Gastrointestinal Bleeding in infancy and childhood Dr. Bassam K. Al-Hajjar Specialist pediatric surgeon
Haemorrhage can occur from any part of alimentary tract and at any age Haemorrhage can occur from any part of alimentary tract and at any age. Sometimes, the haemorrhage threatens the life of the child, on other occasion, it is an important sign of other medical or surgical pathology.
Haemorrhage may be occult & present as iron deficiency anemia or may be seen as blood per rectum which is either in form of melaena (dark changed blood) or bright red bleeding. If bleeding occurs into the upper G.I.T. (above the ligament of trietz), it usually presents as haematamesis which is either coffee ground or frank blood in the vomitus.
Gastrointestinal bleeding can be grouped under four divisions: I Neonatal bleeding. II A small amount of bright blood in a well child. III ill child with acute abdominal condition. IV Massive haemorrhage.
Neonatal Bleeding: There are two important surgical conditions and several important medical conditions that lead to rectal bleeding in this group Necrotizing Enterocolitis: This is an inflammatory condition of neonatal gut, mostly affecting premature neonates. It has multifactorial aetiology in which immaturity of gut and immune system, formula feeds, bacterial infection and impaired gut blood flow have been implicated.
It is a proressive disease…..15-30% Gestational age,,,,birth wt Clinical presentation
Pneumatosis intestinalis Portal venous gas pneumoperitoneum
Initial Management Medical management (10-14 days) Make NPO, start on IVF (consider TPN). Insertion of nasogastric tube to suction for decompression Empiric antibiotics Cardiovasculatory/pulmonary support as needed Pediatric surgery consultation Lab/radiologic monitoring: Q6-8 hours while patient remains acutely ill
Surgical management Surgical intervention Absolute indication for surgery Pneumoperitoneum Relative indication for surgery failure to improve progressive thrombocytopenia Portal vein gas Severe peritonitis Surgical intervention Peritoneal drainage Laparotomy with resection of affected bowel with or without temporary stomas.
2. Volvolus Neonatorum: Volvolus of mid gut due to malrotation occurs at any age but is more likely in neonatal period.
Clinical presentation 60% 2/3 Integral part in abd. Wall defect, D.H.,PBS Malrotation in the neonatal age may present either with acute strangulating obstruction or with recurrent episodes of incomplete I.O
The neonate usually presents with sudden onset of bilious vomiting and rectal bleeding occurs as a late symptom. It need very urgent exploration to save bowel vascularity.
Treatment ladd’s procedure Derotation Release of ladd’s band Widening of mesentry appendicectomy
3. Non surgical causes like: a- Haemorrhagic disease of the newborn. b- Maternal blood swallowing at time of birth or from cracked nipple. c- Anal fissure. d- stress gastritis.
A small amount of blood in a well child Causes: 1. Anal fissure Anal fissure occurs at any age and usually is due to constipation . The child passes a large, hard stool which splits the anus, usually in the midline, either posteriorly or anteriorly. The child complains of pain on defecation and there is bright blood on the surface of the stool or immediately following it. Anal fissures in children almost always respond to adequate treatment of the constipation.
2. polyps Juvenile polyps arc relatively common in children and should be suspected when there is no constipation or no pain on passage of a stool.
3. Rectal prolapse Prolapse of the rectum is easily diagnosed on the history or by direct observation. Rectal prolapse may occur with malabsorption or chronic diarrhoea, straining with constipation, and occasionally, as the presenting symptom of cystic fibrosis.
Questions?
An ill child with an acute abdominal condition 1. Intussusception It is invagination of one part of the intestine(intussusceptum) into another part of the intestine(intussuscipiens) ileocaecal
Intussusception presents with vomiting, colic, pallor and lethargy Intussusception presents with vomiting, colic, pallor and lethargy. In 35% of patients, the stools are blood-stained with the typical "red-currant jelly stool" due to a mixture of blood and mucus. Palpable mass Age of presentation Causes
Diagnosis US is the technique of choice Sensitivity 98-100 Specifity 88-100
Contrast enema
managment
2. Henoch-Schonlein purpura This condition causes arthralgia and a typical rash over the extremities and buttocks. Submucosal haemorrhages in the bowel with abdominal pain and passage of blood rectally also occur.
3. Inflammatory Bowel Disease Crohn's disease may occur anywhere in the bowel and should be suspected in a patient with a chronic illness, unexplained fever, weight loss, bowel symptoms and chronic blood loss in the stools. In patients with ulcerative colitis the diarrhea is more prominent, and again it may contain blood.
Massive haemorrhage In these patients the haemorrhage is enough to cause anaemia or to require acute transfusion. The causes range from oesopbageal varices and peptic ulcer to Meckel's diverticulm and tubular duplications (both latter anomalies can contain ectopic gastric mucosa.
1.PORTAL HYPERTENSION Portal hypertension in children is the result of obstruction of the blood flow from the portal vein system into the inferior vena cava-according to the site of obstruction Types Intra –hepatic obstruction result from liver cirrhosis .whether from hepatitis or biliary atresia.
2. Extra-hepatic which is more common in children usually due to neonatal sepsis with spread of infection and thrombosis along the umbilical vein to the portal vein.
2. Peptic ulcer Peptic ulcer disease is rare in children, but " Stress ulcer" may occur in a child of any age with sever burn, cerebral tumor, head injury or other form of sever stress.
3. Meckel's diverticulum Meckel's diverticulum occurs in 2% of the population and in a small proportion of these patients, ectopic gastric mucosa forms part of the lining of the diverticulum. Acid produced by the gastric mucosa causes ulccration of the adjacent ileal mucosa. Tin bleeding usually presents as painless 'brick-red' stool with associated anaemia. The patient may require transfusion, but the bleeding usually stops spontaneously without the need for emergency surgery. The definitive investigation is surgery, but a technetium scan may show the ectopic gastric mucosa.
These complication present in one of the following ways. Massive hemorrhage. 45% Intestinal obstruction. 25% Acute inflammation. 20% Persistent communication with the umbilicus. 10 %
4. Tubular duplications These are much less common than a Meckel's diverticulum. Tubular duplications of the small bowel occur in the mesenteric side of the bowel and communicate proximally or distally with the bowel.
History Ask about the bleeding: Is the bleeding acute or chronic? . Approach to pediatric G.I.T. bleeding History Ask about the bleeding: Is the bleeding acute or chronic? What is the colour of the blood? Is it bright or dark? What is the quantity of bleeding?
Melaena rather than bright red blood indicates bleeding is higher in the bowel (usually duodenal or above). Anorectal disorders, anal fissures and distal polyps cause bright red bleeding. Dark blood or blood mixed with stool suggests more proximal source of bleeding. Beware that massive upper gastrointestinal bleeding can cause bright red rectal bleeding in children when transit time is short.
Ask about other symptoms, either accompanying or antecedent to the bleeding: Is there any vomiting? Has there been any straining? What is the character of stools passed? Has there been any abdominal pain? Has there been any trauma?
Examination Look for signs of shock. Look for signs of bleeding from other areas (oropharyngeal, nasal, etc.). Examination of the skin may reveal evidence of systemic disorders (for example Henoch-Schönlein purpura, and Peutz-Jeghers polyposis). Examine the abdomen. Hyperactive bowel sounds may occur with upper gastrointestinal haemorrhage. Examine the perianal area. Look for evidence of fissures or fistulas and assess perianal skin. Consider rectal examination. This may reveal polyps, masses, or occult blood.
Management The management will depend on the cause and extent of bleeding. The history and examination should reveal the extent of bleeding. As most cases will be simple, self-limiting and benign management will focus on explanation & reassurance .
When bleeding is profuse or recurrent then management will focus on resuscitation, investigation which may include U/S upper/lower endoscopy, biopsy, technetium scan , arteriography,…etc and then treatment of the cause.
Questions?
Case 1: five years old abd.colic and bleeding per rectum
DIAGNOSIS? RADIOLOGICAL INVESTIGATION?
Case2: three months old with bleeding per rectum and vomiting….RX???
Regarding intussusception in children all false except : is not associated with the passage of blood stained stools. can reduce spontaneously . contrast enema is contraindicated. most commonly occurs after the age of 1 year. always requires surgical intervention.