Presentation is loading. Please wait.

Presentation is loading. Please wait.

GI Bleeding in Children

Similar presentations

Presentation on theme: "GI Bleeding in Children"— Presentation transcript:

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

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

Download ppt "GI Bleeding in Children"

Similar presentations

Ads by Google