Intestinal bleeding in the child

SURGICAL ASPECTS
Dr EW Muller Block 8 2013

Definition - Upper GIB (UGIB)

Bleeding proximal to the ligament of Treitz Source:
Oesophagus Stomach Duodenum
Ligament of Treitz

Definition - Lower GIB (LGIB)

Bleeding is located distal to ligament of Treitz Source: Small bowel Colon Rectum

Relevant history in a bleeding child

Vomiting, diarrhoea, fever: Infectious cause Recurrent forceful vomiting: Mallory - Weiss Drugs: NSAIDS, tetracyclines, caustics or foreign bodies: Damage of gastric mucosa Jaundice, bruising, change in stool color: Liver disease Drugs and foods which might imitate bloody stools: Certain antibiotics, iron supplements, bismuth containing products

Physical examination
Look for signs of shock: Heart rate, BP, capillary refill Rule out epistaxis, nasal polyps, oropharyngeal erosions or the lung as the source of bleeding Abdominal scars: What was reason for surgery? Bowel sounds: Often hyperactive in upper GI bleeding Abdominal tenderness: Intussusception, Ischemia, Ulcer, Gastro-oesophageal reflux

Physical examination
Hepatomegaly, splenomegaly, jaundice: Liver disease and portal hypertension Inspection of the anal area: Fissures, fistulas, skin breakdown, trauma Digital rectal examination: Polyps, masses

CLINIC - UGIB
Haematemesis
Red blood + clots: ongoing bleeding Dark coffee-ground (denatured blood) vomitus: Slow bleeding or bleeding has stopped No haematemesis if source of bleeding is in distal duodenum

Melaena (= tarry black stools) passed per rectum

Melaena = Altered blood (oxidized haemoglobin) after prolonged passage(>14 hours) through bowel

CLINIC - LGIB
Haematochezia: Passage of bright red rectal blood on top or in stool:
Source: Usually distal bowel, but: Severe haemorrhage from oesophagus, stomach or duodenum can also cause haematochezia

Rectorrhagia: Passage of rectal blood, without stool:

Source: rectum, anus

RESUSCITATION
Assess the Location, high or low - Place NGT: Aspiration of blood: UGIB. Aspiration of bile without blood rules out UGIB. Assess severity: Shock, haematemesis, ongoing drainage of blood from NGT or rectum. Oxygen mask 2 good peripheral lines; Ringers lactate bolus 20ml/kg If bleeding continues: Blood 10 15 ml/kg; give somatostatin analogue Urgent referral for therapeutic gastroscopy (UGIB) or colonoscopy (LGIB), but Patient should be stabilised for transport

COMMON CAUSES OF GIB IN CHILDHOOD

Age Group
Neonates

UGIB
Haemorrhagic disease of the Newborn (Vit K) Swallowed maternal blood Stress Gastritis (ICU set up)

LGIB
Necrotizing Enterocolitis (immature infants) Anal fissure Malrotation with volvulus Anal fissure Intussusception Milk protein allergy Polyps Meckel Diverticulum Polyps Inflammatory bowel disease Infectious diarrhoea

Infants 1month to 1 year Infants 1 2 years Children older than 2 years

Oesophagitis (Reflux) Stress Gastritis Peptic Ulcer disease (HP or non HP - related) Gastritis Oesophageal varices Peptic Ulcer disease

Necrotizing Enterocolitis (NEC)

Occurs in premature brittle newborns Aetiology: Bowel wall bacterial infection due to immature mucosal barrier Immunoglobulins in breast milk protect against NEC - Formula fed newborns are at risk Clinic: Sudden feeding intolerance in premature baby: Abdominal distension, vomiting, sepsis, acidosis, shock Diagnosis: Pneumatosis intestinalis on AXR Treatment: NPO, Antibiotics, parenteral feeds. If necrotic bowel or perforation: Operation

Anal fissure
History of painful passage of bright red blood which is not mixed with stool Baby usually in good condition Sometimes associated with constipation Rectal examination: Small very painful anal tear visible, +/- hard stool Treatment: Stool softeners, wait and see

Polyps in Children
2 types: Hamartomas (common) and adenomas (rare) Present with painless red bleeding or can protrude through anus Usually in distal colon Hamartomas: Sporadic, single: with no malignant potential; also called hyperplastic polyps Adenomas associated with familial polyposis syndrome, high cancer risk: Colectomy in early adolescence required

Familial adenomatous polyposis coli

Meckels Diverticulum
Embryology: Remnant of omphalo-mesenteric duct

Meckels Diverticulum

Located in terminal ileum, 60 70 cm proximal to ileocolic juntion

Meckels Diverticulum

Complications associated with

ectopic gastric tissue:
obstruction

Ulceration, perforation, bowel

Bleeding (most common
complication): usually painless, can be
massive, transfusion often necessary

Treatment: Must be surgically excised

Meckels Diverticulum: Diagnosis

Technetium Scan

Intussusception
Condition where the proximal bowel moves into the distal bowel like an inverted sock Proximal bowel = Intussusceptum Distal bowel = Intussuscipiens Intussusception can be ileo-ileal, ileo-colonic (by far the most common presentation) or colocolonic The intussusceptum might even protrude through the anus mimicking a rectal prolapse

Intussusception: Pathophysiology
Caused by lead point which is pulled into the lumen by peristalsis Age group 5 9 months: lead point caused by enlarged bowel lymphoid tissue (Peyers plaques) following viral infection: this is by far the most common reason for intussusception Older age group: Lead point might be Meckels diverticulum, polyps, lymphoma, worms or other foreign bodies

Intussusception: symptoms
Well fed baby who might have a history of recent upper respiratory tract infection or gastro-enteritis Bloody, slimy stool (red currant jelly stool) Signs of bowel obstruction (vomiting, abdominal distension)

Intussusception: Signs
The child might be dehydrated Abdominal tenderness A sausage-shaped mass can often be palpated in the region of the colon

Intussusception: Special investigations

Biochemistry: Electrolyte disturbances and high urea in case of dehydration due to vomiting AXR: Multiple air fluid levels indicating bowel obstruction. Mass effect in the region of the colon. No air in colon. Free air if perforation Sonar: Imaging of choice: Mass visible

Intussusception: Management
Nil per os, nasogastric tube, iv fluids (rehydration and maintenance) Pneumatic reduction should be attempted if
Child fully resuscitated Abdomen without peritonitis No free air on AXR

Laparatomy
If pneumatic reduction is contraindicated If pneumatic reduction has failed Intraoperatively: Trial of manual reduction. If this maneuver fails: Resection of intussusception and primary anastomosis.