Presentation on theme: "GI Bleeding in Children"— Presentation transcript:
1 GI Bleeding in Children Maria Christina H. Ventura, MD, DPPSJuly 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 intestineExcept in Meckel’s diverticulum wherein there is painless bleeding
4 The most common cause of bleeding Erosive damage to the mucosa of the GI tractVariceal 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 melenaMajor 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 melenaAcute Lower GI bleeding usually presents with hematocheziaSevere 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 CausesBacterial EnteritisMilk protein allergyIntussusceptionSwallowed maternal bloodAnal FissureLymphonodular hyperplasia
11 Infants and Neonates Rare Causes Volvulus Necrotizing enterocolitis Meckel diverticulumStress ulcer, stomachCoagulation disorder ( Hemorrhagic Disease of the Newborn )
12 Clinical Algorithm Children Common CausesBacterial enteritisAnal FissureColonic PolypsIntussusceptionPeptic Ulcer/ GastritisSwallowed epistaxisMallory Weiss Syndrome
13 Children Rare Causes Esophageal varices Esophagitis Meckel DicerticulumLymphonodular hyperplasiaHSPForeign bodyHemangioma, AV MalformationSexual abuseHUSIBDCoagulopathy
17 UPPER GI Causes Vascular lesions in the small bowel Peptic Ulceration Meckel’s diverticulumEsophageal varicesMalignancy
18 Peptic UlcerationUlcers and gastritis are classified as primary ( peptic) or secondarycaused by factors known to affect the intergrity of the gastric or duodenal mucosa.Primary : chronic, duodenal and related to H. pylori gastritisSecondary : usually acute and gastric
19 Peptic UlcerULCER : a disruption of the intestinal epithelium exposed to acid or pepsinEROSION : superficial ulcerUlcers are usually 1 cm of less in diameterGastritis : inflammation of the gastric mucosa without disruption of the mucosaA 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 monokinesMucosal defense mechanisms:surface water-unstirred water layerintestinal and pancreatobiliary sources of bicarbonate
21 surface active hydrophobic phospholipids in the mucosal area mucosal blood flowrapid 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 ulcersManifestations : pain. vomiting and chronic gastrointestinal blood loss and a strong familial incidencePrimary gastritis due to H pylori usually occurs with primary peptic ulcers1st month of life : gastrointestinal bleeding and perforation
26 Primary Peptic ulcers Between the neonatal period and 2 years old : recurrent vomitingslow growthgastrointestinal hemorrhage
27 Primary Peptic ulcers Preschool children periumbilical postprandial pain is often elicitedvomiting and hemorrhage
28 Primary Peptic ulcers After 6 years old : similar symptoms in children epigastric abdominal painacute or chronic GI blood loss often leading to IDApredominantly male
29 Secondary Peptic Ulcers Usually due to sepsis in infantsRespiratory or cardiac insufficiencyTrauma or dehydrationStress ulcers and erosions associated with burns are Curling ulcersAssociated with normal gastric secretions ; Common in burn patients (>25 % BSA)
30 Secondary Peptic Ulcers Cushing ulcersFollows head trauma or surgeryAssociated with gastric hypersecretionMost are aysmptomaticMay be associated with severe hemorrhage or perforation
32 Hemorrhoids Usually uncommon in children Usually benign When seen, must suspect portal hypertensionAvoidance of chronic constipation, fecal impaction or other irritating local factors
33 Anal FissureSmall 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 movementPatient retains the stool voluntarily to avoid a painful bowel movementBright red blood on the surface of the stool
35 Anal Fissure Inspection of the Anal area Infant’s hips are put in acute flexionButtocks are separated to expand the folds of the perianal skinFissure becomes evident as a minor laceration(+) TAGPeripheral 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 FissureThe 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 CYCLEsoft 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 patientsInfants without predisposing conditionsOlder children with predisposing conditions
39 Infants relatively common usually boys < 2 years old benign self-limited conditionthe abscess has a communication with one of the crypts of the pectinate line of the anal canalIt is believed that the crypts are the source of infection although the exact mechanism is unknown.
40 InfantsThe abscess eventually drains through an orifice in the perianal areaThen inflammation subsidesBut, a fistula remains that communicates with the affected crypt to the perianal external orificeFistula 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 patientsWhen the patient is extremely uncomfortable, the abscess can be drained under local anesthesiaOnce a chronic fistula forms, it is recommended that a fistulotomy under general anesthesia is done.
42 ChildrenChildren >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 drugsMore serious condition
43 Children Prognosis is related to the predisposing disease Abscess may be deep and may rapidly expand