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Walter Reed Army Medical Center Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology.

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Presentation on theme: "Walter Reed Army Medical Center Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology."— Presentation transcript:

1 Walter Reed Army Medical Center Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology

2 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

3 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

4 History ] Present illness ã source, magnitude, duration of bleeding ã associated GI symptoms (vomiting, diarrhea, pain) ã associated systemic symptoms (fever, rash, joint pains) ] Review of systems ã GI disorders, liver disease, bleeding diatheses ã Anesthesia reactions ã medications (NSAID’s, warfarin) ] Family history

5 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

6 Further assessment ] Is it really blood? ã Hemoccult stool, gastroccult emesis ] Apt-Downey test in neonates ] Nasogastric aspiration and lavage ã Clear lavage makes bleeding proximal to ligament of Treitz unlikely ã Coffee grounds that clear suggest bleeding stopped ã Coffee grounds and fresh blood mean an active upper GI tract source

7 Substances that deceive ] Red discoloration ã candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin ] Black discoloration ã bismuth, activated charcoal, iron, spinach, blueberries, licorice

8 Laboratory studies ] CBC, ESR; BUN, Cr; PT, PTT in all cases ] Others as indicated: ã Type and crossmatch ã AST, ALT, GGTP, bilirubin ã Albumin, total protein ã Stool for culture, ova and parasite examination, Clostridium difficile toxin assay

9 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

10 Endoscopy: indications ] EGD : hematemesis, melena ] Flexible sigmoidoscopy : hematochezia ] Colonoscopy : hematochezia ] Enteroscopy : obscure GI blood loss

11 DDx: neonates ] Upper GI bleeding ã swallowed maternal blood ã stress ulcers, gastritis ã duplication cyst ã vascular malformations ã vitamin K deficiency ã hemophilia ã maternal ITP ã maternal NSAID use ] Lower GI bleeding ã swallowed maternal blood ã dietary protein intolerance ã infectious colitis ã necrotizing enterocolitis ã Hirschsprung’s enterocolitis ã duplication cyst ã coagulopathy ã vascular malformations

12 Neonatal stress ulcers or gastritis ] Causes ã Shock ã Sepsis ã Dehydration ã Traumatic delivery ã Severe respiratory distress ã Hypoglycemia ã Cardiac condition

13 DDx: infants ] Hematemesis, melena ã Esophagitis ã Gastritis ã Duodenitis ] Hematochezia ã Anal fissures ã Intussusception ã Infectious colitis ã Dietary protein intol. ã Meckel’s diverticulum ã Duplication cyst ã Vascular malformation

14 DDx: children ] Upper GI bleeding ã Esophagitis ã Gastritis ã Peptic ulcer disease ã Mallory-Weiss tears ã Esophageal varices ã Pill ulcers ] Lower GI bleeding ã Anal fissures ã Infectious colitis ã Polyps ã Lymphoid nodular hyperplasia ã IBD ã HSP ã Intussusception ã Meckel’s diverticulum ã HUS

15 Esophageal varices

16 Erosive esophagitis

17 DDx: adolescents ] Hematemesis, melena ã Esophagitis ã Gastritis ã Peptic ulcer disease ã Mallory-Weiss tears ã Esophageal varices ã Pill ulcers ] Hematochezia ã Infectious colitis ã Inflammatory bowel disease ã Anal fissures ã Polyps

18 NSAID induced ulcers

19 Peptic Ulcer

20 Mallory-Weiss Tear

21 Risk of rebleeding of ulcer ] Stigmata of recent hemorrhage ã Visible vessel ã Clot ã Spot ã Clean base ] Rate of rebleed ã 40-50% ã 25-30% ã 10% ã 2-4%

22 Ulcer with red spot

23 Therapy ] Supportive care : begin promptly ã IV fluids, blood products, pressors ] Specific care ã Barrier agents (sucralfate) ã H 2 receptor antagonists (cimetidine, ranitidine, etc.) ã Proton pump inhibitors (omeprazole, lansoprazole) ã Vasoconstrictors (somatostatin analogue, vasopressin) ] Endoscopic therapy : stabilize and prepare patient first ã Coagulation (injection, cautery, heater probe, laser) ã Variceal injection or band ligation ã Polypectomy

24 Bleeding Ulcer


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