RICHARD L. MONES MDCOLUMBIA UNIVERSITY

HARLEM HOSPITAL CENTER

GASTROINTESTINAL BLEEDING IN PEDIATRICS

ESPECIALLY IF IT’S YOURS

RICHARD L. MONES MD 2012

“ BLEEDING FROM ANY ORIFICE IS A GREAT SOURCE OF ANXIETY “

LEARN THE CAUSES OF GI BLEEDING IN CHILDHOOD

UNDERSTAND THE DIAGNOSTIC APPROACH TO BLEEDING

TREATMENT AND MANAGEMNT OF BLEEDING

GOALS

REVIEW THE INITIAL APPROACH TO BLEEDINGLEARN THE CAUSES OF BLEEDING BY AGE

GROUPLEARN DETAILS OF THE MORE COMMON

CAUSES YOU ARE LIKELY TO ENCOUNTER IN PRACTICE

LIST THE UNCOMMON CAUSES ( BOARD EXAMS) OF BLEEDING FOR FURTHER READING

SHOW DIAGNOSTIC TECHNIQUES

ORGANIZATION OF LECTURE

ASSESS VITAL SIGNS REMEMBER THAT CHILDREN MAINTAIN B.P. IN

THE FACE OF SEVERE VOLUME DEPLETION AND FALL OFF THE CLIFF

?? LOCPALOR, Cap Refill, ORTHOSTASIS ( LATE IN

CHILDREN )ABDOMINAL PAINFLUID RECUSSITATIONCORRECT COAGULOPATHY

INR 1.5>/PLATELTS<50,OOO

ABCs ANY BLEEDING PATIENT

SIGNS OF CHRONIC LIVER DISEASE OR PORTAL HYPERTENSION

PETECHIAE/ECCHYMOSESHAMANGIOMAEPISTAXISNASOPHARYNGEAL BLOOD

PHYSICAL FINDINGS

HEMOGLOBIN/HEMATOCRITHEMOCONCENTRATION CAN MAKE H/H

DECEIVINGPLATELETSCOAG. PANELLFTsTYPE AND CROSS FOR TRANSFUSIONRECTAL EXAM-----HEMOCCULT

LAB EVALUATION

NO LONGER USED FOR THERAPY

EXCELLENT WAY TO ASSESS THE SEVERITY, LOCATION ON PERSITENCE OF UGI BLEEDING

NG TUBE PLACEMENT

REAGENT CONTAINS PEROXIDE WHICH INTERACTS WITH PEROXIDASES IN HEMOGLOBIN TO CAUSE COLOR CHANGE

FALSE NEGATIVE---- LARGE AMOUNT OF ASCORBIC ACID

FALSE POSITIVELARGE AMOUNT OF RED MEATBROCCOLI,TURNIPS RADISHES AND

CANTALOUPE

HEMOCCULT TEST

BEETSJUICEKOOL-AIDIRONPEPTO-BISMOLCEFDINIR

BLOOD IN STOOL THAT IS NOT BLOOD

NEWBORNINFANTSCHILDREN/ADOLESCENTS

UPPER GI BLEEDING

HEMATEMESIS IS THE VOMITING OF BRIGHT RED BLOOD

COFFEE EMESIS IS BLOOD DENATURED BY GASTRIC ACID

MELENA IS THE RESULT OF BACTERIAL OXIDATION OF BLOOD ANYWHERE FROM THE CECUM PROXIMALLY

BACTERIATRANSIT

50-100 ML.

FORMS OF UGI BLEEDING

HEMATEMESIS

COFFEE GROUND EMESIS

MELENA

SWALLOWED MATERNAL BLOODHEMORRHAGIC DIEASE OF NBOTHER COAGULOPATHYGASTIRTIS AND GASTIC ULCERVASCULAR ANOMALYMILK PROTEIN ALLERGY

NEONATES……..UGI BLEEDING

VAGINAL BLOOD AT DELIVERY

APT TEST

NIPPLES CRACKED/FISSURED

PUMP AND OBSERVE

SWALLOWED MATERNAL BLOOD

BORN WITH VERY HIGH GASRTIN LEVELS

GASTRIC ULCERS

EMPIRIC TREATMENT WITH RANITIDNE

10 MG./KG/24H IN 3 DIVIDED DOSES

PEPTIC DISEASE

VITAMIN K NOT GIVEN

OVERSIGHT OR INTENTIONAL

Rx GIVE VIT. K 1 MG IM

HEMORRHAGIC DISEASE OF NB

USUALLY THERE IS A CLUE

A VASCULAR LESION ON THE SKIN

VASCULAR ANOMALIES

INTESTINAL HEMANGIOMA

ANAL FISSUREMP ALLERGYINFECTIONNECHIRSCHPRUNG’SMECKEL’SVOLVULUSDUPLICATION

NEONATE LOWER GI BLEED

BLACK IS BLACK…I WANT MY BABY BACKTELL TO COMPARE STOOL TO TELPHONE

CORD OR OTHER BLACK OBJECTDARK GREEN STOOL CAN BE DECEIVINGIF DOUBT…. TEST TEST TEST!!!

“ MY BABY’S POOP IS BLACK”

ESSENTIALLY THE LIST OF CAUSES OF UGI AND LGI BLEEDING IS SIMILAR TO THE NEONATE

CAN REMOVE NECCAN BEGIN TO ADD JUVENILE POLYPSCONSTIPATION AS A CAUSE OF ANAL FISSURE

COMES INTO PLAYTHE ORDER OF LIKLEHOOD CHANGES

WHAT ABOUT INFANTS??

JUVENILE POLYPS MAKE A BIG ENTRANCE AT THIS AGE

SO DOES LYMPHONODULAR HYPERPLASIA (LNH)

WE BEGIN TO SEE INFLAMMATORY BOWEL DISEASE AND HENOCH-SCHONLEIN PURPURA

ANAL FISSURES STILL A BIG PLAYER DUE TO THE HIGH PREVALENCE OF STOOL WITHHOLDING AT THIS AGE

MALLORY-WEISS TEARS DUE TO WRETCHING AND VOMITING SEEN AT THIS AGE

THE YOUNG CHILD

PEPTIC DISEASE…..H. PYLORI RELATED??GASTRITIS, ESOPHAGITIS, DUODENAL ULCER

HEMORRHOIDSPSUEDOMEMBRANOUS COLITISIBD

ADOLESCENT/OLDER CHILD

EVERY DAY/WEEK/MONTH STUFF

THINGS YOU WILL SEE FREQUENTLY

STREAKS AND SPOTSNOT EVERY DAYNOT EVERY BMSCARYFISSURE VS. CMPA

HEMATOCHEZIA NEWBORNS/YOUNG INFANT

FISSURE-IN-ANO

CONSTIPATION VS, NORMAL LOOSE STOOL VS. DIARRHEA

EXPLOSIVEMAY NOT SEE THE FISSUREEXAM ANUS PROPERLYTREATMENT WITH REASSURANCENO OCCULT BLOOD TESTING !!!!

FISSURE-IN-ANO

WAY OVER DIAGNOSEDMAKING DIAGNOSIS SPECIFICALLY IS NOT

PRACTICALBREAST VS. FORMULADO NOT D/C BREAST FEEDING??TRIAL OF ELEMENTAL FORMULA 2 WEEKS$$$$$$$$USUALLY RESOLVES NO MATTER WHAT YOU

DO

PROTEIN ALLERGY

TODLERS AND OLDER CHILDRENBLEEDING PRECEEDED BY

VOMITING/RETCHINGUSUALLY NO CHANGE IN HGB/HCTNG TUBE BASICALLY NEG. OR COFFE GROUNDOBSERVATION ? IN HOSPITALCAN USE ENDOCLIPS FOR BLEEDING CONTROL

MALLORY-WEISS TEAR

MALLORY-WEISS TEAR

ESOPHAGITIS, GASTRITIS,DUODENITIS, DUODENAL ULCER

USUALLY ACID RELATED?ROLE OF H. PYLORIBEGIN PPIENDOSCOPY FOR DIAGNOSISCROHN’S, BEHCET’S DISEASE, CGD, Z-E

SYNDROME,CELIAC ALL MAY CAUSE UGI ULCERATION

PEPTIC DISEASE

DUODENAL ULCER

H. PYLORI GASTRITIS

BLEEDING MAY BE INITIAL PRESENTATIONPORTAL HYPERTENSION

CIRHOSISLIVER DISEASE POST SINUSOIDAL LIVER DISEASE CONGENITAL FIBROSIS

PORTAL VEIN THROMBOSIS/ANOMALIESPRE-SINUSOIDAL

ESOPHAGEAL VARICES

ESOPHAGEAL VARICES

SPLENOMEGALYCAPUT MEDUSAELARGE, HARD LIVERJAUNDICESPIDER ANGIOMALFTs/GGPT

SIGNS OF PORTAL HYPERTENSION

SPIDER ANGIOMATA

COLONIC POLYPSMECKEL’ DIVERTICULUMIINFLAMMATORY BOWEL DISEASEINFECTIOUS COLITIS

0THER DIAGNOSES THAT YOU ENTERTAIN FREQUENTLY

E.COLI, SHIGELLA, AMEBIASIS, C.DIFFICILE, CAMPYLOBACTER SPP. ( JEJUNI/FETI)CMVGET CULTURES EARLY ONINDISTINGUISHABLE FROM EARLY IBDMAY NEED EMPIRIC TREATMENTALLMAY GIVE TOXIC MEGACOLON

INFECTIOUS COLITIS

ULCERATIVE COLITISCROHN’S COLITISINDETERMINATE COLITIS ( 10%)CAN PRESENT IN FULMINANT FORMVERY DIFFICULT TO DISTINGUISH FROM ACUTE

INFECTIOUS COLITIS

INFLAMMATORY BOWEL DISEASE

THUMBPRINTING ON KUB ABDOMEN

COLITIS

IBD-PSEUDOPOLYPS

RULE OF 2’S2% OF PEOPLE2 FEET FROM TI2 INCHES LONG2 TYPES OF ECTOPIC TISSUE

GASTRIC PANCREATIC

2/3 BLLED BEFORE AGE 2 YEARS

MECKEL’S DIVERTICULUM

BRRB BLEEDINGPAINLESSMAROON, MELENA, OCCULTANY AGETECHNETIUM SCANLAPAROTOMYHIGH INDEX OF SUSPICION

MECKEL’S

MECKEL’S SCAN

JUVENILE POLYPS HAMARTOMATOUSNAME FROM PATH NOT AGE OF PATIENT5 OR MORE

JUVENILE POLYPOSIS SYNDROMEGENERALIZED FORM -- PRE-CANCEROUS

MOST LEFT SIDED AUTO-AMPUTATE PAINLESSSYNDROME ASSOCIATON

POLYPS OF THE COLON

JUVENILE POLYP

JP REMOVAL

JUVENILE POLYP

GENETICS : MUTATION IN THE APC GENE AUTOSOMAL DOMINANT20-30 % SPONTANEOUS MUTATION PRE-CANCEROUSCOLECTOMY

FAMILIAL ADENOMATOUS POLYPOSIS(FAP)

FAP COLON

FAP-DUODENUM

PEUTZ-JEHGERSAUTOSOMAL DOMINANT/CHROM. STK11

GARDINERSCOWDENBRRSTENTURCOTMIXED

OTHER POLYPOSIS SYNDROMES SYNDROMES

PJ SYNDROME MUCOCUTANEOUS LESIONS

NO ULCERNOT SOLITARYPAINLESS BRRBVERY SPECIFIC PATHOLGYSELF STIMULATIONUSUALLY NO IDENTIFIABLE CAUSEUNDERAPRECIATEDPROLAPSE OF RECTAL MUCOSA OR SELF-

STIMULATIONSPECIFIC CAUSE NOT KNOWN

SOLITARY RECTAL ULCER SYNDROME

SOLITARY RECTAL ULCER SYNDROME

SOLITARY RECTAL ULCER--PATHOLOGY

HSPCHILD/SEXUAL ABUSEMUNCHAUSEN’S BY PROXYINTUSSECEPTIONGI FOREIGN BODY

OTHER DIAGNOSES ON YOUR RADAR

HSP GI SYMPTOMS PAIN/BLOOD CAN PRECEED RASH

HSP

ANO-RECTAL EXAM KUB OF ABDOMENULTRASOUND WITH DOPPLER LIVER/GB PORTAL VEINENDOCOPYRADIONUCLIDE SCANANGIOGRAPHYCAPSULE ENDOSCOPYPUSH ENTEROSCOPYCTSBS

DIAGNOSTIC MODALITIES

CAPSULE ENDOSCOPY

CAPSULE ENDOSCOPY

BLEEDING SCAN

GI FOREIGN BODY

BARON VON MUNCHAUSEN

MUNCHAUSEN’S BY PROXY

GASTROENTEROLOGY CLINICS OF NORTH AMERICAVICTOR FOX VOL 29 NUMBER 1 MARCH 2000

INCIDENCE OF PEPTIC ULCER BLEEDING IN THE US PEDIATRIC POPULATION BROWN K. ET.AL JPGN 54,\; 6, JUNE 2012

PREDICTORS OF CLICALLY SIGNIFICANT UPPER GASTROINTESTINAL HEMORRHAGE AMONG CHILDREN WITH HEMATEMESIS. FREEDMAN S.B. ET. AL. JPGN 54, 6; 2012 737-743

REFERENCES