Gastrointestinal Hemorrhage

1
Gastrointestinal Hemorrhage

• Carolyn A. Sullivan, MD
• Pediatric Gastroenterology

2
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

3
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

4
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 (NSAIDs, warfarin)
• Family history

5
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

6
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

7
Substances that deceive

• Red discoloration
• candy, fruit punch, Jell-o, beets, watermelon,
  laxatives, phenytoin, rifampin
• Black discoloration
• bismuth, activated charcoal, iron, spinach,
  blueberries, licorice

8
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

9
Imaging studies and indications

• Upper GI series dysphagia, odynophagia, drooling
• Barium enema intussusception, stricture
• Abdominal US portal hypertension
• Meckels scan Meckels diverticulum
• Sulfur colloid scan, labeled RBC scan,
  angiography obscure GI bleeding

10
Endoscopy indications

• EGD hematemesis, melena
• Flexible sigmoidoscopy hematochezia
• Colonoscopy hematochezia
• Enteroscopy obscure GI blood loss

11
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
• Hirschsprungs 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

13
DDx infants

• Hematemesis, melena
• Esophagitis
• Gastritis
• Duodenitis

• Hematochezia
• Anal fissures
• Intussusception
• Infectious colitis
• Dietary protein intol.
• Meckels 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
• Meckels 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

18
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

24
Bleeding Ulcer