gastrointestinal hemorrhage
TRANSCRIPT
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Walter Reed Army Medical Center
Gastrointestinal Hemorrhage
Carolyn A. Sullivan, MDPediatric Gastroenterology
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Objectives
Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding
Review the most common etiologies for GI bleeding in pediatric patients in various age groups
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Definitions Melena: passage of black, tarry stools;
suggests bleeding proximal to the ileocecal valve
Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding
Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz
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History Present illness
source, magnitude, duration of bleeding associated GI symptoms (vomiting, diarrhea, pain) associated systemic symptoms (fever, rash, joint
pains) Review of systems
GI disorders, liver disease, bleeding diatheses Anesthesia reactions medications (NSAID’s, warfarin)
Family history
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Physical examination
Vital signs, including orthostatics Skin: pallor, jaundice, ecchymoses,
abnormal blood vessels, hydration, cap refill HEENT: nasopharyngeal injection, oozing;
tonsillar enlargement, bleeding Abdomen: organomegaly, tenderness,
ascites, caput medusa Perineum: fissure, fistula, induration Rectum: gross blood, melena, tenderness
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Further assessment Is it really blood?
Hemoccult stool, gastroccult emesis Apt-Downey test in neonates Nasogastric aspiration and lavage
Clear lavage makes bleeding proximal to ligament of Treitz unlikely
Coffee grounds that clear suggest bleeding stopped
Coffee grounds and fresh blood mean an active upper GI tract source
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Substances that deceive
Red discoloration candy, fruit punch, Jell-o, beets,
watermelon, laxatives, phenytoin, rifampin
Black discoloration bismuth, activated charcoal, iron,
spinach, blueberries, licorice
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Laboratory studies
CBC, ESR; BUN, Cr; PT, PTT in all cases Others as indicated:
Type and crossmatch AST, ALT, GGTP, bilirubin Albumin, total protein Stool for culture, ova and parasite
examination, Clostridium difficile toxin assay
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Imaging studies and indications
Upper GI series: dysphagia, odynophagia, drooling
Barium enema: intussusception, stricture
Abdominal US: portal hypertension Meckel’s scan: Meckel’s diverticulum Sulfur colloid scan, labeled RBC scan,
angiography : obscure GI bleeding
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Endoscopy: indications
EGD: hematemesis, melenaFlexible sigmoidoscopy:
hematocheziaColonoscopy: hematocheziaEnteroscopy: obscure GI blood
loss
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DDx: neonates
Upper GI bleeding swallowed maternal
blood stress ulcers, gastritis duplication cyst vascular
malformations vitamin K deficiency hemophilia maternal ITP maternal NSAID use
Lower GI bleeding swallowed maternal blood dietary protein
intolerance infectious colitis necrotizing enterocolitis Hirschsprung’s
enterocolitis duplication cyst coagulopathy vascular malformations
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Neonatal stress ulcers or gastritis
Causes Shock Sepsis Dehydration Traumatic delivery Severe respiratory distress Hypoglycemia Cardiac condition
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DDx: infants
Hematemesis, melena
Esophagitis Gastritis Duodenitis
Hematochezia Anal fissures Intussusception Infectious colitis Dietary protein intol. Meckel’s diverticulum Duplication cyst Vascular
malformation
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DDx: children
Upper GI bleeding
Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers
Lower GI bleeding Anal fissures Infectious colitis Polyps Lymphoid nodular
hyperplasia IBD HSP Intussusception Meckel’s diverticulum HUS
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Esophageal varices
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Erosive esophagitis
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DDx: adolescents
Hematemesis, melena
Esophagitis Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers
Hematochezia Infectious colitis Inflammatory bowel
disease Anal fissures Polyps
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NSAID induced ulcers
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Peptic Ulcer
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Mallory-Weiss Tear
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Risk of rebleeding of ulcer
Stigmata of recent hemorrhage
Visible vessel Clot Spot Clean base
Rate of rebleed
40-50% 25-30% 10% 2-4%
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Ulcer with red spot
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Therapy Supportive care: begin promptly
IV fluids, blood products, pressors Specific care
Barrier agents (sucralfate) H2 receptor antagonists (cimetidine, ranitidine, etc.) Proton pump inhibitors (omeprazole, lansoprazole) Vasoconstrictors (somatostatin analogue, vasopressin)
Endoscopic therapy: stabilize and prepare patient first Coagulation (injection, cautery, heater probe, laser) Variceal injection or band ligation Polypectomy
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Bleeding Ulcer