Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric 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? Apt-Downey test in neonates 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, melena Flexible sigmoidoscopy: hematochezia Colonoscopy: hematochezia Enteroscopy: obscure GI blood loss

DDx: neonates Upper GI bleeding Lower 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 Hematochezia Esophagitis Gastritis Duodenitis Hematochezia Anal fissures Intussusception Infectious colitis Dietary protein intol. Meckel’s diverticulum Duplication cyst Vascular malformation

DDx: children Upper GI bleeding Lower 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 Hematochezia 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