Gastrointestinal bleeding in infancy and childhood in infancy and childhood د. عبد الرحمن عبد العزيز استشاري جراحة عامة وجراحة اطفال

Bleeding whether mild or massive can occur from either end of the alimentary tract. The appearance of even small amount of blood in the vomits or mixed with stool Is the cause of anxiety to parents and hospital staff. The assessment of blood lose should be related to the size and weight of the child. Blood volume in the children usually estimated as 80 ml of blood per kg body weight. So the blood volume in the neonate who's weight is 3 kg is 240 ml (approximately half pint)

Alimentary tract bleeding may present with a variety of symptoms, according to the level and rate of hemorrhage. It may be ‘occult’ and present as iron-deficiency anemia, or it may be seen as blood passed per rectum; in this instance, there may be malena (dark changed blood)or bright red bleeding.

GASTRO INTESTINAL BLEEDING CAN BE GROUPED UNDER FOUR DIVISION 1.Anorectal bleeding 2.Hemorrhage in the neonates. 3.Bleeding with other clinical feature. 4.Massive bleeding (haematamess and malena)

ANO RECTAL BLEEDING To know the cause of ano rectal bleeding we have to ask about the following: 1.Amount of the bleeding. 2.Color of the bleeding. 3Whether painless of painful. 4.Presence or absence of any prolapsing mass. 5.History of trauma or fall. 6. Any familial bleeding tendency.

On physical examination we have to look for: 1.General appearance of the patient: including the face,the skin,and mouth looking for anemia. Purpora haemangioma and circum oral melanin spots.

2.Abdominal examination: looking for liver or splenic enlargements ascites or any dilated veins. 3. Examination of the extremities: for painfull or swollen joints

On local examination Inspection of the anal verge may reveal fissure in the anal mucosa or rectal prolapse or polyp. Rectal examination my reveal fecal impaction constipation and juvenile rectal polyp which can be delivered out side the anus. Some time the cause of the bleeding can not be determined by history and clinical examination.

Further investigation may be required 1. Stool examination to see whether there is any pus cells,or worm infestation. 2. Barium enema and double contrast enema as in case of multiple familial polyposis.

3.Endoscopic examination whether rigid sigmoidoscope or flexible colonoscopy to look for Ulcerative colitis or polyps or hemangioma or telangactasias

RECTAL BLEEDING : In the neonate is very rare. Dark blood mixed with mucous occur in the volvulous neonatorum. Bloody diarrhea with abdominal distension and vomiting is a feature of necrotizing Enterocollitis Which could occur in the newborn baby especially at the first two weeks of life and usually occur in the premature babies Or baby subjected to a distress such as respiratory distress syndrome

HAEMORRHAGE WITH OTHER SYMPTOM AND SIGNS Here in these condition bleeding is one of the less important clinical feature examples: 1.INTUSSUSCEPTION :which occur at the age of 6-9 months usually the baby present with screaming or crying,vomiting and abdominal mass with passage of red current jelly stool,which is due to blood mixed with mucous secretion of the alimentary tract.

2.ULCERATIVE COLLITIS: Can affect young children between years and the main feature here is weight loss, anemia, chronic diarrhea and abdominal pain. in rare situation the patients may develop Massive hemorrhage which may necessitate urgent surgical treatments(total colectmy) 3.GASTRO INTERITIS : here the condition occur acutely with abdominal pain,vomiting and diarrhea The condition is usually associated with fever and in rare condition bleeding may occur

4.HENOCH-SCHOENLIEN PURPURA: Gastrointestinal bleeding may occur here the patient has got purpuric spots,joint involvement in addition to GIT involvement.

MASSIVE GASTROINTESTINAL BLEEDING This is not a common pediatric problem, but 2 conditions are common and have to be considered 1.Hematamesis from esophageal varices in portal hypertension. 2. Malena from peptic ulcer especially from the site of mickle,s diverticulum

1.PORTAL HYPERTENSION Portal hypertension in children is the result of obstruction of the blood flow from the portal vein system into the inferior vena cava- according to the site of obstruction tow type were recognized. 1.Intra –hepatic obstruction result from liver cirrhosis.whether from hepatitis or biliary atresia.

2. Extra-hepatic which is more common in children usually due to neonatal sepsis with spread of infection and thrombosis along the umbilical vein to the portal vein. The portal venous pressure will rise to ml of water this will cause enlargement of the spleen and development of the collateral circulation specially the gastro – esophageal venous plexus were bleeding may developed

2.MICKLES DIVERTICULUM Some times bleeding from mickles diverticum is very difficult to diagnose. mickles diverticum is present in 2 % of population.Ectopic tissue in the lining is found in more than 50% of them.gastric mucosa or pancreatic tissue may be found may be found and it is not rare to find both lining together. The diverticulum is symptom less until complication occur.

These complication present in one of the following ways. 1.Massive hemorrhage. 45% 2. Intestinal obstruction. 25% 3. Acute inflammation. 20% 4. Persistent communication with the umbilicus. 10 %

Massive hemorrhage occur in children less than 3 years,usually stared as malena than become bright red,it is painless bleeding and sometime very difficult to prove the diagnosis 1.Barium meal, follow through and enema is not helpful. 2.The diverticulum is not with in reach of colonoscopy. 3.Angiogram,if the rate of bleeding is rapid (helpful)

4.Technetium scan (TC 99 ), here the isotope is concentrated in mickles diverticulum A technetium scan showing ectopic gastric mucosa

5. Laparotomy or laparoscopy may be required in some cases to diagnose and to treat such problem