Welcome Applicants!!Morning Report: Thursday, January 26th

GI Bleeding in Infants and Children

Initial Approach

Step 1: ABCs!! Assess hemodynamic status of the patient› Orthostatic changes- best indicator of

significant blood loss Step 2: Establish severity of bleeding

› Coffee ground emesis, melena: lower rate of bleeding

› Bright red blood: ?higher rate of bleeding

UGI vs. LGI Bleeding

Step 3: Determine the location of the bleeding› UGI: bleeding above the ligament of Treitz

Hematemesis› LGI: bleeding distal to the ligament of Treitz

Bloody diarrhea Bright red blood mixed with or coating stool

› Hematochezia, melena, or occult blood loss can be due to both UGI or LGI bleeds Passing NGT can determine if the blood is

originating from the UGI tract or LGI tract

Is It Blood?

Simulates bright red blood› Food coloring› Colored gelatin or

children’s drinks› Red candy› Beets› Tomato skins› Antibiotic syrups

Simulates melena› Bismuth or iron

preparations› Spinach› Blueberries› Grapes› Licorice

Peptic Ulcer Disease in Children

Pathogenesis

Cytotoxic factors:1. Acid2. Pepsin3. Medications4. Bile acids5. Infection with

H.Pylori

Cytoprotective factors:1. Mucous layer2. Local bicarb

secretion3. Mucosal blood

flow

Clinical Presentation

Epigastric abdominal pain Recurrent vomiting (at least 3x/mo) Symptoms associated with eating (anorexia/

wt loss) Pain awakening the child at night Heartburn Oral regurgitation Chronic nausea Excessive belching/ hiccuping FHx of PUD, dyspepsia, or IBS

History

Symptoms? Dietary history?

› Specific foods that worsen pain? Medications? Alcohol or tobacco use? Doses of acid-suppressive meds?

Physical Exam

Height, weight and BMI PLOT! HEENT

› Funduscopic exam › OP: aphthous ulcers Crohn’s dz, dental enamel erosion

GER, Eating d/o Lungs

› Wheezing GER Abdomen

› Splenomegaly portal HTN Rectum

› Perianal disease Crohn’s dz Extremities

› Clubbing Crohn’s dz, Russell sign Eating d/o

Evaluation

Screening labs› CBC with diff› ESR› LFTs› Electrolytes› Stool for O&P› UA

Endoscopy› Indications

Evidence of GI bleeding

Abnormality on UGI Odynophagia Refusal to eat Persistant

unexplained vomiting

Lack of response to medications

Helicobacter pylori Infection

The Basics…

Gram negativebacillus Transmission fecal-oral, gastric-oral, or

oral-oral *Organism associated with a significant

proportion of duodenal ulcers & chronic active gastritis› To a lesser extent, gastric ulcers

Also linked to the development of gastric adenocarcinoma and lymphoma

Epidemiology

50 % of the world’s population is infected› Most are asymptomatic

Infection most common in developing countries› Incidence 3-10% in developing countries› Incidence 0.5% in industrialized countries

Asian Americans, African Americans and Hispanic individuals living in North America have a prevalence of infection similar to that of a developing country› Ethnic or genetic predisposition?

*Risk Factors

Poor socioeconomic status Family overcrowding Child care attendance Poor hygiene Living with an infected family member

*Testing

The ideal test does not yet exist!› Endoscopy with biopsies from the

prepyloric antrum= gold standard Histologic identification Culture Immunologic detection of H.Pylori urease PCR

› Urease breath test› Anti-H. Pylori IgG› Stool antigen testing

*Testing

Stool antigen testing› Sensitivity and specificity> 98%› Sample easy to obtain› Less expensive than the urease breath test

The AAP says…don’t test for it if you are not going to treat it!!› Active peptic ulcer disease› History of ulcers› MALT lymphoma or gastric cancer

*Treatment

Goals› Eradicate the organism› Heal the ulcer› Prevent recurrence of infection and the

emergence of resistant organisms Two antimicrobials + PPI

› First line: clarithromycin+ Amoxicillin OR metronidazole+ PPI

› Alternative (age>8): tetracycline+ metronidazole+ bismuth subsalicylate+ H2 blocker

*Treatment

Length of treatment: 14days Cure rates 75-90% To check for eradication, wait 6 weeks-3 months after the completion of therapy

› Urease breath test› Stool antigen test

A Question…

A 12 yo boy who has a h/o recurrent abdominal pain presents to your office for an annual health supervision visit. The boy complains of periumbilical pain, unrelated to meals, occuring twice a month and lasting 15 minutes. PE is normal. FOBT is negative. His father, who is a physician, asks if the boy should undergo testing for H. Pylori. Of the following, a TRUE statement about H. Pylori infection is:› A. All children who have positive H. Pylori serologies should undergo

endoscopy› B. Antibiotic therapy for H. Pylori is most effective when combined with a

PPI› C. H. Pylori is difficult to detect on gastric histology without special

immunofluorescent staining› D. H. Pylori infection is less prevalent in children from the developing

world› E. H. Pylori organisms rarely develop antibiotic resistance

Thanks for your attention!!Noon Conference: Pseudoasthma, Dr. Pepiak