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A PPROACH TO GI B LEEDING Simon Lam October 13, 2011 ACH Resident Academic Half Day.

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Presentation on theme: "A PPROACH TO GI B LEEDING Simon Lam October 13, 2011 ACH Resident Academic Half Day."— Presentation transcript:

1 A PPROACH TO GI B LEEDING Simon Lam October 13, 2011 ACH Resident Academic Half Day

2 O VERVIEW Case 1 and Case 2 Presentation History Physical Labs Classification DDx – UGIB Case 1 – Cont’d Initial Management DDx –LGIB Case 2 – Cont’d Case 3

3 C ASE 1 A. S mo male with GDD presents with “a cup” of bright red hematemsis ABC stable S – No other symptx, no melena/hematochezia. A – No allergies M – Vit D and Iron supplements P – Ex 32 wk, had a UVC placed as neonate and 1 episode of CONS sepsis in NICU. L – Last meal 2 hours ago E – “Just happened all of a sudden”

4 C ASE 2 2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting ABC stable S – 2 day history of periumbilical pain A – No allergies M – Vit D P – Had severe reflux as an infant, resolved by 12 mos L – Last meal 2 hours ago E – Has had about 3 BM today, all full of blood.

5 P RESENTATION Hematemesis Coffee ground emesis Melena stool Hematochezia Normal stools with blood Bloody Diarrhea

6 H ISTORY Onset, duration, volume and associated symptoms Colour of blood/emesis/stool Consistency of accompanying stool Blood coating or mixed into stool Hx of dyspepsia, heartburn, abdominal pain, constipation, diarrhea or weight loss Hx of jaundice, easy bruising may suggest liver disease Hx of NSAID use

7 O N E XAM ABC Vitals HEENT CVS RESP ABD Must include DRE! GU Worrisome Signs Pallor Diaphoresis Restlessness Increased HR Decreased BP Orthostatic changes Increase HR 20 bpm Decrease BP 10 mmHg

8 L ABS CBC Hct MCV Plts Iron studies Creatinine Alb CRP/ESR ALT/AST INR/PTT Stool WBC, C+S, O+P

9 G UAIAC T EST Used to confirm the presence of hemoglobin False positives Ascrobic acid (Vit C) Animal myoglobin/hemoglobin

10 A PT T EST Differentiates maternal vs infant blood Maternal = 2α2β Fetal/infant = 2α2γ NaOH will denature maternal blood and not fetal/infant Positive test = Pink Negative test = Yellow/Brown

11 C LASSIFICATION Commonly classified based on location Above Ligament of Treitz = UGBI Below Ligament of Treitz = LGIB

12 May try to pass NG into stomach and aspirate. If + blood, likely UGBI. However if negative, does not exclude UGBI

13 U PPER G ASTROINTESTINAL B LEED DDx Swallowed blood Mallory-Weiss tear Variceals Gastritis* Peptic ulcer AV malformations Hemangiomas Angiodysplasia Dieulafoy lesion Hemobilia Vitamin K deficiency Thrombocytopenia

14 C ASE 1 A. S mo male with GDD presents with “a cup” of bright red hematemsis ABC stable S – No other symptx, no melena/hematochezia. A – No allergies M – Vit D and Iron supplements P – Ex 32 wk, had a UVC placed as neonate and 1 episode of CONS sepsis in NICU. L – Last meal 2 hours ago E – “Just happened all of a sudden”

15 O N E XAM HR 150 BP 80/62 HEENT – No scleral icterus, mild conjunctival pallor CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT = 3 Resp – N Abd – Soft non tender. Spleen ~14cm below CM on MCL. No hepatomegaly, No sigmata of chronic liver diease MSK N CNS – Playful during exam

16 L ABS Hb – 80 MCV 90 Plts -150 INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N

17 DD X ? Sounds like UGBI Esophagel varicies Congestive gastropathy Dieulafoy lesion Peptic ucler

18 I NITIAL M ANAGEMENT ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood, FFP, Cryoprecipitate Proton Pump Inhibitors Octreotide

19 PPI Helpful for gastric mucosal bleeds Thought to decrease the activation of pepsinogen to pepsin which may degrade the fibrin clot pH greater than 6 allow for better platelet aggregation CHILDREN <40 kg: 2 mg/kg IV loading dose over 15 minutes 0.2 mg/kg/hour for 72 hours CHILDREN ≥40 kg: 80 mg IV loading dose over 15 minutes 8 mg/hour for 72 hours

20 O CTREOTIDE Decreases splanchnic blood flow Decreases bleeding from esophageal and gastric varices S/E is hyperglycemia, angina, arrhythmias, and headache 1-2 mcg/kg (Max 50mcg) initial I.V. bolus followed by 1-2 mcg /kg/hour (max 50mcg/hr) one hour after loading dose continuous infusion

21 E NDOSCOPY Bleeding varicies Banding Sclerotherapy – small percentage will have esophageal ulcerations leading to strictures

22 S ENGSTAKEN -B LAKEMORE TUBE If unable to stablize, may need to use in PICU setting Patient will to be sedated ETT to secure airway Stabilize before going into endoscopy Consider angiography

23 S WALLOWED B LOOD Infant – Maternal blood Apt test Child – epitaxis, recent dental extraction or tonsillectomy

24 Mallory – Weiss Tear Repeated vomiting or retching Acute mucosal laceration of the gastroesophageal junction Tx – Up to 50 – 80% stop before time of endoscopy Electrocoagulation, heater-probe application, or sclerotherapy

25 G ASTRITIS Diffuse Trauma Burn Surgery Severe medical problems Locailzed NSAID H. pylori EtOH Bezoar Tx – Proton Pump Inhbitors, may need antibiotics in certain situations

26 AV M ALFORMATION Hemangiomas Angiodysplasia Dieulafoy lesion Tx – Endoscopy Thermal ablation

27 L OWER G ASTROINTESTINAL B LEED DDx Anal fissure Sloughed polyp Meckel’s Diverticulum Vasculitis Vascular malformation UGBI Don’t want to miss Necrotizing entercolitis Malrotation/Volvulu s Intussusception Incarcerated hernia Hirschsprung entercolitis

28 C ASE 2 2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting ABC stable S – 2 day history of periumbilical pain A – No allergies M – Vit D P – Had severe reflux as an infant, resolved by 12 mos L – Last meal 2 hours ago E – Has had about 3 BM today, all full of blood.

29 O N E XAM HR 150 BP 80/62 HEENT – No scleral icterus, mild conjunctival pallor CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT = 3 Resp – N Abd – Soft, slightly tender in RLQ with deep palpation. No masses. BRBPR on DRE MSK N CNS – responsive to exam

30 DD X ? Meckel’s Diverticulum Massive UGIB Malrotation with Volvulus Intussusception

31 I NITIAL M ANAGEMENT ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood, FFP, Cryoprecipitate

32 L ABS Hb – 80 MCV 90 Plts -150 INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N Normal AXR Normal Abd Ultrasound Previously normal barium swallow (done for reflux as infant)

33 Meckel’s Diverticulum Remnant of the omphalomesteric duct Rule of 2s – 2 % of population, 2 % of affected become symptomatic, 50% present before the age of 2, 2 inches long and 2 feet from ileocecal valve May contain acid secreting cells which erode the mesenteric side of lumen causing profuse bleeding Tx – Surgical excision Technetium 99 absorbed by gastric mucosa

34 A NAL F ISSURE Usually associated with constipation or recent history of passing large stool Painful defecation Spotting on toilet paper Resolves with regular soft stooling

35 S LOUGHED J UVENILE P OLYP Intermittant painless rectal bleeding Ages 1 – 10 Maybe bright red, streaked on stools or mixed in May get intermittent abdominal pain, colocolonic intussusception and prolapse through anal canal Often out grow their vascular supply and will auto-amputate May be seen in stool

36 V ASCULITIS Henoch Schonlein Purpura (HSP) IgA mediated small vessel vasculitis affecting skin, kidney, GI tract and joints May have guaiac postive stools Tx - Supportive

37 B LOODY D IARRHEA - DD X Infectious Ulcerative colitis Crohn’s disease Allergic colitis

38 I NFECTIOUS Salmonella EHEC (O157:H7) Campylobacter Shigella Yersinia C. Diff Amox, TMP-SMX Supportive Erythromycin TMP - SMX Supportive, TMP- SMX, aminoglycosides Metronidazole or PO Vancomycin

39 I NFLAMMATORY B OWEL D ISEASE Crohn’s Disease Insidious, may present with abdo pain, growth delay, delayed puberty ASCA Transmural inflammation Skip lesions, Terminal Ileum involved 60% Ulcerative colitis Presents with bloody diarrhea and tenesmus p-ANCA Mucosa inflammation Continuous Rectum involved and progresses proximally

40 A LLERGIC C OLITIS Inflammatory enteropathy caused by the ingestions of cow milk protein Stools often loose with occult or frank blood present Tx – Elimination diet Soy formula may have up to 50% cross reactivity Usually resolves by 1 year of age

41 W HEN TO CONSULT GI? True UGBI bleed r/o swallowed blood Mallory Weis tear may not need consult LGIB r/o Meckel’s r/o Infectious r/o CMPA

42 C ASE 3 14 year old male with recurrent blood mixed in with stool x 1 year. Feeling tired all of the time. Occasional dark stools, no hematemesis. +FOBT by GP. Negative celiac screen A – No allergies M – Ventolin P – Epitaxis, exercise induced asthma FHx – Dad also gets lots of nose bleeds and ‘lung problems’, paternal grandfather died of stroke no IBD, no celiac, no FHx of hemophilia L – This morning at 08:00 E – GP referred to GI

43 O N E XAM See 5mm red/purple stains on skin over face, upper trunk, arms. Also noted on buccal mucosa and tongue. Lesions blanch with pressure Some look like they branch out from centre DRE revealed some frank blood Exam otherwise normal

44 L ABS Hb – 90 MCV 70 Plts -200 Retics 5% INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP – N Ferritin – Low TIBC - High Hypochromic microcytic

45 E NDOSCOPY FINDING

46 Hereditary Hemorrhagic Telangiectasia Also known as Osler-Weber- Rendu Diease Autosomal dominant mutation in transforming growth factor beta signalling pathway Important for vascular growth and repair Triad = Telangiectasia, affected first degree relative and epitaxis Dx – 3 of 4 Criteria Epistaxis - Spontaneous, recurrent nosebleeds Telangiectases - Multiple at characteristic sites (lips, oral cavity, fingers, nose) Visceral lesions - Such as gastrointestinal (GI) telangiectasia (with or without bleeding), pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM Family history - A first-degree relative with HHT

47 Treatment – GI standpoint Estrogen-progesterone therapy Transfusion Aminocaproic acid Endoscopic photoablation or electrocautery

48 Boyle 2008

49 R EFERENCES JT Boyle Gastrointestinal Bleeding in Children and Infants. Pediatrics in Review. (2) 39 – 51 C Ramsook and EE Endom Diagnostic approach to lower gastrointestinal bleeding in children. Up to date. c-approach-to-lower-gastrointestinal-bleeding-in- children?source=search_result&search=lower+gi+bleed&selectedTit le=3%7E102. Accessed October 12, c-approach-to-lower-gastrointestinal-bleeding-in- children?source=search_result&search=lower+gi+bleed&selectedTit le=3%7E102 Soares et al J Port Gastrenterol. v.17 n.5 Lisboa set A. Panigrahi Pediatric Osler-Weber-Rendu Syndrome. Medscape reference. overview. Accessed October 12, 2011http://emedicine.medscape.com/article/ overview. Accessed October 12 X Villa Approach to upper gastrointestinal bleeding in children. Up to date. to-upper-gastrointestinal-bleeding-in- children?source=search_result&search=upper+gi+bleed&selectedTit le=2%7E150. Accessed October 12, to-upper-gastrointestinal-bleeding-in- children?source=search_result&search=upper+gi+bleed&selectedTit le=2%7E150

50 T HANKS ! Special Thank You to Dr. C. Waterhouse


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