Walter Reed Army Medical Center

Gastrointestinal Hemorrhage

Carolyn A. Sullivan, MDPediatric Gastroenterology

Objectives

Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding

Review the most common etiologies for GI bleeding in pediatric patients in various age groups

Definitions Melena: passage of black, tarry stools;

suggests bleeding proximal to the ileocecal valve

Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding

Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz

History Present illness

source, magnitude, duration of bleeding associated GI symptoms (vomiting, diarrhea, pain) associated systemic symptoms (fever, rash, joint

pains) Review of systems

GI disorders, liver disease, bleeding diatheses Anesthesia reactions medications (NSAID’s, warfarin)

Family history

Physical examination

Vital signs, including orthostatics Skin: pallor, jaundice, ecchymoses,

abnormal blood vessels, hydration, cap refill HEENT: nasopharyngeal injection, oozing;

tonsillar enlargement, bleeding Abdomen: organomegaly, tenderness,

ascites, caput medusa Perineum: fissure, fistula, induration Rectum: gross blood, melena, tenderness

Further assessment Is it really blood?

Hemoccult stool, gastroccult emesis Apt-Downey test in neonates Nasogastric aspiration and lavage

Clear lavage makes bleeding proximal to ligament of Treitz unlikely

Coffee grounds that clear suggest bleeding stopped

Coffee grounds and fresh blood mean an active upper GI tract source

Substances that deceive

Red discoloration candy, fruit punch, Jell-o, beets,

watermelon, laxatives, phenytoin, rifampin

Black discoloration bismuth, activated charcoal, iron,

spinach, blueberries, licorice

Laboratory studies

CBC, ESR; BUN, Cr; PT, PTT in all cases Others as indicated:

Type and crossmatch AST, ALT, GGTP, bilirubin Albumin, total protein Stool for culture, ova and parasite

examination, Clostridium difficile toxin assay

Imaging studies and indications

Upper GI series: dysphagia, odynophagia, drooling

Barium enema: intussusception, stricture

Abdominal US: portal hypertension Meckel’s scan: Meckel’s diverticulum Sulfur colloid scan, labeled RBC scan,

angiography : obscure GI bleeding

Endoscopy: indications

EGD: hematemesis, melenaFlexible sigmoidoscopy:

hematocheziaColonoscopy: hematocheziaEnteroscopy: obscure GI blood

loss

DDx: neonates

Upper GI bleeding swallowed maternal

blood stress ulcers, gastritis duplication cyst vascular

malformations vitamin K deficiency hemophilia maternal ITP maternal NSAID use

Lower GI bleeding swallowed maternal blood dietary protein

intolerance infectious colitis necrotizing enterocolitis Hirschsprung’s

enterocolitis duplication cyst coagulopathy vascular malformations

Neonatal stress ulcers or gastritis

Causes Shock Sepsis Dehydration Traumatic delivery Severe respiratory distress Hypoglycemia Cardiac condition

DDx: infants

Hematemesis, melena

Esophagitis Gastritis Duodenitis

Hematochezia Anal fissures Intussusception Infectious colitis Dietary protein intol. Meckel’s diverticulum Duplication cyst Vascular

malformation

DDx: children

Upper GI bleeding

Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers

Lower GI bleeding Anal fissures Infectious colitis Polyps Lymphoid nodular

hyperplasia IBD HSP Intussusception Meckel’s diverticulum HUS

Esophageal varices

Erosive esophagitis

DDx: adolescents

Hematemesis, melena

Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers

Hematochezia Infectious colitis Inflammatory bowel

disease Anal fissures Polyps

NSAID induced ulcers

Peptic Ulcer

Mallory-Weiss Tear

Risk of rebleeding of ulcer

Stigmata of recent hemorrhage

Visible vessel Clot Spot Clean base

Rate of rebleed

40-50% 25-30% 10% 2-4%

Ulcer with red spot

Therapy Supportive care: begin promptly

IV fluids, blood products, pressors Specific care

Barrier agents (sucralfate) H2 receptor antagonists (cimetidine, ranitidine, etc.) Proton pump inhibitors (omeprazole, lansoprazole) Vasoconstrictors (somatostatin analogue, vasopressin)

Endoscopic therapy: stabilize and prepare patient first Coagulation (injection, cautery, heater probe, laser) Variceal injection or band ligation Polypectomy

Bleeding Ulcer