1. GI Bleeding in Children
Maria Christina H. Ventura, MD, DPPS
July 8, 2010

2. Bleeding may occur anywhere along the GI tract
Identification of the site may be challenging

3. The least likely site of bleeding
Small intestine
Except in Meckel’s diverticulum wherein there is painless bleeding

4. The most common cause of bleeding
Erosive damage to the mucosa of the GI tract
Variceal bleeding secondary to portal hypertension also occurs frequently.

5. Rare cause of bleeding in children
Vascular malformations

6. Clinical Definition HEMATEMESIS HEMATOCHEZIA MELENA
When bleeding originates in the esophagus, stomach or duodenum, it may cause hematemesis.
When the blood is exposed to the gastric or intestinal juices, blood quickly darkens to resemble coffee grounds.
Massive bleeding is likely to be red.
Red or maroon blood in the stools signifies either a distal bleeding site ofr massive hemorrhage above the distal ileum.
When there is moderate to mild bleeding from sites above the distal ileum, this would cause tarry black stools known as melena
Major hemorrhages in the duodenum or above can cause melena.

7. Upper vs. Lower GI Bleeding
Acute Upper GI bleeding usually presents with hematemesis or the passage of melena
Acute Lower GI bleeding usually presents with hematochezia
Severe Acute GI bleeding may present with hematochezia because the blood is not altered during the very rapid transit the digestive tract.

8. Children with profuse upper and lower GI bleeding can present with hypovolemia and shock.

9. CLUES History Physical Examination
Laboratory and Radiographic techniques

10. Clinical Algorithm Infants and Neonates
Common Causes
Bacterial Enteritis
Milk protein allergy
Intussusception
Swallowed maternal blood
Anal Fissure
Lymphonodular hyperplasia

11. Infants and Neonates Rare Causes Volvulus Necrotizing enterocolitis
Meckel diverticulum
Stress ulcer, stomach
Coagulation disorder ( Hemorrhagic Disease of the Newborn )

12. Clinical Algorithm Children
Common Causes
Bacterial enteritis
Anal Fissure
Colonic Polyps
Intussusception
Peptic Ulcer/ Gastritis
Swallowed epistaxis
Mallory Weiss Syndrome

13. Children Rare Causes Esophageal varices Esophagitis
Meckel Dicerticulum
Lymphonodular hyperplasia
HSP
Foreign body
Hemangioma, AV Malformation
Sexual abuse
HUS
IBD
Coagulopathy

14. ADOLESCENT Common Causes Bacterial enteritis IBD
Peptic Ulcer/ Gastritis
Mallory Weiss Syndrome
Colonic Polyps

15. Adolescent Rare causes Hemorrhoids Esophageal varices Esophagitis
Telangiectasia angiodysplasia
Gay bowel disease
Graft versus Host disease

16. Indirect Imaging
Arteriography
Scintigraphy
CT Scan
MRI

17. UPPER GI Causes Vascular lesions in the small bowel Peptic Ulceration
Meckel’s diverticulum
Esophageal varices
Malignancy

18. Peptic Ulceration
Ulcers and gastritis are classified as primary ( peptic) or secondary
caused by factors known to affect the intergrity of the gastric or duodenal mucosa.
Primary : chronic, duodenal and related to H. pylori gastritis
Secondary : usually acute and gastric

19. Peptic Ulcer
ULCER : a disruption of the intestinal epithelium exposed to acid or pepsin
EROSION : superficial ulcer
Ulcers are usually 1 cm of less in diameter
Gastritis : inflammation of the gastric mucosa without disruption of the mucosa
A fibrinous coat of leukocytes and red cells covers a zone of fibrinoid necrosis surrounded by an infiltration of acute and chronic inflammatory cells.

20. Factors in the development of gastritis
mediators of mucosal inflammation of the gastric mucosa :Oxygen free radicals, lymphokines and monokines
Mucosal defense mechanisms:
surface water-unstirred water layer
intestinal and pancreatobiliary sources of bicarbonate

21. surface active hydrophobic phospholipids in the mucosal area
mucosal blood flow
rapid rate of cell replacement enhanced by factors ( EGF)

22. Duodenal Ulcers Increased acid secretion
Acid secretion does not correlate with with ulcer size or duration of symptoms.
Family history : %
Partially due to the known clustering of H. pylori in families

23. OTHER FACTORS Blood Type O cigarette smoking climatic conditions
dietary habits ( consumption of alcohol)
emotional stress

24. Factors related to acid are more important in duodenal ulcers
Tissue resistance is of more importance in gastric ulcers

25. Primary Peptic ulcers
Manifestations : pain. vomiting and chronic gastrointestinal blood loss and a strong familial incidence
Primary gastritis due to H pylori usually occurs with primary peptic ulcers
1st month of life : gastrointestinal bleeding and perforation

26. Primary Peptic ulcers Between the neonatal period and 2 years old :
recurrent vomiting
slow growth
gastrointestinal hemorrhage

27. Primary Peptic ulcers Preschool children
periumbilical postprandial pain is often elicited
vomiting and hemorrhage

28. Primary Peptic ulcers After 6 years old : similar symptoms in children
epigastric abdominal pain
acute or chronic GI blood loss often leading to IDA
predominantly male

29. Secondary Peptic Ulcers
Usually due to sepsis in infants
Respiratory or cardiac insufficiency
Trauma or dehydration
Stress ulcers and erosions associated with burns are Curling ulcers
Associated with normal gastric secretions ; Common in burn patients (>25 % BSA)

30. Secondary Peptic Ulcers
Cushing ulcers
Follows head trauma or surgery
Associated with gastric hypersecretion
Most are aysmptomatic
May be associated with severe hemorrhage or perforation

31. ANAL Causes Hemorrhoids Fissure Perianal abscess/ fissure
Anal carcinoma

32. Hemorrhoids Usually uncommon in children Usually benign
When seen, must suspect portal hypertension
Avoidance of chronic constipation, fecal impaction or other irritating local factors

33. Anal Fissure
Small laceration of the mucocutaneous junction of the anus.
Acquired lesion secondary to the forceful passage of a hard stool, mainly seen in infancy.
Fissures appear to be the consequence and not the cause of constipation.

34. Anal Fissure Usually a history of constipation is elicited.
painful bowel movement
Patient retains the stool voluntarily to avoid a painful bowel movement
Bright red blood on the surface of the stool

35. Anal Fissure Inspection of the Anal area
Infant’s hips are put in acute flexion
Buttocks are separated to expand the folds of the perianal skin
Fissure becomes evident as a minor laceration
(+) TAG
Peripheral to the laceration, the patient might be seen to have a small skin appendage that represents epithelialized granulomatous tissue secondary to chronic inflammation

36. Anal Fissure
The most important element in the treatment is for the parents to understand the origin of the laceration and the mechanism of the cycle of constipation.
Goal of the treatment : REVERSE the CYCLE
soft stools to avoid overstretching

37. Anal Fissure Stool softener Avoid hard stools and diarrhea
Treat the primary cause of constipation

38. Perianal Abscess and Fistula
Two different groups of pediatric patients
Infants without predisposing conditions
Older children with predisposing conditions

39. Infants relatively common usually boys < 2 years old
benign self-limited condition
the abscess has a communication with one of the crypts of the pectinate line of the anal canal
It is believed that the crypts are the source of infection although the exact mechanism is unknown.

40. Infants
The abscess eventually drains through an orifice in the perianal area
Then inflammation subsides
But, a fistula remains that communicates with the affected crypt to the perianal external orifice
Fistula becomes chronic but usually disappears spontaneously before 2yrs.

41. Infants low grade fever, mild rectal pain, area of perianal cellulitis
No evidence indicates that antibiotics are useful in these patients
When the patient is extremely uncomfortable, the abscess can be drained under local anesthesia
Once a chronic fistula forms, it is recommended that a fistulotomy under general anesthesia is done.

42. Children
Children >2 years old with perianal or perirectal abscess and with a predisposing illness.
Drug-induced or autoimmune neutropenia, leukemia, AIDS, DM, Crohn disease, prior rectal surgery, immunosuppresant drugs
More serious condition

43. Children Prognosis is related to the predisposing disease
Abscess may be deep and may rapidly expand

44. RECTAL Causes
Polyp
Carcinoma
Proctitis

45. Juvenile Colonic Polyp
MOST COMMON childhood bowel tumor
3-4% in less than 21 years old
Rarely appear before 1 yr. of age
Mostly between 2-10 years old
Usually proximal in the descending colon

46. Bright red painless rectal bleeding during or immediately after a bowel movement
Colonoscopy
Removal of the polyp

47. Familial Polyposis Syndromes
Familial Adenomatous Polyposis Coli
Gardner Syndrome
Peutz-Jeghers Syndrome

48. COLONIC Causes Polyp Cancer Diverticular diseases
Colitis ( Inflammatory, Infective or Ischemic)
Angiodysplasia