lower GIT bleeding: is bleeding from a source distal to the ligament of Treitz (duodenojejunal junction), presented as Hematochezia is blood passed with stool from the anus, Melena is black, tarry stool produced by the oxidation of heme by intestinal flora; as little as 50 mL of blood may result in melena, and it may persist for 3 to 5 days following resolution of the bleed. Maroon-colored stool is associated with rapidly bleeding small bowel lesions in which the transit of blood is too fast for complete oxidation. Currant-jelly stool is associated with ischemic small bowel or proximal colonic lesions such as may be seen in intussusception. Upper GIT bleeding: is bleeding from a source proximal to the ligament of Treitz (duodenojejunal junction). Discussion included the definition of bleeding per rectum, it's types according to child age groups, it's presentation, how to diagnose each type and how to treat.

1. Bleeding per -
rectum
Dr. Ahmed Hasan Mohammed
Al-batool teaching hospital
5th of march 2023

2. Overview
gastrointestinal tract bleeding
Gastrointestinal (GI) bleeding occurs rarely in children; severity varies
from the insidious bleeding, with only iron-deficiency anemia
suggestive of occult hemorrhage, to dramatic hemorrhage with
rapidly evolving, life-threatening hypovolemic shock.
Upper GI bleeding is bleeding from a source proximal to the ligament
of Treitz (duodenojejunal junction), presented with Hematemesis that
is vomiting of frank blood and suggests a rapidly bleeding lesion and
Coffee-ground emesis describes the appearance of vomited blood
that has been coagulated by gastric acid.

3. LOWER GIT BLEEDING
is bleeding from a source distal to the ligament of Treitz
(duodenojejunal junction), presented as Hematochezia that is blood
passed with stool from the anus, Melena is black, tarry stool produced by
the oxidation of heme by intestinal flora; as little as 50 mL of blood may
result in melena, and it may persist for 3 to 5 days following resolution of
the bleed. Maroon-colored stool is associated with rapidly bleeding small
bowel lesions in which the transit of blood is too fast for complete
oxidation. Currant-jelly stool is associated with ischemic small bowel or
proximal colonic lesions such as may be seen in intussusception.

4. Blood limited to the outside of otherwise unremarkable stool
suggests a rectal origin; blood mixed throughout the stool suggests a
colonic source.
Occult GI bleeding is bleeding that occurs in the absence of overt
bleeding and is usually suspected due to chronic iron-deficiency
anemia or is identified by hemoccult examination.
Large-volume upper intestinal hemorrhage may present with lower GI
bleeding, particularly in infants, so it is important to consider causes
of upper GI bleeding in the differential diagnosis.

7. LOWER GIT BLEEDING IN NEONATE
Hematochezia or melena in newborns should prompt
concerns for necrotizing enterocolitis, particularly in
premature or critically ill newborns. Bowel obstruction,
such as with midgut volvulus, should also be considered.

8. 31 week GA male baby , delivered by NVD, cried
immediately after birth but owing to poor respiratory
efforts needed intubation and ventilation, on the 7
day of life he was noted to have abdominal distension
that rapidly progress to shiny red abdomen associated
with bloody loose stool.
Q what’s most likely diagnosis?

9. Necrotising enterocolitis
it typically presents with abdominal distension and bile-stained
vomiting, resembling obstruction. The passage of blood per rectum
and a characteristic appearance on abdominal x-ray help to
distinguish necrotising enterocolitis from neonatal bowel obstruction.

10. The radiological findings are
typical. Plain abdominal x-
rays demonstrate dilated
loops of bowel in which
there are intramural bubbles
of gas (pneumastosis
intestinalis). Gas within the
portal vein and/or its radicles
may be visible. Free gas in
the peritoneal cavity, best
seen under the diaphragm, is
present if the intestine has
perforated. Separation of
adjacent loops of bowel
suggests appreciable

12. Case
A 1-day-old baby presents with bile-stained vomiting but no
abdominal distension.
Q What are the causes of a high neonatal bowel obstruction?

13. Volvulus neonatorum
The typical case is a healthy full-term baby who is well for the first few
days of life but then develops feeding difficulties with bile-stained
vomiting. At this early stage, the abdomen is soft and non-distended.
The diagnosis should be suspected at this stage and confirmed with
an urgent upper gastrointestinal contrast study. Abdominal distension
with tenderness and passage of blood per rectum are late features
and indicate major gut ischaemia.

14. Investigations
An upper gastrointestinal
contrast study will
demonstrate the abnormal
position of the duodeno-
jejunal junction and the
contrast may spiral through
the twisted gut . Investigation
is urgent but must not be
allowed to delay the definitive
surgical treatment.

15. Eosinophilic proctocolitis may result from dietary protein intolerance
and may present with painless hematochezia in otherwise healthy-
appearing newborns.
A history of constipation in an infant presenting With bloody diarrhea
may suggest a diagnosis of enterocolitis associated with Hirschsprung
disease.
Hemorrhagic disease of the newborn should be considered in
newborns not receiving vitamin K at birth.
Swallowing of maternal blood, either during delivery or from a
cracked nipple, may give rise to blood in vomit or stool,
masquerading as alimentary tract haemorrhage.

16. LOWER GIT BLEEDING IN INFANT
AND CHILDREN

17. Case
A 6-month-old baby presents with pain and rectal
bleeding with defaecation.
Q What is the likely diagnosis and management of
this common problem?

18. Anal fissure
Anal fissure occurs at any age and usually is due to constipation . The
child passes a large, hard stool, which tears the anal mucosa, usually
in the midline, either posteriorly or anteriorly. If old enough, the child
complains of pain on defaecation, and there is bright blood on the
surface of the stool, The fissure may be seen by gently parting the
anus. Rectal examination causes severe pain.

19. Rectal polyp
Juvenile rectal polyps are isolated
benign hamartomas and are a
relatively common cause of rectal
bleeding. Bright bleeding is
produced painlessly at the end of
defecation and is typically
intermittent over long periods. The
polyp is almost always within reach
of an examining finger, and
occasionally prolapses through the
anus

20. Rectal prolapse
Most children with rectal
prolapse have normal pelvic
anatomy. The prolapse rolls out
painlessly only during
defaecation and usually returns
spontaneously; manual
replacement is required
infrequently. The mucosa
may become abraded while it is
prolapsed and cause minor
bleeding

21. A 5-month-old boy has a 48 h history of being unwell and
vomiting. At times, he appears to have been in severe pain. He
looks pale and lethargic. There is a vague impression of a mass on
the right side of his abdomen.
Q1. What is the likely diagnosis?

22. Intussusception
Pain is the most important symptom (85%). It typically commences as
a colicky pain lasting 2–3 min, during which time the infant screams
and draws up his knees. Spasms typically occur at intervals of 15–20
min. The infant becomes intermittently pale and clammy (similar to a
syncopal episode in older children), exhausted and lethargic between
spasms. After 12 h or so, the pain becomes more continuous.

23. A mass (sometimes described as
sausage shaped) is palpable in more
than half the infants and is usually
found in the right hypochondrium,
is most likely to be felt early, before
being concealed by abdominal
distension and increasing abdominal
tenderness.
About half the patients pass a stool
containing blood and mucus (red
currant jelly)

24. The diagnosis is
confirmed on
ultrasonography, which
is usually the first
investigation when
intussusception is
suspected , An air or
contrast enema study
will also confirm the
diagnosis and may be
therapeutic .

25. Gastroenteritis
Patients with severe gastroenteritis also often have vomiting, colic and
specks of blood mixed with the stool. The differential diagnosis of bloody
stool includes infectious causes (e.g., Salmonella, Shigella, Campylobacter,
and Yersinia species; Clostridioides difficile (formerly known as Clostridium
difficile), Escherichia coli 0157:H7, and Entameba histolytica), inflammatory
bowel Disease
Colic and the passage of blood and mucus in severe cases of gastroenteritis
may mimic intussusception, except that the volume of diarrhoea is greater .
in intussusception, the small loose stools passed early in the course of the
disease simply represent evacuation of the stimulated colon beyond the
obstruction. Persistent vomiting and pain without diarrhoea is unlikely to be
gastroenteritis.

26. Case 1
A 6-year-old girl presents with a 1-month history of weight
loss
and mild diarrhea, containing blood and mucus.
Q What is the likely diagnosis

27. Inflammatory Bowel Disease
Crohn disease
Is a chronic inflammatory disorder of unknown aetiology that can
affect any part of the gastrointestinal tract, presents with a broad
spectrum of symptoms and signs. The most common symptoms
include recurrent abdominal pain and bowel disturbance, usually
diarrhoea together with rectal bleeding. However, these symptoms
may be relatively mild, and patients may present with long-term
effects of the disease such as weight loss, growth failure and delayed
onset of puberty.
Endoscopy has a crucial role in diagnosis, initial evaluation and
continuing assessment of Crohn disease.
In patients with ulcerative colitis, the diarrhoea is more prominent,

28. Henoch–Schönlein purpura
This condition causes arthralgia and a typical nonblanching
rash over the extremities and buttocks. Submucosal
haemorrhages in the bowel cause abdominal pain as well as
passage of blood rectally

29. Meckel’s diverticulum
Meckel’s diverticulum occurs in 2% of
the population.
In a small proportion of these
heterotopic gastric mucosa forms
part of the lining of the diverticulum
[Fig. 23.2]. Acid produced by the
gastric mucosa causes ulceration of
the adjacent ileal mucosa. Bleeding
usually presents as painless brick-red
stools with associated marked
anaemia. The patient may require
transfusion, but the bleeding usually
stops spontaneously without an
emergency operation. The definitive
investigation is laparoscopy

31. Tubular duplications
These are much less common than a Meckel’s diverticulum. Tubular
duplications of the small bowel occur in the mesenteric side of the
bowel and communicate proximally or distally with the bowel. They
may be lined by heterotopic gastric mucosa and cause bleeding when
adjacent small bowel mucosa becomes ulcerated. Like a Meckel’s
diverticulum, they may be demonstrated by a technetium nuclear
scan.