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AN APPROACH TO CHILD WITH        GI BLEED    Syed Awais Ul Hassan Shah     1st year Trainee Pediatrics
Background• Gastrointestinal (GI) bleeding in infants and  children is a fairly common problem,  accounting for 10%-20% of...
Definitions• Melena is the passage of black, tarry stools;  suggests bleeding proximal to the ileocecal valve• Hematochezi...
PATHOPHYSIOLOGY OF GI BLEED• 1. Consequences of blood loss• 2. Risk of hemorrrhagic shock• 3. Compensatory mechanism
1. PATHOPHYSIOLOGIC     CONSEQUENCES OF BLOOD LOSS• LOSS OF FLUID(BLOOD)  DEC. ECF   DEHYDRATION  SHOCK  DEC GFRANURI...
2. Higher risk for hemorrhagic shock in                 children• Age-dependent vital signs  inaccurate  interpretation o...
3. Sequence of compensatory             mechanism• Loss of less than 15% of BV is compensated  by:  – Contraction of the v...
• Loss 15%-30% BV  – Sympathetic stimulation  – Secretion of aldosterone, ADH, prostaglandins  – Release of catecholamine ...
• Loss of more than 30%  – Hypotension (Shock), dec. cardiac output    acidosis tissue damage  – Acute renal failure  –...
SYMPTOMS OF UPPER GI BLEED• Symptoms of upper gastrointestinal bleeding  include:  – vomiting bright red blood (hematemesi...
SYMPTOMS OF LOWER GI BLEED• Symptoms of lower gastrointestinal bleeding  include:  – passing pure blood (hematochezia) or ...
• Hematemesis : 50% of upper gastrointestinal  bleeding cases• Hematochezia : 80% of all gastrointestinal  bleeding.• Mele...
CAUSES
Causes of GI bleed in neonates• Upper GI bleeding            • Lower GI bleeding  – swallowed maternal            –   swal...
Causes of GI bleed in infants• Hematemesis, melena   • Hematochezia  –   Esophagitis         –   Anal fissures  –   Gastri...
Causes of GI Bleed in Children 1 -12 yrs • Upper GI bleeding          • Lower GI bleeding   –   Esophagitis               ...
Causes of GI Bleed in Adolescents• Hematemesis, melena        • Hematochezia  –   Esophagitis              – Infectious co...
Esophageal varices
Erosive esophagitis
NSAID induced ulcers
Peptic Ulcer
Mallory-Weiss Tear
HISTORY• GENERAL QUESTIONS  – Acute or chronic bleeding  – Color and quantity of the blood in stools or vomitus  – Anteced...
HISTORY• NEONATE  – MILK OR SOY PROTEIN ENTERITIS  – NSAIDs, heparin, indomethacin  – Maternal medications e.g Aspirin and...
HISTORY• CHILDREN AGED 1 MONTH TO 1 YEAR    • Episodic abdominal pain that is cramping in nature, vomiting,      and curra...
HISTORY• CHILDREN AGED 1-2 YRS  – Upper GI Bleed    • systemic diseases, such as burns (Curling ulcer), head trauma      (...
HISTORY• CHILDREN OLDER THAN 2 YRS  – lower GI bleeding occurs in association with profuse    diarrhea :- Infectious Diarr...
• A history of vomiting, diarrhea, fever, ill contacts, or travel  infectious etiology• Sudden onset of melena in combina...
PHYSICAL EXAMINATION• Signs of shock• Vital signs, including orthostatics• Skin: pallor, jaundice, ecchymoses, abnormal bl...
Substances that deceive• Red discoloration  – candy, fruit punch, beets, watermelon, laxatives,    phenytoin, rifampin• Bl...
CONSIDERATIONS• Place NG tube to confirm presence of fresh  blood or active bleed. if confirmed  – Esophagogastroduosenosc...
FURTHER ASSESSMENT• Is it really blood (haemoccult test)• Apt-Downey test in neonates   – Used to differentiate between ma...
Laboratory studies• CBC in all cases   – Normal hematocrit  hypovolemia and hemoconcentration   – Leukocytosis  infectio...
LAB STUDIES (contd..)• Endoscopy  – Identifies site of upper GI bleed in 90 % cases  – FORRESS classification     • I – Ac...
Endoscopy: indications•   EGD: hematemesis, melena•   Flexible sigmoidoscopy: hematochezia•   Colonoscopy: hematochezia•  ...
LAB STUDIES (contd..)• Colonoscopy  – Identifies site of lower GI bleed in 80 % cases  – Polyps, FAP syndrome, haemangioma...
LAB STUDIES (contd..)• Barium contrast studies   – GER, FB, esophagitis, IBD, Polyps, malrotation, volvulus• Doppler USG (...
INITIAL MANAGEMENT• The initial approach to all patients with  significant GI bleed is :  – to establish adequate oxygen d...
Therapy• Supportive care: begin promptly   – Bowel Rest and NG decompression (esp in NEC)   – IV fluids   – Blood products...
Therapeutic Procedures• Endoscopy: stabilize and prepare patient first   – Coagulation (injection, cautery, heater probe, ...
Surgical options• If all medical measures fail  – Laprotomy  – Laproscopy  – Vagotomy  – Pyloroplasty  – Fissurotomy, fist...
THANKS
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Gi bleed peds awais

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  1. 1. AN APPROACH TO CHILD WITH GI BLEED Syed Awais Ul Hassan Shah 1st year Trainee Pediatrics
  2. 2. Background• Gastrointestinal (GI) bleeding in infants and children is a fairly common problem, accounting for 10%-20% of referrals to pediatric gastroenterologists.
  3. 3. Definitions• Melena is the passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve• Hematochezia is passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding• Hematemesis is passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz
  4. 4. PATHOPHYSIOLOGY OF GI BLEED• 1. Consequences of blood loss• 2. Risk of hemorrrhagic shock• 3. Compensatory mechanism
  5. 5. 1. PATHOPHYSIOLOGIC CONSEQUENCES OF BLOOD LOSS• LOSS OF FLUID(BLOOD)  DEC. ECF  DEHYDRATION  SHOCK  DEC GFRANURIA PRE-RENAL A.R.F (INC. BUN AND NITROGEN) SMALL VOL CONCENTRATED URINE WITH HIGH SPECIFIC GRAVITY
  6. 6. 2. Higher risk for hemorrhagic shock in children• Age-dependent vital signs  inaccurate interpretation of early signs• High ratio surface area to body mass  limited thermoregulation hypothermia  pulmonary HT hypoxemia acidosis• Smaller total body volume• Lower hematocrit level
  7. 7. 3. Sequence of compensatory mechanism• Loss of less than 15% of BV is compensated by: – Contraction of the venous system – Fluid shift ECFC IVFC – Preferential direction of blood to the brain and the heart No hemodynamic changes
  8. 8. • Loss 15%-30% BV – Sympathetic stimulation – Secretion of aldosterone, ADH, prostaglandins – Release of catecholamine – Release of ACTH and corticosteroids Hemodynamic instability Tachycardia, O2 consumption, tissue hypoxia Maintain blood volume
  9. 9. • Loss of more than 30% – Hypotension (Shock), dec. cardiac output acidosis tissue damage – Acute renal failure – Liver failure – Heart failure
  10. 10. SYMPTOMS OF UPPER GI BLEED• Symptoms of upper gastrointestinal bleeding include: – vomiting bright red blood (hematemesis) – vomiting dark clots, or coffee ground-like material – passing black, tar-like stool (melena)
  11. 11. SYMPTOMS OF LOWER GI BLEED• Symptoms of lower gastrointestinal bleeding include: – passing pure blood (hematochezia) or blood mixed in stool – bright red or maroon blood in the stool
  12. 12. • Hematemesis : 50% of upper gastrointestinal bleeding cases• Hematochezia : 80% of all gastrointestinal bleeding.• Melena – 70% of upper gastrointestinal bleeding – 33% of lower gastrointestinal bleeding – To form black, tarry stools (melena), there must be 150-200 cc of blood and the blood must be in the gastrointestinal tract for 8 hours to turn black
  13. 13. CAUSES
  14. 14. Causes of GI bleed in neonates• Upper GI bleeding • Lower GI bleeding – swallowed maternal – swallowed maternal blood blood – dietary protein intolerance – stress ulcers, gastritis – infectious colitis/enteritis – vascular malformations – necrotizing enterocolitis – HDN – Hirschsprung’s enterocolitis – coagulopathy – hemophilia – vascular malformations – maternal ITP – maternal NSAID use
  15. 15. Causes of GI bleed in infants• Hematemesis, melena • Hematochezia – Esophagitis – Anal fissures – Gastritis – Intussusception – Duodenitis – Infectious colitis/enteritis – Coagulopathy – Dietary protein intol. – Meckel’s diverticulum – Vascular malformation – Coagulopathy
  16. 16. Causes of GI Bleed in Children 1 -12 yrs • Upper GI bleeding • Lower GI bleeding – Esophagitis – Anal fissures – Infectious colitis – Gastritis – Polyps – Peptic ulcer disease – Lymphoid nodular – Mallory-Weiss tears hyperplasia – Esophageal varices – IBD – HSP – Pill ulcers – Intussusception – Swallowed epistaxis – Meckel’s diverticulum – Foreign body – HUS – Coagulopathy – Sexual abuse – Coagulopathy
  17. 17. Causes of GI Bleed in Adolescents• Hematemesis, melena • Hematochezia – Esophagitis – Infectious colitis – Gastritis – Inflammatory bowel – Peptic ulcer disease disease – Mallory-Weiss tears – Anal fissures – Esophageal varices – Polyps – Pill ulcers
  18. 18. Esophageal varices
  19. 19. Erosive esophagitis
  20. 20. NSAID induced ulcers
  21. 21. Peptic Ulcer
  22. 22. Mallory-Weiss Tear
  23. 23. HISTORY• GENERAL QUESTIONS – Acute or chronic bleeding – Color and quantity of the blood in stools or vomitus – Antecedent symptoms – History of straining – Abdominal pain – Trauma – History of foods consumed or drugs
  24. 24. HISTORY• NEONATE – MILK OR SOY PROTEIN ENTERITIS – NSAIDs, heparin, indomethacin – Maternal medications e.g Aspirin and Phenobarbital – Stress gastritis e.g prematurity, neonatal distress, and mechanical ventilation
  25. 25. HISTORY• CHILDREN AGED 1 MONTH TO 1 YEAR • Episodic abdominal pain that is cramping in nature, vomiting, and currant jelly stools (intussusception) • Fussiness and increased frequency of bowel movements in addition to lower gi bleed (milk protein allergy)
  26. 26. HISTORY• CHILDREN AGED 1-2 YRS – Upper GI Bleed • systemic diseases, such as burns (Curling ulcer), head trauma (Cushing ulcer), malignancy, or sepsis • NSAID – Lower GI Bleed • Polyps :- painless fresh streaks of blood in stools
  27. 27. HISTORY• CHILDREN OLDER THAN 2 YRS – lower GI bleeding occurs in association with profuse diarrhea :- Infectious Diarrhea – Recent antibiotic use : antibiotic-associated colitis and Clostridium difficile colitis
  28. 28. • A history of vomiting, diarrhea, fever, ill contacts, or travel infectious etiology• Sudden onset of melena in combination with bilious emesis in a previously healthy, nondistended baby INTESTINAL MALROTATION• Bloody diarrhea and signs of obstruction VOLVULUS, INTUSSUSCEPTION or NECROTIZING ENTEROCOLITIS, particularly in premature infants• Recurrent or forceful vomiting  Mallory-Weiss tears• Familial history or NSAID use  ulcer disease• Ingested substances, such as NSAIDs, tetracyclines, steroids, caustics, and foreign bodies, can irritate the gastric mucosa enough to cause blood to be mixed with the vomitus• Recent jaundice, easy bruising, and changes in stool color liver disease• Evidence of coagulation abnormalities elicited from the history disorders of the kidney or reticuloendothelial system
  29. 29. PHYSICAL EXAMINATION• Signs of shock• Vital signs, including orthostatics• Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill• HEENT: Epistaxis, nasal polyps, oropharyngeal erosions from caustic ingestions• Abdomen: – organomegaly, tenderness, ascites, caput medusa – Abdominal Surgical scars, Hyperactive bowel sounds (upper gi bleeding) – Abdominal tenderness, with or without a mass(intussusception or ischemic Bowel disease)• Perineum: fissure, fistula, trauma• Digital Rectum Examination: polyps, mass, occult blood, evidence of child abuse
  30. 30. Substances that deceive• Red discoloration – candy, fruit punch, beets, watermelon, laxatives, phenytoin, rifampin• Black discoloration – bismuth, activated charcoal, iron, spinach, blueberries, licorice
  31. 31. CONSIDERATIONS• Place NG tube to confirm presence of fresh blood or active bleed. if confirmed – Esophagogastroduosenoscopy – 90% – Colonoscopy – 80%• False negative results in 16 % if duodenopyloric regurgitation is absent
  32. 32. FURTHER ASSESSMENT• Is it really blood (haemoccult test)• Apt-Downey test in neonates – Used to differentiate between maternal and baby blood. blood placed in test tubeadd sterile water (to hemolye the RBCs yielding free Hb)  mix with 1% sodium hydroxide if solution turns yellow or brownmaternal blood• 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
  33. 33. Laboratory studies• CBC in all cases – Normal hematocrit  hypovolemia and hemoconcentration – Leukocytosis  infectious etiology• ESR in all cases• BUN, Cr in all cases• 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 – Plain abdominal Xray (NEC in neonates)
  34. 34. LAB STUDIES (contd..)• Endoscopy – Identifies site of upper GI bleed in 90 % cases – FORRESS classification • I – Active hemorrhage – Ia :- bright red bleeding – Ib :- slow bleeding • II – Recent hemorrhages – IIa :- non bleeding visible vessel – IIb :- adherent clot on base of lesion – IIc :- flat pigmented spot • III – No evidence of bleeding
  35. 35. Endoscopy: indications• EGD: hematemesis, melena• Flexible sigmoidoscopy: hematochezia• Colonoscopy: hematochezia• Enteroscopy: obscure GI blood loss
  36. 36. LAB STUDIES (contd..)• Colonoscopy – Identifies site of lower GI bleed in 80 % cases – Polyps, FAP syndrome, haemangiomas, vascular malformations, ulceration, biopsy
  37. 37. LAB STUDIES (contd..)• Barium contrast studies – GER, FB, esophagitis, IBD, Polyps, malrotation, volvulus• Doppler USG (Intussusception)• Barium enema (IBD, polyps, intussusception)• H.pylori stool antigen, IgG levels, rapid urease test or mucosal biopsy• Ultrasound abdomen (intussusception)• Fasting plasma gastrin level (Z-E syndrome)• Technetium scan (Meckel’s diverticulum)• Enteroscopy• Arteriography (helpful when endoscopy has failed)
  38. 38. INITIAL MANAGEMENT• The initial approach to all patients with significant GI bleed is : – to establish adequate oxygen delivery. – to place intravenous line. – to initiate fluid and blood resuscitation – to correct any underlying coagulopathies.
  39. 39. Therapy• Supportive care: begin promptly – Bowel Rest and NG decompression (esp in NEC) – IV fluids – Blood products (FFPs, RCC)• Specific care – Barrier agents (sucralfate) – H2 receptor antagonists (cimetidine, ranitidine, etc.) – Proton pump inhibitors (omeprazole, lansoprazole) – Vasoconstrictors (somatostatin analogue[Octreotide], vasopressin, Beta Blockers) – Inj Vitamin K (HDN) – Stool Softeners (Anal Fissure) – Prokinetics (to reduce vomiting) – Antibiotics (for enteritis, Cl. Difficile ass. Colitis) – Withdrawl of offending milk protein (in cases of milk protein allergy) – H.pylori Eradication ( triple therapy)
  40. 40. Therapeutic Procedures• Endoscopy: stabilize and prepare patient first – Coagulation (injection, cautery, heater probe, laser) – Variceal injection or band ligation• Colonoscopy : – To treat colonic polyps, hemangiomas, AV malformations,• Barium or saline enema : – Intussusception• Arteriography• TIPS (variceal bleeds)• Sengstaken Blakemore balloon tamponade
  41. 41. Surgical options• If all medical measures fail – Laprotomy – Laproscopy – Vagotomy – Pyloroplasty – Fissurotomy, fistulectomy – Diverticulectomy
  42. 42. THANKS
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