BLEEDING PER RECTUM IN CHILDREN SURGICAL CAUSES AND MANAGEMENT DR NANDLAL KELLA ASSOCIATE PROFESSOR AND CHAIRMAN DEPT; OF PEDIATRIC SURGERY LUMHS JAMSHORO

Mommy, the toilet

’

s red!!

DR NANDLAL KELLA ASSOCIATE PROFESSOR AND CHAIRMAN DEPT; OF PEDIATRIC SURGERY LUMHS JAMSHORO

Objectives

• Definitions • • Common causes of GI bleeding in different age group Differential Diagnoses  Diagnostic and therapeutic approach diagnostic and therapeutic approach to the pediatric patient with GI bleeding • Review the most common etiologies for GI bleeding in pediatric patients in various age groups

Important Definitions

Hematochezia

– passage of bright or dark red blood per rectum • in general, the redder the blood, the more distal the site of bleeding

Melena

– the passage of black, tarry stools • indicates likely UGI bleed (proximal to the ileocaecal valve)

Hemetemesis

– vomitus containing frank blood or brown-black “ coffee grounds ” (proximal to ligament of Treitz)

Further assessment

• • • Is it really blood?

– Hemoccult stool, gastroccult emesis Apt-Downey test in neonates Nasogastric aspiration and lavage – Clear lavage makes bleeding proximal to ligament of Treitz unlikely – – Coffee grounds that clear suggest bleeding stopped Coffee grounds and fresh blood mean an active upper GI tract source

Substances that deceive

• Red discoloration – candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin • Black discoloration – bismuth, activated charcoal, iron, spinach, blueberries, licorice

History

• Present illness – duration of bleeding , Quality of bleeding ))fresh, clotted or mixed) or quantity of bleeding – associated GI symptoms (vomiting, diarrhea, pain) • Review of systems – GI disorders, liver disease, bleeding diatheses • – medications (NSAID ’ s, warfarin) Family history :hemophilia or other bleeding disorder

History

• • • • • • • In newborn We have to focus mode of delivery Laboured delivered Meconeum aspiration Severe respiratory distress Trauma Sepsis/shock

Physical examination

• • • • • • Vital signs, including orthostatics Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill ENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding Abdomen: organomegaly, tenderness, ascites, caput medusa Perineum: fissure, fistula, induration Rectum: gross blood, melena, tenderness

Gastrointestinal Bleeding

• • • • Blood streaks on the stool indicates anal outlet bleeding Blood mixed with stool indicates bleeding source higher than the rectum Blood with mucus indicates an infectious or inflammatory disease Currant jelly-like material indicates vascular congestion and hyperemia (intussusception or midgut volvulus)

DDx: neonates

•

Upper GI bleeding

–

swallowed maternal blood

–

stress ulcers, gastritis

– – duplication cyst vascular malformations – –

vitamin K deficiency

hemophilia – – maternal ITP maternal NSAID use •

Lower GI bleeding

– – – – –

swallowed maternal blood

dietary protein intolerance infectious colitis

necrotizing enterocolitis

Hirschsprung ’ s enterocolitis – – – duplication cyst

coagulopathy

vascular malformations

Presentation and Management in newborn in bleeding

• • • • • • • presentation S/s of sepsis Respiratory distress Distension of abdomen Shock Hypothermia Hypoglycemia • • • • • • • • Diagnosis Clinical Examination Investigations; CBC, PT APTT Calcium Level ,Glucose level, Urea Creatinine and blood C/S Ultrasound and X-Rays

• • • • • • • • Temp Maintenance NPO and NG Tube I/V Fluid Blood Transfusion Vit K Fresh frozen plasma I/V antibiotics Oxygen inhalation

Management

• If surgical issue ; intestinal perforation After resuscitation intervention may be done or patient is very sick then only peritoneal cannulation or catheterization is help full.

Neonatal stress ulcers or gastritis

• Causes – Shock – Sepsis – Dehydration – Traumatic delivery – Severe respiratory distress – Hypoglycemia – Cardiac condition

Clinical Findings in PUD Neonatal Period

• • • Gastric ulcers are more common than duodenal ulcers in neonates Spontaneous Perforation is a more common presentation than bleeding Frequently associated with: – Hypoxia, Sepsis, RDS, CNS disorder

DDx: infants

•

Hematemesis, melena

– – – Esophagitis Gastritis Duodenitis •

Hematochezia

– – – –

Anal fissures Intussusception

Infectious colitis Dietary protein intol.

– – – Meckel ’ s diverticulum Duplication cyst Vascular malformation

DDx: children

•

Upper GI bleeding

– Esophagitis – – – – – Gastritis Peptic ulcer disease Mallory-Weiss tears Esophageal varices Pill ulcers •

Lower GI bleeding

–

Anal fissures

– – – Infectious colitis

Polyps and prolapse

Lymphoid nodular hyperplasia – – – IBD HSP

Intussusception

– –

Meckel

’

s diverticulum

HUS

Upper GI Bleeding <2 Mo

Swallowed maternal blood Stress ulcer Vascular malformation Hemorrhagic disease of newborn (vitamin K deficiency) Coagulopathy/bleeding diathesis

2 Mo –2 Y >2 Y

Gastroenteritis Toxic ingestion Mallory-Weiss tear Vascular malformation Esophagitis Stress ulcer Bleeding diathesis GI duplication Foreign body Gastroenteritis Mallory-Weiss tear Peptic ulcer disease Toxic ingestion Vascular malformation Gastritis Varices Hematobilia Foreign body

Lower GI Bleeding <2 Mo

Swallowed maternal blood Milk allergy Infectious colitis Intussusception Volvulus Meckel diverticulum Necrotizing enterocolitis Vascular malformation Hemorrhagic disease of newborn Hirschsprung disease Congenital duplications

2 Mo –2 Y

Anal fissure Gastroenteritis Milk allergy Intussusception Volvulus Meckel diverticulum Hemolytic uremic syndrome Henoch Schönlein purpura Polyps; benign, familial Inflammatory bowel disease GI duplication

>2 Y

Anal fissure Gastroenteritis Polyps Colitis (infectious, ischemic) Meckel diverticulum Intussusception Hemolytic uremic syndrome Henoch Schönlein purpura Inflammatory bowel disease Angiodysplasia Celiac disease Rectal ulcer syndrome Peptic ulcer disease

Clinical Findings in PUD Infants and Toddlers

• • Presenting symptoms: – Vomiting – Poor feeding – Irritability during and after eating – Abdominal distention – Hematemesis, melena Commonly associated with underlying disease in this age group

Clinical Findings in PUD Pre-Schoolers

• • • • Periumbilical or generalized abdominal pain Vomiting after eating Nocturnal or early morning pain Gastric ulcers are as common as duodenal ulcers • Primary ulcers are as common as secondary ulcers

Clinical Findings in PUD School Age

• • • • • Male: Female ratio is 3:1 Burning epigastric pain Nocturnal pain Melena, hematemesis, fecal occult blood Primary ulcers are more common than secondary ulcers

Anal Causes

• • • • Hemorrhoids Fissure Perianal abscess/ fissure Anal carcinoma

Hemorrhoids

• • • Usually uncommon in children Usually benign When seen, must suspect portal hypertension • Avoidance of chronic constipation, fecal impaction or other irritating local factors

Anal Fissure

• • • Small laceration of the mucocutaneous junction of the anus. Acquired lesion secondary to the forceful passage of a hard stool, mainly seen in infancy.

Fissures appear to be the consequence and not the cause of constipation.

Anal Fissure

Acute posterior anal fissure producing pain on digital exam. Sphincter tone increased. Exam limited by pain that may respond to NTG and Lidocaine.

Anal Fissure

• • • Usually a history of constipation is elicited.

painful bowel movement Patient retains the stool voluntarily to avoid a painful bowel movement • Bright red blood on the surface of the stool

Anal Fissure

• • • Inspection of the Anal area Infant ’ s hips are put in acute flexion Buttocks are separated to expand the folds of the perianal skin • Fissure becomes evident as a minor laceration

Anal Fissure

• The most important element in the treatment is for the parents to understand the origin of the laceration and the mechanism of the cycle of constipation.

• Goal of the treatment : REVERSE the CYCLE • soft stools to avoid overstretching

Anal Fissure

• • • • Stool softener Avoid hard stools and diarrhea Treat the primary cause of constipation Local application of pain killer

Anal Fissures in older children

1. A linear tear in the skin of the anal canal caused by passage of a hard stool, diarrhea, straining, sitting too long. May be seen in IBD or after rectal surgery. Increased sphincter tone.

2. Deep fissures expose underlying internal sphincter, white color.

3. Spasm, irritation, itching, pain after BM, and bleeding.

4. Acute fissures may heal with sitz baths, fiber, brief Rx steroid cream, leading to thin skin and sentinel pile. Pile may shrink after Rx. If persists may be excised after Rx of fissure completed.

5. Associated hemorrhoids are common.

6. NTG, Lidocaine ointment, fiber, fluids, no straining, banding. 7. Infected fissures Rx Flagyl.

Anal Fissure Rx

• 6 weeks of twice a day intra-rectal NTG ointment, .12%, then 6 weeks of once a day NTG. Watch for headaches, tachycardia, or light headiness. needed.

• 2 % Diltiazem, calcium channel blocker. ointment is an alternative in those with headaches and is used three time per day and may take longer.

• Botox effectively paralyzes internal sphincter but costs $600 per vial and may cause incontinence. May be used in combination with NTG.

• Surgery is effective but has a 10% incontinence rate.

Skin tags

 Skin tags are extra folds of skin around the anal verge. Caused by stretching of skin from dilated external hemorrhoids. May interfere with cleaning and add to pruritus ani. Cosmetic issue to some.

 Skin tag and can be removed or left alone depending on preference.

 Removal requires local anesthesia and office excision. Takes 15 minutes and leads to 2-3 days of discomfort.

Associated skin tags

Colon Polyps

• The term polyp of the colon refers to a protuberance into the lumen from the normally flat colonic mucosa. • Polyps are usually asymptomatic but may ulcerate and bleed, cause tenesmus if in the rectum,.

Colon Polyps

• Neoplastic (adenomas and carcinomas), • Hamartomatous, • Non-neoplastic, and • Submucosal (neoplastic / non-neoplastic).

Non-neoplastic polyps

• Hyperplastic • Mucosal • Inflammatory pseudopolyps • Submucosal

Juvenile Polyps

• Juvenile polyps are hamartomatous lesions that consist of a lamina propria and dilated cystic glands rather than increased numbers of epithelial cells

Juvenile Polyp

• May be single or a few, located throughout the colon; virtually always benign • Occasionally multiple (juvenile poyposis coli) o In JPC, may have potential for adenomatous change • Diagnosis: Colonoscopy • Treatment: Endoscopic Polypectomy

Juvenile colonic polyp

Familial Juvenile Polyposis

• FJP is associated with an increased risk for the development of colorectal cancer, and in some families, gastric cancer, especially where there are both upper and lower gastrointestinal polyps.

Diagnosis and Treatment

• Diagnosis almost always is made at digital rectal examination.

• • Double contrast barium enema is not suggested • Endoscopy for diagnostic as well for therapeutic Polyps biopsy necessary to exclude malignancy

Rectal prolapse

Definition

• Protrusion of few or all layers of rectal wall through anal sphincter

Etiology

• • • • • • Constipation Diarrhoea Parasites Neuro muscular and pelvic disorders Malnutrition Surgical causes ARM Cloacal exstrophy

Presentation

• • • Prolapse of rectum Incontinence of stool Bleeding from prolapse

management

• • • • • • Treat the cause Pushing back of prolapsed rectum Decrease straining Laxatives and stool softener High protein diet Rarely surgery or sclerotherpy

What is Meckel’s

• A Meckel's diverticulum is a small bulge in the small intestine present at birth • It is a vestigial remnant of the omphalomesenteric duct, and is the most frequent malformation of the gastrointestinal tract • It is present in approximately 2% of the population, found twice as frequently in males as females, although males more frequently experience symptoms • It is named after Johann Friedrich Meckel, who first described this type of diverticulum in 1809

What is Meckel’s

• It can usually be found within about 60 100 cm of the ileocecal valve. It is typically 3-5 cm long, runs antimesenterically and has its own blood supply

Symptoms of Meckel’s

• Approximately 98% of people afflicted with Meckel's diverticulum are asymptomatic. If symptoms do occur, they typically appear before the age of two.

• The most common presenting symptom is painless rectal bleeding, followed by intestinal obstruction, volvulus and intussusception. • Occasionally, Meckel's diverticulitis may present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. • At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area.

Diagnosing Meckel’s

• –

OTHER CONSIDERATIONS/RATIONALE:

The radiopharmaceutical is actively secreted by gastric mucosa. Although all Meckel's diverticula do not contain functioning gastric mucosa, most that bleed do – Patient's with active hemorrhage can also be studied with tagged red blood cells. While only 20% of Meckel's Diverticula contain ectopic mucosa, greater than 90% of diverticula that bleed do.

Meckel Scan

• Technetium-99 pertechnetate • Concentrates in gastric mucosa • Premedicate with H2 blocker to enhance uptake and minimize risk of stomach or bleeding obscuring the diverticulum • Can also identify duplications ONLY 50% OF PROVEN MECKEL ’ S HAVE A POSITIVE SCAN

FIGURE 59.8. Meckel Diverticulum.

A small focus (

arrow

) of technetium-99 pertechnetate uptake gradually becomes visible in the ectopic gastric mucosa of a Meckel diverticulum in the midabdomen. http://www.msdlatinamerica.com/ebooks/FundamentalsofDiagnosticRadiology/sid613328.html

Treatment of Meckle’s

• Treatment is surgical, consisting of a resection of the affected portion of the bowel.

INTUSSUSCEPTION

DEFINITION



Telescoping of a proximal segment of the intestine (intussusceptum) into a distal segment (intussuscipiens)

Intussusception: invagination of one segment of intestine into another segment Ileocolic intussusception

INTUSSUSCEPTION

EPIDEMIOLOGY



Incidence 2 - 4 / 1000 live births



Usual age group 3 months - 3 years



Greatest incidence 6-12 months



Male predominance (1.5-2 : 1)



No clear hereditary association



No seasonal distribution



Frequently preceded by viral infection

 Second most common cause of acute abdominal pain in children following appendicitis

Why does Intussusception happen?

 Idiopathic 60% Most are ileocolic  Lead point <10% • Most common is Meckel ’ s diverticulum • Other possibilities include : polyps, hemangiomas, lymphomas, cysts, buried appendix, parasites, cystic fibrosis and HSP • American and European studies showing <10% of cases having a lead point  More common post-surgery patients  Hypotheses of etiologies: -Lymphoid tissue swelling

INTUSSUSCEPTION

ANATOMIC LOCATIONS



ILEOCOLIC

– MOST COMMON IN CHILDREN 

ILEO-ILEOCOLIC

– SECOND MOST COMMON 

ENTEROENTERIC

– ILEO-ILEAL, JEJUNO-JEJUNAL – MORE COMMON IN ADULTS – MAY NOT BE SEEN ON BARIUM ENEMA 

CAECOCOLIC, COLOCOLIC

– MORE COMMON IN AFRICAN CHILDREN

Pathophysiology

invagination of the bowel Obstruction resulting in compression of the vessels and venous congestion and bowel wall edema Infarction, perforation If left untreated,

FATAL

Classic Triad

Colicky abdominal pain -pulling knees up to abdomen “ Currant Jelly ” bloody stools Abdominal Mass -sausage shaped • Multiple studies have shown that classic triad is only present in 20 • 70% found to have 2 symptoms • 9% found to have 1 symptom

Differential diagnosis of bleeding per rectum



Dysentery



Bleeding disorder



Sepsis/DIC



Malrotation



Volvulous



Rectal polyp



Fissure/ rectal prolapse

Diagnosis

The longer you take to diagnose, the higher the probability of surgery and mortality Diagnosis made by clinical presentation and imaging However, clinical suspicion can guide the modality of imaging…

Abdominal X-Ray

 Conventionally, first-line modality for suspected intussusception Low sensitivity, high false negative rate Can be negative in early IS  Uses: -Diagnosis of IS -Evaluating for risk of perforation before enema treatment -Diagnosis of other diseases (Small BO, Large BO, volvulus) • Findings: 1) Intracolonic mass 2) Target sign

Where is the target sign?

Created by gas trapped between two layers of intestinal wall

Where is the crescent sign?

Created by gas surrounding invagination

Gas in RLQ?

There is dilation of LUQ, but no presence of gas anywhere else in the bowel.

Ultrasound

• Used to diagnose IS and prevent unnecessary enemas High sensitivity and specificity No radiation exposure • Findings: -target sign (transverse) -pseudokidney or sandwich sign (longitudinal)

Treatment

17% of IS spontaneously reduce 1 st 2 nd – NPO, IV fluids, NG tube – surgery consult • Successful when flow moves into ileum • Pt is under sedation • Disadvantages – missed lead points, higher recurrence rate, perforation, and radiation exposure • But benefits • Indications – irreducible by enema, necrotic IS, age, long duration of sx, SBO, or clinical signs/sx of peritonitis or bowel infarction

Surgical Emergencies with Lower GI Bleeding

Hirschprung

’

s

• Bloody stool portends enterocolitis • May be mimicked by severe GI allergy

Malrotation and Volvulus

Imaging studies and indications

• • • • •

Upper GI series

: dysphagia, odynophagia, drooling

Barium enema

: intussusception, stricture

Abdominal US

: portal hypertension

Meckel

’

s scan

: Meckel ’ s diverticulum

Sulfur colloid scan, labeled RBC scan, angiography

: obscure GI bleeding

Endoscopy: indications

• • • •

EGD

: hematemesis, melena

Flexible sigmoidoscopy

: hematochezia

Colonoscopy

: hematochezia

Enteroscopy

: obscure GI blood loss

Esophageal varices

The Likely Causes of GI Bleeding Differ at Varying Ages

Infectious Enterocolitis

• Bacterial infections o o

Salmonella, Shigella, Campylobacter, E coli C. difficile

– may not have clearcut history of antibiotic exposure • Viral infections - only CMV in the immunocompromised host • Parasitic - amebiasis

Inflammatory Bowel Disease

• Both Crohn ’ s and UC can present with bloody diarrhea • Exclude infectious causes before initiating invasive diagnostic procedures o CT evidence of diffuse or segmental bowel inflammation does not preclude an infectious etiology

Proctitis/Proctosigmoiditis

• Most common presentation of colitis in adults • Typically, painless hematochezia is only symptom o Tenesmus often mistaken for constipation • Laboratory evaluation often entirely normal

Anal Lesions

External hemorrhoids Crohn ’ s anal tags • Hemorrhoids are extremely uncommon in the child and adolescent • Fleshy rather than vascular lesions should raise the suspicion of Crohn ’ s disease

Milk Protein Allergy

• Presentations o Hematochezia – usually in first 3 months of life  Diarrhea, irritability, ± poor weight gain o Hypoalbuminemia, anasarca o “ GE reflux ” • Labs o Variable eosinophilia in blood and biopsy o Skin prick, RAST testing negative • Treatment o Casein hydrolysate or amino acid based formula

Esophageal Varices

Vascular Anatomy of Portal Hypertension

www.bio.ri.ccf.org

Portal Hypertension

• Intrahepatic (e.g. cirrhosis) • Post-sinusoidal o Budd Chiari syndrome (hepatic vein thrombosis) • Presinusoidal o o Splenic vein thrombosis Cavernous transformation of the portal vein

Endoscopic Therapy for Varices

Sclerotherapy Band Ligation