Gastrointestinal bleeding in children

1. Gastrointestinal Bleeding
in
Children
• Dr. C.S.N.Vittal

2. Epidemiology
• GI bleeding – one of the commonest emergencies in pediatrics
• Account for 10%-20% of referrals to pediatric gastroenterologists.
• 6.4% of PICU admissions of which 0.4% is life threatening (Lacroix)
• Mortality : 4 – 9% in best centers

3. Presentation of GI Bleeding
Term Definition
Hemetemesis • Vomiting of blood – bright red/ coffee brown , small or large , with /without
clots.
• Indicates upper GI bleeding
Melena • Black tarry stools, shiny, sticky or foul smelling ( > 60 ml, stays for > 6 hrs)
• Suggests bleeding proximal to the ileocecal valve
Hematochezia • Passage of bright red/ maroon blood per rectum
• Indicates colonic source or massive upper GI bleeding
Occult blood • No obvious bleeding , slow continuous oozing
• Demonstrated by lab exam
Hematobilia • Bleeding into small intestine from biliary tract

4. Classification of GI Bleeds
Upper GI
• Esophagus
• Stomach
• Proximal
duodenum
Lower GI
• Distal to
duodeno-
jejunal
junction

5. Upper GI Bleeding
•Causes

6. Upper GI Bleeding - Neonates
• Swallowed maternal blood
• Hemorrhagic disease of the
newborn
• Stress gastritis
• Cow’s milk protein allergy
• Coagulopathy
• Vascular anomaly

7. Upper GI Bleeding - Infants
• Esophagitis
• Stress ulcer / gastritis
• Duplication cysts,
• Foreign body ingestion,
• Medication-induced
bleeding (Eg, NSAIDs)
• Peptic ulcer bleeding

8. Upper GI Bleeding - Children
• Erosive esophagitis,
• Gastritis,
• Caustic ingestions,
• Peptic ulcer bleeding sec to burns (Curling ulcer)
• Sepsis
• NSAIDs
• Varices
• Mallory-Weiss tear
• Coagulation disorders
• Helicobacter pylori infection
• Zollinger-Allison syndrome

9. The Forrest Classification of Upper GI Bleeds
Endoscopic findings into the following 3 categories:
I - Active hemorrhage
• Ia = bright-red bleeding,
• Ib = slow bleeding
II - Recent hemorrhage
• IIa = nonbleeding visible vessel,
• IIb = adherent clot on base of lesion,
• IIc = flat pigmented spot
III - No evidence of bleeding.

10. Lower GI Bleeding
•Causes

11. Lower GI Bleeding - Neonates
• Anal fissure
• Necrotizing enterocolitis
• Malrotation with volvulus
• Hirschsprung enterocolitis
• Systemic vasculitis

12. Lower GI Bleeding - Infants
• Anal fissure
• Infectious colitis
• Intussusception
• TB abdomen
• Gangrenous bowel
• Cow’s milk protein allergy
• Meckel’s diverticulum
• Pseudomembranous enterocolitis

13. Lower GI Bleeding - Children
• Polyps
• Meckel’s diverticulum
• Anorectal fissure
• Intussusception
• Juvenile Polyps
• Inflammatory bowel disease
• Infectious diarrhea (Esch coli and Shigella)
• Vascular lesions / malformations
• HS Purpura
• Hemorrhoids

14. Diagnostic workup
It is done only after initial stabilization of the child
Step 1…. documentation of bleeding (Is it really blood?)
Step 2…. assessment of severity
Step 3…. establishing the clinical setting of bleeding
Step 4…. identification of specific site

15. Step 1: Is it really blood??
Red vomitus Black stools
• Red food color agents
• Fruit juices like tomato,
watermelon
• Antibiotic syrups, laxatives,
phenytoin, rifampin
• candy, fruit punch, Jell-o, beets
• Iron
• Chocolate
• Bismuth
• Activated charcoal, spinach,
• Blueberries,
• Licorice

16. Step 2: Assessment of severity
• Parental estimate of volume of blood in terms of
drops /spoon/ cup/ glass
• Bright red colour means rapid rate of bleeding
• Melena indicates 60-100 ml blood loss
• Hemetemesis and melena together indicate massive
blood loss
• Clinical assessment
• Sick, Pallor, pulse, BP

17. Step 2: Assessment of severity
Vital sign Blood Loss % Interpretation
Resting hypotension
(Shock)
20-25% Massive
Postural hypotension 10 -12 % Moderate
Normal < 10 % Minor

18. Step 3: Establishing the clinical setting of
bleeding
History:
- Drug ingestion (NSAID)
- Child in ICU setting – Stress ulcer
- Pain abdomen preceding the h/o bleeding - Gastritis
- Preceding h/o vomiting & retching - Mallory Weiss
- Present/past history suggestive of liver disease – Variceal bleed

19. Step 4: Establishing the site of bleeding
Physical examination
- Cutaneous stigmata of CLD
- Bleeding from other sites (muco-cutaneous). - Bleeding diathesis
- Cutaneous hemangioma - Malformations
- Splenomegaly (95% PHT vs 5% non-PHT) – Liver disease
- Liver: s/o CLD
- Ascites – Portal hypertension

20. Investigations for upper GI bleed
• Lab studies
• leucopenia, thrombocytopenia, abnormal liver enzymes, bilirubin and
albumin
• USG abdomen
• for portal hypertension
• Doppler USG
• accurate portal and venous blood flow, obstruction
• CT scan
• better delineate the portal vein and liver parenchyma change
• Upper GI Endoscopy
• Radionuclide study
• non invasive method of determining site

21. Apt Downy Test in Neonates
• Purpose:
• To differentiate between maternal and fetal blood.
• Procedure:
• The blood is placed in a test tube; sterile water is added to hemolyze the RBCs,
yielding free hemoglobin. This solution then is mixed with 1% sodium hydroxide.
• Interpretation:
• If the solution turns yellow-brown, the hemoglobin is maternal or adult
hemoglobin, which is less stable than fetal hemoglobin.
• If the solution remains the same color, it is the more stable fetal hemoglobin;
therefore, the newborn is the source of the bleeding.

22. Treatment - General
• Supportive care- Colloids with wide bore cannula
• Ryle’s tube lavage (wide bore tube): ongoing bleeding
• Blood transfusion:
1. Continued hemodynamic instability despite colloid infusion
2. Continuous bleeding
3. Persistently low hematocrit (<20%, target 30%)

23. Treatment - Specific
• Variceal bleeding
• Drugs to reduce bleeding. Eg. Vasopressin, telepressin, somatostatin,
Octreotride
• Balloon tamponade
• Endoscopic variceal ligation (EVL)
• Transjugular intrahepatic portosystemic shunt (TRIPS)
• Surgery
• Shunt surgery
• Non-shunt surgeries (Sugiura procedure)
• Esophageal transaction & devascularization of gastroesophageal varices

24. Treatment - Specific
• Non-Variceal bleeding
• H2 receptor antagonists
• Protein Pump Inhibitors
• Vasoactive agents Eg. Stomatostatin, Octreotide
• Endotherapy
• Eg. Electrothermal agents, endoclips and argon plasma coagulation

25. Treatment - Specific
• Anal fissures
• Laxatives, sitz bath, topical 0.2% glyceryl nitrate
• Solitary rectal ulcer
• Sucralfate enema
• Hemorrhagic infective colitis
• Antimicrobials
• Polyps
• Colonoscopic snare polypectomy
• Crohn’s disease
• Steroids, azathioprine, infliximab, metronidazole, cyclosporine

26. • Dr.C.S.N.Vittal