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G I Bleeding In Children


G I bleeding in infants & children routinely provokes parental anxiety. Gastrointestinal (GI) bleeding in infants and children is a fairly common problem and usually is limited, allowing time for diagnosis and treatment. GI bleeding accounts for 10-15% of referrals to pediatric gastroenterologists. Even small amount of blood appear large when spread out or mixed with stool or vomitus. Confirming the presence of blood and assessing the severity of the bleeding are the priorities of the practitioner. Prompt referral to a hospital will be indicated in the majority of cases of documented upper GI bleed, while passage of blood per rectum will in many cases be of a less emergent nature.

TERMINOLOGIES –

Hematemesis -vomiting of blood, it can be bright red or dark, depending on whether there has been sufficient time for the hemoglobin to be acid-denatured in the stomach. Coffee ground vomitus is a graphic term that describes this darker appearing hemoglobin. Hematemesis results from lesions in the esophagus, stomach, and sometimes from the duodenum. Bleeding from the nasopharynx and oral structures (gums, tongue, or teeth) can be unapparent and can present as hematemesis. Blood is a relatively potent emetic. Blood passed per rectum can be bright red – hematochezia or tarry black and sticky with a very characteristic smell – melena.

Hematochezia usually results from lesions in the colon or terminal ileum while melena is typical of sources above the ligament of Treitz and upper small intestine. Because blood is also a cathartic, profuse upper intestinal bleed can present as hematochezia; on the other hand, blood can become dark if it remains in the colon for a long enough time.

COMMON CAUSES –

Because GI bleeding occurs in children across all ages and size groups and results from several dozen different diagnosis it is most appropriate to divide the patients into four diagnostic age groups. Within each group, evaluation is directed at establishing the most common cause, always keeping in mind the strange or remote cause.

Age group Upper GI bleeding Lower GI bleeding
Neonates Swallowed maternal blood
Hemorrhagic disease of newborn
Septicemia
Stress gastritis
Coagulopathy
Anal fissures
Necrotizing enterocolitis
Malrotation with volvulus
Infants (upto 1yr) Esophagitis
Gastritis
Anal fissures
Intussusception
Gangrenous bowel
Milk protein allergy
1 year – 2 year Peptic ulcer disease
Gastritis
Polyps
Meckel’s diverticulum
Children (above 2yr) Esophageal varices
Gastric varices
Drugs
Polyps
Inflammatory bowel disease
Infectious diarrhea
Vascular lesions
Duplications
Rectal prolapse

CONFIRMING THE PRESENCE OF BLOOD –

One of the first considerations is to determine whether blood is indeed present in the vomiting or stool. Food coloring added to cereals, drinks, medications, gelatin desserts, ketchup, and other tomato dishes can be deceivingly similar to blood, especially to an anxious parent. Dark vegetables, bismuth compounds such as found in Pepto-Bismol, iron-fortified cereals, Oreo cookies, or medicinal iron supplements can turn the stools black. Identification of blood containing products is based on the interaction of peroxidase activity found in hemoglobin and various reagents. Among the most commonly used is guaiac, orthotoluidin or benzidine. Several consecutive stools should be sampled when searching for occult bleeding, since polyps and other lesions can bleed only intermittently. In the adult, loss of more than 2.5 cc of blood per day is considered abnormal. Actual quantitation of the hemoglobin present per gram of stool has emerged as an accurate diagnostic test mainly used in adults for carcinoma screening purposes.

HEMODYNAMIC EFFECTS OF BLEEDING –

Once we have determined that the child is loosing blood, the severity of the bleeding and its hemodynamic effects need to be assessed as accurately as possible. These effects are more prominent when the patient has bled acutely. Slow GI bleeds can be tolerated remarkably well and might present only with tiredness, pallor, dizziness, or fainting. Remembering that the circulating blood volume of a child is about 80-85 ml/kg and that orthostatic changes appear when there has been more than 20% reduction of blood volume, one can roughly appraise the severity of the bleed and the need for intensive care. Orthostatic changes are present when the pulse accelerates by 20 beats/minute or the systolic blood pressure drops by 10 mm Hg when the patient’s position is changed from recumbent to seating.

APPROACH TO A BLEEDING CHILD –

The initial approach to all patients with significant GI bleeding begins with the establishment of adequate oxygen delivery, fluid resuscitation, and blood resuscitation; the establishment of intravenous access; and the correction of underlying coagulopathies. A preliminary differential diagnosis is sketched based on the nature and amount of the bleed, age of the patient, and clinical features: fever, vomiting, pain, decreased urine output, diarrhea, mental changes, skin lesions, etc.

Even if the suspected sources are esophageal varices, no harm will be done if a well lubricated nasogastric tube is inserted. This should be one of the first steps in the diagnostic approach of the patient with GI bleeding, whether it presents as melena or hematemesis. A 10 to 14F sump tube should be used. Finding clots of blood, coffee ground material, or fresh blood suggests an esophageal or gastric source, but blood from the duodenum can sometimes flow retrogradely and appear in the aspirates as well.

If blood is found in the stomach, repeated lavage with saline will help assess the briskness of the bleed. Recent studies suggest that the old practice of using ice-cold lavage solution is not any more effective than using it at room temperature. Of greater concern are the reports of abnormal coagulation function induced by the iced solution and potentially detrimental changes in mucosal blood flow.

If the bleeding does not subside after repeated lavage, the next step will depend on the severity of the bleed. If the rate is profuse, early use of esophagogastroduodenoscopy (EGD) determines the source of upper GI bleeding in 90% of individuals when performed in the first 24 hours. The bleeding can be controlled with epinephrine injections around the responsible vessel and cautery can obliterate it. Other therapeutic options with EGD scopy are sclerotherapy or banding of varices.

The infusion of vasopressin or octeotride shunts blood away from the splanchnic circulation and tends to control bleeding from varices, gastritis, or other unidentified sources. Close monitoring of serum electrolytes (increased risk of hyponatremia when using vasopressin), cardiovascular status, and peripheral circulation is mandatory.

Colonoscopy identifies the cause of bleeding in 80% of children with lower GI bleeding. It has therapeutic value also in cases of polyps (excision using snare), vascular lesions (electro coagulation or laser fulguration), and reduction of intussusception or biopsy of various lesions.

In cases of episodic or obscure bleeding, nuclear medicine radio nucleotide studies or arteriography are employed to assist in identifying the site of blood loss. Radio nuclear imaging with technetium-labeled red blood cells can be used to detect bleeding as minute as 0.1 ml per minute. Localization permits either selective angiography to better delineate the source of bleeding or a suspected site in the GI tract, which is often difficult to determine at the time of laparotomy. If the bleeding is intermittent and severe and no sources are found after upper endoscopy (if indicated) or colonoscopy, an arteriography should be planned if labeled red cell scanning fails to document a bleeding site. Arteriography can detect bleeding at a rate of 0.5 ml per minute and offers the advantage of treatment as well as diagnosis. Treatment consists of embolization and intra-arterial administration of vasoconstrictors.

Despite the current ability to aggressively investigate neonates, the cause of neonatal GI bleeding remains unexplained in at least 50% of cases. However, undiagnosed bleeding requires special studies such as small bowel enema, arteriography or tagged red cell scanning. At times, celiotomy and careful exploration is required. At least half of the children with persistent GI bleeding have a demonstrable lesion detected at surgery; lesions include arteriovenous malformations, hemangiomas, duplications and foreign bodies.

In summary, after stabilizing the patient’s vital signs, nasogastric aspiration becomes the first, simplest, and most revealing diagnostic step. Once the source is identified (endoscopy, air/barium contrast studies, nuclear medicine, arteriography), the therapeutic options will be adjusted to the address the case at hand.

     
Bleeding intestinal polyp Radio nucleotide scan Meckel’s diverticulum with ulcer

 

DR AMIT SITAPARA
MCh (Pediatric surgery)
DNB (Pediatric surgery)
Consultant pediatric & neonatal laparoscopic surgeon
Laxmi Children Hospital,
2 nd floor, Opal Plaza,
Akshar marg – Amin marg corner
Ph : 0281- 2458666
Rajkot.