydrocolonic ultrasound (ultrasound after a warm saline enema) [38], sigmoidoscopy
(rigid and flexible) and colonoscopy. The first two methods are capable of diagnosis only and should
be reserved as screening tools in circumstances in which colonoscopy is not readily available.
Sigmoidoscopy is useful in the diagnosis and treatment of most juvenile polyps but would miss
proximal polyps, which occur in as many as 15 percent of cases [36].
Colonoscopy is the best way to diagnose polyps and permits their immediate painless removal
under mild sedation [39]. All polyps should be removed. Follow-up examinations are not necessary
for patients with one or two polyps because recurrence after polypectomy is uncommon (<5
percent of patients) [37]. In contrast, patients with three or more polyps (especially >10 polyps),
polyps with adenomatous change, and those with a family history of polyps may have familial
polyposis and should undergo colonoscopy and biopsy every few years to exclude colorectal
neoplasia.

9. Lymphonodular hyperplasia—Lymphonodular hyperplasia is a
common finding in infants and young children who undergo
endoscopy of the intestinal tract [19,20]. The etiology is
unknown. Some consider it to be a normal finding
[21,22]whereas others believe it to be an immunologic response
to a variety of stimulants [20,23,24]. It occurs frequently in
children with food protein induced colitis, in whom it may be an
abnormal finding at colonoscopy [25]. (See 'Milk-or soy-
induced colitis'above and "Food protein-induced
proctitis/colitis, enteropathy, and enterocolitis of
infancy".)
Because lymphonodular hyperplasia disrupts the normal mucosa,
it leads to mucosal thinning and predisposes to ulceration, which
may cause hematochezia [19]. Blood loss is usually minimal and
painless but is present in multiple stools [26]. Lymphonodular
hyperplasia resolves spontaneously over time, and is an unlikely
source of bleeding in children older than 7 years [26].

10. Meckel's diverticulum—Meckel's diverticulum results from incomplete obliteration of
the omphalomesenteric duct. (See "Care of the umbilicus and management of
umbilical disorders", section on 'Embryology' and "Care of the umbilicus and
management of umbilical disorders", section on 'Omphalomesenteric duct
anomalies'.)
The rule of twos best describes Meckel's diverticulum [15]. It occurs in 2 percent of
the population with a male-to-female ratio of 2:1, is found within two feet of the
ileocecal valve, and is two inches long. Approximately 2 percent develop a
complication over the course of their lives. There is probably no familial
predisposition for Meckel's diverticulum, although a few cases of occurrence within
the same family have been reported [16].
Meckel's diverticulum is usually asymptomatic [17]. Sixty percent of patients having
complications are younger than 2 years of age. Bleeding usually is painless and
results from mucosal ulceration within ectopic gastric tissue. One-half of Meckel's
diverticula do not have gastric mucosa and are therefore not associated with
bleeding.
The diagnosis is made by a Meckel scan. The scan consists of the intravenous
administration of 99m technetium pertechnetate, which has an affinity for gastric
mucosa, followed by scintigraphy to identify areas of ectopic gastric mucosa. The
accuracy of a Meckel scan is improved by administration of H2 blockers 24 to 48
hours before the test. A symptomatic Meckel's diverticulum should be resected. An
asymptomatic Meckel's diverticulum discovered incidentally at laparotomy in children
are usually also resected. However, whether such asymptomatic lesions should be
resected in adults is controversial because of the low incidence of complications in
older patients who have never had symptoms

11. Milk-or soy-induced colitis—Milk or soy-induced colitis is
an inflammatory enteropathy caused by ingestion of milk or
soy proteins, and occurs almost exclusively in infants. It
can also occur in breast-fed infants because of maternally
ingested cow's milk protein. Affected infants have loose
stools, often with occult or gross blood but are otherwise
healthy. Up to 25 percent of patients with cow's milk
protein intolerance will have a cross-reaction to soy protein.
Treatment involves elimination of the causative protein
from the mother’s diet if the infant is breastfed, or the use
of a casein-hydrolysate formula. The intolerance usually
resolves by one year of age, at which time an unrestricted
diet can be resumed. Food protein-induced enteropathy and
enterocolitis syndrome are separate but related disorders,
in which vomiting rather than rectal bleeding is the
prominent feature. (See "Food protein-induced
proctitis/colitis, enteropathy, and enterocolitis of
infancy".)