Transcript Approach to GI Bleeding

APPROACH TO GI BLEEDING
Simon Lam
October 13, 2011
ACH Resident Academic Half Day
OVERVIEW
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Case 1 and Case 2
Presentation
History
Physical
Labs
Classification
DDx – UGIB
Case 1 – Cont’d
Initial Management
DDx –LGIB
Case 2 – Cont’d
Case 3
CASE 1
A. S. - 23 mo male with GDD presents with “a cup” of
bright red hematemsis
 ABC stable
 S – No other symptx, no melena/hematochezia.
 A – No allergies
 M – Vit D and Iron supplements
 P – Ex 32 wk, had a UVC placed as neonate and 1
episode of CONS sepsis in NICU.
 L – Last meal 2 hours ago
 E – “Just happened all of a sudden”
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CASE 2
2 yo male presents with 1 day history of dark red
“bloody diarrhea”. The diaper is full of blood and very
little stool. No vomitting
 ABC stable
 S – 2 day history of periumbilical pain
 A – No allergies
 M – Vit D
 P – Had severe reflux as an infant, resolved by 12 mos
 L – Last meal 2 hours ago
 E – Has had about 3 BM today, all full of blood.
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PRESENTATION
Hematemesis
 Coffee ground emesis
 Melena stool
 Hematochezia
 Normal stools with blood
 Bloody Diarrhea
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HISTORY
Onset, duration, volume and associated symptoms
 Colour of blood/emesis/stool
 Consistency of accompanying stool
 Blood coating or mixed into stool
 Hx of dyspepsia, heartburn, abdominal pain,
constipation, diarrhea or weight loss
 Hx of jaundice, easy bruising may suggest liver
disease
 Hx of NSAID use
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ON EXAM
ABC
 Vitals
 HEENT
 CVS
 RESP
 ABD
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Must include DRE!
GU
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Worrisome Signs
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Pallor
Diaphoresis
Restlessness
Increased HR
Decreased BP
Orthostatic changes
Increase HR 20 bpm
 Decrease BP 10 mmHg
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LABS
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CBC
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Hct
MCV
Plts
Iron studies
 Creatinine
 Alb
 CRP/ESR
 ALT/AST
 INR/PTT
 Stool WBC, C+S, O+P
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GUAIAC TEST
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Used to confirm the
presence of
hemoglobin
False positives
Ascrobic acid (Vit C)
 Animal
myoglobin/hemoglobin
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APT TEST
Differentiates
maternal vs infant
blood
 Maternal = 2α2β
 Fetal/infant = 2α2γ
 NaOH will denature
maternal blood and
not fetal/infant
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Positive test = Pink
Negative test =
Yellow/Brown
CLASSIFICATION
Commonly classified
based on location
 Above Ligament of
Treitz = UGBI
 Below Ligament of
Treitz = LGIB
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May try to pass NG into
stomach and aspirate. If
+ blood, likely UGBI.
However if negative,
does not exclude UGBI
UPPER GASTROINTESTINAL BLEED
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DDx
Swallowed blood
 Mallory-Weiss tear
 Variceals
 Gastritis*
 Peptic ulcer
 AV malformations
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Hemangiomas
 Angiodysplasia
 Dieulafoy lesion
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Hemobilia
Vitamin K deficiency
Thrombocytopenia
CASE 1
A. S. - 23 mo male with GDD presents with “a cup” of
bright red hematemsis
 ABC stable
 S – No other symptx, no melena/hematochezia.
 A – No allergies
 M – Vit D and Iron supplements
 P – Ex 32 wk, had a UVC placed as neonate and 1
episode of CONS sepsis in NICU.
 L – Last meal 2 hours ago
 E – “Just happened all of a sudden”
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ON EXAM
HR 150 BP 80/62
 HEENT – No scleral icterus, mild conjunctival pallor
 CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT =
3
 Resp – N
 Abd – Soft non tender. Spleen ~14cm below CM on
MCL. No hepatomegaly, No sigmata of chronic liver
diease
 MSK N
 CNS – Playful during exam
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LABS
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Hb – 80 MCV 90
Plts -150
INR – 1.0
 Alb – 35
 ALT/AST – N
 ESR/CRP - N
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DDX?
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Sounds like UGBI
Esophagel varicies
 Congestive
gastropathy
 Dieulafoy lesion
 Peptic ucler
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INITIAL MANAGEMENT
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ABCs
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2 large bore IV
O2 and monitors
Type + Screen
Crossmatch
May consider Blood,
FFP, Cryoprecipitate
Proton Pump
Inhibitors
 Octreotide
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PPI
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Helpful for gastric
mucosal bleeds
Thought to decrease
the activation of
pepsinogen to pepsin
which may degrade
the fibrin clot
pH greater than 6
allow for better
platelet aggregation
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CHILDREN <40 kg: 2
mg/kg IV loading
dose over 15 minutes
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0.2 mg/kg/hour for 72
hours
CHILDREN ≥40 kg:
80 mg IV loading dose
over 15 minutes
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8 mg/hour for 72 hours
OCTREOTIDE
Decreases splanchnic
blood flow
 Decreases bleeding
from esophageal and
gastric varices
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S/E is hyperglycemia,
angina, arrhythmias,
and headache
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1-2 mcg/kg (Max
50mcg) initial I.V.
bolus followed by 1-2
mcg/kg/hour (max
50mcg/hr) one hour
after loading dose
continuous infusion
ENDOSCOPY
Bleeding varicies
 Banding
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Sclerotherapy – small
percentage will have
esophageal
ulcerations leading to
strictures
SENGSTAKEN-BLAKEMORE TUBE
If unable to stablize,
may need to use in
PICU setting
 Patient will to be
sedated
 ETT to secure airway
 Stabilize before going
into endoscopy
 Consider angiography
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SWALLOWED BLOOD
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Infant – Maternal
blood
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Apt test
Child – epitaxis,
recent dental
extraction or
tonsillectomy
Mallory – Weiss Tear
Repeated vomiting or
retching
 Acute mucosal
laceration of the
gastroesophageal
junction
 Tx – Up to 50 – 80%
stop before time of
endoscopy
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
Electrocoagulation,
heater-probe
application, or
sclerotherapy
GASTRITIS
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Diffuse
Trauma
 Burn
 Surgery
 Severe medical problems
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Locailzed
NSAID
 H. pylori
 EtOH
 Bezoar
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Tx – Proton Pump Inhbitors, may need
antibiotics in certain situations
AV MALFORMATION
Hemangiomas
 Angiodysplasia
 Dieulafoy lesion
 Tx – Endoscopy
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Thermal ablation
LOWER GASTROINTESTINAL BLEED
DDx
 Anal fissure
 Sloughed polyp
 Meckel’s Diverticulum
 Vasculitis
 Vascular
malformation
 UGBI
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Don’t want to miss
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Necrotizing
entercolitis
Malrotation/Volvulu
s
Intussusception
Incarcerated hernia
Hirschsprung
entercolitis
CASE 2
2 yo male presents with 1 day history of dark red
“bloody diarrhea”. The diaper is full of blood and very
little stool. No vomitting
 ABC stable
 S – 2 day history of periumbilical pain
 A – No allergies
 M – Vit D
 P – Had severe reflux as an infant, resolved by 12 mos
 L – Last meal 2 hours ago
 E – Has had about 3 BM today, all full of blood.
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ON EXAM
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HR 150 BP 80/62
HEENT – No scleral
icterus, mild
conjunctival pallor
CVS – S1S2 No S3S4,
SEM noted, ppp, mmm,
CRT = 3
Resp – N
Abd – Soft, slightly
tender in RLQ with
deep palpation. No
masses. BRBPR on DRE
MSK N
CNS – responsive to
exam
DDX?
Meckel’s Diverticulum
 Massive UGIB
 Malrotation with
Volvulus
 Intussusception
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INITIAL MANAGEMENT
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ABCs
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2 large bore IV
O2 and monitors
Type + Screen
Crossmatch
May consider Blood,
FFP, Cryoprecipitate
LABS
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Hb – 80 MCV 90
Plts -150
INR – 1.0
 Alb – 35
 ALT/AST – N
 ESR/CRP - N
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Normal AXR
 Normal Abd
Ultrasound
 Previously normal
barium swallow (done
for reflux as infant)
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Meckel’s Diverticulum
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Remnant of the
omphalomesteric duct
Rule of 2s – 2% of
population, 2% of affected
become symptomatic, 50%
present before the age of 2,
2 inches long and 2 feet
from ileocecal valve
May contain acid secreting
cells which erode the
mesenteric side of lumen
causing profuse bleeding
Tx – Surgical excision
Technetium 99 absorbed by
gastric mucosa
ANAL FISSURE
Usually associated
with constipation or
recent history of
passing large stool
 Painful defecation
 Spotting on toilet
paper
 Resolves with regular
soft stooling
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SLOUGHED JUVENILE POLYP
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Intermittant painless
rectal bleeding
Ages 1 – 10
Maybe bright red, streaked
on stools or mixed in
May get intermittent
abdominal pain,
colocolonic intussusception
and prolapse through anal
canal
Often out grow their
vascular supply and will
auto-amputate
May be seen in stool
VASCULITIS
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Henoch Schonlein
Purpura (HSP)
IgA mediated small
vessel vasculitis
affecting skin, kidney,
GI tract and joints
 May have guaiac
postive stools
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•
Tx - Supportive
BLOODY DIARRHEA - DDX
Infectious
 Ulcerative colitis
 Crohn’s disease
 Allergic colitis
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INFECTIOUS
Salmonella
 EHEC (O157:H7)
 Campylobacter
 Shigella
 Yersinia
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C. Diff
Amox, TMP-SMX
 Supportive
 Erythromycin
 TMP - SMX
 Supportive, TMPSMX, aminoglycosides
 Metronidazole or PO
Vancomycin
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INFLAMMATORY BOWEL DISEASE
Crohn’s Disease
 Insidious, may
present with abdo
pain, growth delay,
delayed puberty
 ASCA
 Transmural
inflammation
 Skip lesions, Terminal
Ileum involved 60%
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Ulcerative colitis
 Presents with bloody
diarrhea and
tenesmus
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p-ANCA
 Mucosa inflammation
 Continuous
 Rectum involved and
progresses proximally
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ALLERGIC COLITIS
Inflammatory
enteropathy caused by
the ingestions of cow
milk protein
 Stools often loose with
occult or frank blood
present
 Tx – Elimination diet
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Soy formula may have
up to 50% cross
reactivity
 Usually resolves by 1
year of age
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WHEN TO CONSULT GI?
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True UGBI bleed
r/o swallowed blood
 Mallory Weis tear may
not need consult
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LGIB
r/o Meckel’s
 r/o Infectious
 r/o CMPA
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CASE 3
14 year old male with recurrent blood mixed in with
stool x 1 year. Feeling tired all of the time. Occasional
dark stools, no hematemesis. +FOBT by GP. Negative
celiac screen
 A – No allergies
 M – Ventolin
 P – Epitaxis, exercise induced asthma
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FHx – Dad also gets lots of nose bleeds and ‘lung problems’,
paternal grandfather died of stroke
 no IBD, no celiac, no FHx of hemophilia
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L – This morning at 08:00
 E – GP referred to GI
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ON EXAM
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See 5mm red/purple
stains on skin over face,
upper trunk, arms. Also
noted on buccal mucosa
and tongue.
Lesions blanch with
pressure
Some look like they
branch out from centre
DRE revealed some
frank blood
Exam otherwise normal
LABS
Hb – 90 MCV 70
Plts -200
 Retics 5%
 INR – 1.0
 Alb – 35
 ALT/AST – N
 ESR/CRP – N
 Ferritin – Low
 TIBC - High
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Hypochromic microcytic
ENDOSCOPY FINDING
Hereditary Hemorrhagic Telangiectasia
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Also known as Osler-WeberRendu Diease
Autosomal dominant mutation
in transforming growth factor
beta signalling pathway
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Dx – 3 of 4 Criteria
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Epistaxis - Spontaneous,
recurrent nosebleeds
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Important for vascular growth
and repair
Triad = Telangiectasia, affected
first degree relative and
epitaxis
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Telangiectases - Multiple at
characteristic sites (lips, oral
cavity, fingers, nose)
Visceral lesions - Such as
gastrointestinal (GI)
telangiectasia (with or without
bleeding), pulmonary AVM,
hepatic AVM, cerebral AVM,
spinal AVM
Family history - A first-degree
relative with HHT
Treatment – GI standpoint
Estrogen-progesterone
therapy
 Transfusion
 Aminocaproic acid
 Endoscopic
photoablation or
electrocautery
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Boyle 2008
REFERENCES
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JT Boyle. 2008. Gastrointestinal Bleeding in Children and Infants.
Pediatrics in Review. (2) 39 – 51
C Ramsook and EE Endom. 2011. Diagnostic approach to lower
gastrointestinal bleeding in children. Up to date.
http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/diagnosti
c-approach-to-lower-gastrointestinal-bleeding-inchildren?source=search_result&search=lower+gi+bleed&selectedTit
le=3%7E102. Accessed October 12, 2011
Soares et al 2010. J Port Gastrenterol. v.17 n.5 Lisboa set
A. Panigrahi. 2011. Pediatric Osler-Weber-Rendu Syndrome.
Medscape reference. http://emedicine.medscape.com/article/957067overview. Accessed October 12, 2011
X Villa. 2011. Approach to upper gastrointestinal bleeding in
children. Up to date.
http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/approachto-upper-gastrointestinal-bleeding-inchildren?source=search_result&search=upper+gi+bleed&selectedTit
le=2%7E150. Accessed October 12, 2011
THANKS!
Special Thank You to Dr. C. Waterhouse