Gastrointestinal Bleeding in Children Clinical Cases

Transcription

1 Gastrintestinal Bleeding in Children Clinical Cases Hematchezia passage f bright r dark red bld per rectum in general, the redder the bld, the mre distal the site f bleeding Dr. Nam Zevit Schneider Children s Medical Center f Israel Sackler Faculty f Medicine - Tel Aviv University Sme slides curtesy f James Markwitz M.D. Marginalia- ~1450 Melena the passage f black, tarry stls indicates likely UGI bleed (prximal t the ligament f Treitz) Hemetemesis vmitus cntaining frank bld r brwnblack cffee grunds 14th-century illustratin f vmiting frm the Casanatense Tacuinum Sanitatis based n الصحة frmتقويم 11 th Century Baghdad

2 Bldy Vmitus des nt always mean GI pathlgy Always ask: Is it Bld Vincenz Grimaldi, Tuberculsis. Sanctuary f the Martyred Saints Alfi, Cirini, and Filadelf), Trecastagni, Sicily 1927 Nse Bleed Tth Extractin/abbcess Thrat laceratin Hemptysis Maternal Bld Red Jell-O Red Candy Beets Cranberries Tmat Juice, Tmat Sup Rifampin Mxypen Is it really Melena? Case 1 6 yr ld by cmplains that my pp is red N previus episdes f red clred stls Healthy child, n underlying cnditins N pain, fever, systemic symptms N recent illness, travel N prescribed r OTC medicatins N family histry GI disease PE: VS: Pulse 120/min; BP 70/40; + rthstasis Exam therwise unremarkable

3 CBC: Hgb 9 mg/dl Hct 27% Platelets 360k BUN 25 Creatinine 1.0 Impressin: Red bld PR = likely hematchezia.1 Orthstatic, anemic = significant bleeding.2 Painless.3 Differential Diagnsis Case 1 Hematchezia in a Child Anal fissure Juvenile plyp Ndular lymphid hyperplasia Infectius clitis Hemlytic uremic syndrme Inflammatry bwel disease Intussusceptin Hench-Schnlein purpura Meckel s diverticulum Intestinal duplicatin Vascular malfrmatins Neutrpenic clitis Meckel s Diverticulum

4 Technetium-99-pertechnetate Cncentrates in gastric mucsa Premedicate with H2 blcker t enhance uptake and minimize risk f stmach r bleeding bscuring the diverticulum Can als identify duplicatins ONLY 50% OF PROVEN MECKEL S HAVE A POSITIVE SCAN Meckel s Diverticulum Case yr ld by cmplains that my pp is red N previus episdes f red clred stls Healthy child, n underlying cnditins N pain, fever, systemic symptms N recent illness, travel N prescribed r OTC medicatins N family histry GI disease 80 80/5 PE: VS: Pulse 120/min; 0 BP 70/40; + rthstasis Exam therwise unremarkable CBC: Hgb 12 mg/dl Hct 36% Platelets 360k BUN 5 Creatinine 0.6 Differential Diagnsis Case 1 Hematchezia in a Child Anal fissure Juvenile plyp Ndular lymphid hyperplasia Infectius clitis Hemlytic uremic syndrme Inflammatry bwel disease Intussusceptin Hench-Schnlein purpura Meckel s diverticulum Intestinal duplicatin Vascular malfrmatins Neutrpenic clitis

5 Juvenile Plyp VASCULAR MALFORMATIONS May be single r a few, lcated thrughut the cln; virtually always benign Occasinally multiple (juvenile pypsis cli) In JPC, may have ptential fr adenmatus change Diagnsis: Clnscpy Treatment: Endscpic Plypectmy Case yr ld by Red bld in the stl Previusly healthy Cramps, vmiting (nnbldy) Lse, stls mixed with bld and mucus Differential Diagnsis Case 1 Hematchezia in a Child Anal fissure Juvenile plyp Ndular lymphid hyperplasia Infectius clitis Hemlytic uremic syndrme Inflammatry bwel disease Intussusceptin Hench-Schnlein purpura Meckel s diverticulum Intestinal duplicatin Vascular malfrmatins Neutrpenic clitis

6 Infectius Enter-clitis Bacterial infectins Salmnella, Shigella, Campylbacter, E cli C. difficile may nt have clearcut histry f antibitic expsure Viral infectins - nly CMV in the immuncmprmised hst Parasitic - amebiasis Inflammatry Bwel Disease Bth Crhn s and UC can present with bldy diarrhea Exclude infectius causes befre initiating invasive diagnstic prcedures CT/US/MRI evidence f diffuse r segmental bwel inflammatin des nt preclude an infectius etilgy Intusseptin

7 Case 2 Painless hematchezia in an Adlescent 17 year ld girl with streaks f bright red bld PR. Healthy adlescent; nt sexually active N weight lss, systemic symptms Menses regular Slid BM every ther day; nt hard r large N prescriptin r OTC meds PE: Healthy appearing, VS nrmal Nrmal abdminal examinatin PR? Hematchezia in the Adlescent Anal fissure Infectius clitis Inflammatry bwel disease Meckel s diverticulum Plyps Intestinal duplicatin Neutrpenic clitis Hemrrhids Vascular Malfrmatins Anal Fissure

8 Prctitis/Prctsigmiditis בריא Anal Lesins חולה Mst cmmn presentatin f clitis in adults Typically, painless hematchezia is nly symptm Tenesmus ften mistaken fr cnstipatin Labratry evaluatin ften entirely nrmal External hemrrhids Hemrrhids are extremely uncmmn in the child and adlescent Fleshy rather than vascular lesins shuld raise the suspicin f Crhn s disease Crhn s anal tags Plyps Plyps are unusual in adlescents May indicate a plypsis syndrme, ften malignant Familial Adenmatus Plypsis (FAP) Hereditary Nnplypsis Cln Cancer Syndrme (HNPCC)

9 Case 3 Hematchezia in an Infant 6 week ld girl with streaks f bright red bld PR. Full term, n nenatal prblems Breast fed x 2 weeks but changed t intact milk prtein frmula due t cnstipatin At 4 weeks, develped streaks f bld in mucusy stl. Pr intake n all feeds except breast milk ( She didn t like the taste ), and gained weight prly PE: Irritable but cnslable Temp 38 ; ther vitals nrmal fr age Weight 50% at birth 25% nw Benign abdmen, nrmal perineal anatmy Hematchezia in an Infant Swallwed maternal bld Dietary prtein intlerance (Milk/sy) Infectius clitis/enteritis Necrtizing enterclitis Hirschprung s Disease Cagulpathy Vascular Malfrmatins Aut-immune cnditins (rare)

10 Milk Prtein Allergy Presentatins Hematchezia usually in first 3 mnths f life Diarrhea, irritability, ± pr weight gain Hypalbuminemia, anasarca GE reflux Labs Variable esinphilia in bld and bipsy Skin prick, RAST testing negative Treatment Casein hydrlysate r amin acid based frmula Case 3b Hematchezia in an Infant 6 week ld girl with streaks f bright red bld PR. Full term, n nenatal prblems Breast fed x 2 weeks but changed t intact milk prtein frmula due t cnstipatin At 4 weeks, develped streaks f bld in mucusy stl that persisted when transferred t extensively hydrlized frmula. Pr intake n all feeds except breast milk ( She didn t like the taste ), and gained weight prly PE: Irritable Temp 38 ; Tachypneic and hyptensive. Weight 50% at birth 25% nw Abdmen distended and firm, nrmal perineal anatmy WBC 25k, Hgb 10, Plt 350k, Albumin 2.8 Hematchezia in an Infant Swallwed maternal bld Dietary prtein intlerance (Milk/sy) Infectius clitis/enteritis Necrtizing enterclitis Hirschprung s Disease Cagulpathy Vascular Malfrmatins Aut-immune cnditins (rare)

11 Hirschsprung s Disease Intestinal malrtatin Failure t pass mecnium Early cnstipatin Pr Weight Gain Distended Abdmen Surgical treatment Imprtance f early identificatin Enterclitis may be catastrphic Case 4 17 year ld male with episde f cffee grund emesis Finished 11 th grade - 1 week befre Denied alchl r NSAID use 1 mnth histry f pstprandial epigastric pain Mther had recurrent ulcers as a yung wman PE: Mildly dehydrated, minimally tender in epigastrium, n stigmata f chrnic liver disease Labs: Hgb 10 Hct 30% Nrmal LFTs

12 Case 4 Main Differential Hemetemesis/Melena Esphagitis Gastritis (H. pylri) Gastritis H. pylri negative (infectius, ther) Gastric/dudenal ulcer (H. pylri) Mallry Weiss tear Esphageal varices Prtal hypertensive gastrpathy Pill induced ulcers NSAIDs Alchl Hemrrhagic Gastritis NSAIDs Dudenal Ulcer 1. Supprtive care 2. Acid suppressin (H2 blcker r PPI) Reflux esphagitis Helicbacter pylri Antral ndularity Dudenal ulcer 1. Acid suppressin (PPI) 2. Weight Lss, lw fat diet, gum, lw alchhl and caffeine. 3.? Fundplicatin

13 Mallry Weiss Tear At least 50% f individuals is the wrld are thught t be infected Frequency: develping > develped wrld Prevalence increased in areas f the wrld with lwer standard f living, increased ppulatin density Infectin acquired at all ages Therapy Triple therapy: PPI + 2 antibitics (e.g. amxacillin, metrnidazle, clarithrmycin) Case 5 8 y.. male with 3 large bad smelling tarry stls and ne bldy emesis. Histry brn 28 wkspremature, 6 weeks in NICU Labs WBC 2.2; Hgb8 g/dl; Hct24%; Plts60K Liver enzymes nrmal Physical Exam Mild Dehydratin Liver nt palpable, spleen + 4 cm N Jaundice A few Petechiae Acute upper GI bleed

14 Case 5 Differential Diagnsis Prtal Hypertentin Hemetemesis/Melena in a Child Esphagitis Gastritis (H. pylri) Gastric/dudenal ulcer (H. pylri) Mallry Weiss tear Esphageal varices Prtal hypertensive gastrpathy Pill induced esphagitis Prtal Hypertensin Causes Esphageal Varices Intrahepatic (e.g. cirrhsis) Pst-sinusidal Presinusidal Budd Chiari syndrme (hepatic vein thrmbsis) Splenic vein thrmbsis Cavernus transfrmatin f the prtal vein

15 Case 6 One day ld full term male with bldy emesis Unremarkable pregnancy Cmplicated delivery: Apgars 4 and 8 Breast feeding, but taking prly PE: Well Develped, 3.5 kg. Anicteric, nrmal abdminal exam Case 6 differential diagnsis Hemetemesis/Melena in the Infant Swallwed maternal bld Stress gastritis Intestinal duplicatin Vascular malfrmatin Vitamin K deficiency Hemphilia Maternal ITP Maternal NSAID use Case 6 - Evaluatin Apt test Esphaggastrdudenscpy Treatment: Supprtive care H2 blcker/ppi Hemrrhagic stress gastritis

16 GI Bleeding - Treatment Emergency management f GI Bleeding Assess hemdynamic status and stabilize Determine Upper vs. Lwer Establish Differential Diagnsis Clinical Assessment Appearance f the patient Wrrisme signs: pallr, diaphresis, restlessness, lethargy, abdminal pain Hemdynamic status f the patient tachycardia, hyptensin, shck? rthstatic changes in heart rate and bld pressure? Drp f 10 mmhg r mre in systlic BP and/r an increase f 20 beats/min in pulse when mved frm supine t sitting Character f the bleeding Estimate vlume f bld lst Hematcrit Remember: With an acute bleed, Hct will nt drp significantly until intravascular vlume is repleted! Stabilize the Patient (1) Insert the largest bre IV catheter pssible: the r 4 factr

17 Omeprazle/Esmeprazle: prtn pump inhibitr Fr Severe Bleed Adult 80mg blus 8mg/hr Children 2mg/kg blus 0.2mg/kg/hr Nn-Severe Bleed 0.5-1mg/kg bid up t 20-40mg (fr infants cnsider Ranitidine 3-6mg/kg/day divided 3/d) Octretide Decreases prtal pressure by decreasing splanchnic bld flw Lading dse: 1 µg/kg blus (maximum f 50 µg) Cntinuus infusin f 1 µg/kg/hur; can be increased gradually t 4 µg/kg/hur Upper vs Lwer GI Bleed: Rle f Nasgastric Lavage Diagnstic: Establishes UGI bleed Rm temperature saline, nt iced Iced saline may induce mucsal ischemia and wrsen bleeding Lavage may reduce clts, allwing better visualizatin at endscpy Lavage may remve clts, preventing hemstasis Fr varices Sclertherapy Sdium mrrhuate Sdium tertadecyl sulfate Ethanlamine Band ligatin Therapeutic Endscpic Interventins Fr Mucsal Lesins Injectin therapy Epinephrine Cagulatin Heater prbe Biplar prbe Laser Mechanical Hemclip Banding Additinal therapies t be cnsidered when endscpic techniques fail Angigraphy Emblizatin Selective vaspressin infusin Surgery ALWAYS INVOLVE THE SURGEON EARLY IN THE COURSE OF MANAGING A SEVERE GI BLEED