Approach to GI BleedingSimon Lam

October 13, 2011

ACH Resident Academic Half Day

Overview 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”

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.

Presentation

Hematemesis Coffee ground emesis Melena stool Hematochezia Normal stools with blood Bloody Diarrhea

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

On Exam

ABC Vitals HEENT CVS RESP ABD

Must include DRE! GU

Worrisome Signs Pallor Diaphoresis Restlessness Increased HR Decreased BP Orthostatic changes

Increase HR 20 bpm Decrease BP 10

mmHg

Labs CBC

Hct MCV Plts

Iron studies Creatinine Alb CRP/ESR ALT/AST INR/PTT Stool WBC, C+S,

O+P

Guaiac Test

Used to confirm the presence of hemoglobin

False positives Ascrobic acid (Vit C) Animal

myoglobin/hemoglobin

Apt Test

Differentiates maternal vs infant blood

Maternal = 2α2β Fetal/infant = 2α2γ NaOH will denature

maternal blood and not fetal/infant

Positive test = Pink

Negative test = Yellow/Brown

Classification

Commonly classified based on location

Above Ligament of Treitz = UGBI

Below Ligament of Treitz = LGIB

May try to pass NG into stomach and aspirate. If + blood, likely UGBI. However if negative, does not exclude UGBI

Upper Gastrointestinal Bleed DDx

Swallowed blood Mallory-Weiss tear Variceals Gastritis* Peptic ulcer AV malformations

Hemangiomas Angiodysplasia Dieulafoy lesion

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”

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

Labs

Hb – 80 MCV 90 Plts -150

INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N

DDx?

Sounds like UGBI Esophagel varicies Congestive

gastropathy Dieulafoy lesion Peptic ucler

Initial Management

ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood,

FFP, Cryoprecipitate Proton Pump

Inhibitors Octreotide

PPI 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

CHILDREN <40 kg: 2 mg/kg IV loading dose over 15 minutes 0.2 mg/kg/hour for

72 hours

CHILDREN ≥40 kg: 80 mg IV loading dose over 15 minutes 8 mg/hour for 72

hours

Octreotide

Decreases splanchnic blood flow

Decreases bleeding from esophageal and gastric varices

S/E is hyperglycemia, angina, arrhythmias, and headache

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

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

Swallowed Blood

Infant – Maternal blood 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 Electrocoagulation,

heater-probe application, or sclerotherapy

Gastritis

Diffuse Trauma Burn Surgery Severe medical

problems

Locailzed NSAID H. pylori EtOH Bezoar

Tx – Proton Pump Inhbitors, may need antibiotics in certain situations

AV Malformation

Hemangiomas Angiodysplasia Dieulafoy lesion Tx – Endoscopy

Thermal ablation

Lower Gastrointestinal Bleed

DDx Anal fissure Sloughed polyp Meckel’s

Diverticulum Vasculitis Vascular

malformation UGBI

Don’t want to miss Necrotizing

entercolitis Malrotation/

Volvulus 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.

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, 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

Initial Management

ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood,

FFP, Cryoprecipitate

Labs

Hb – 80 MCV 90 Plts -150

INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N

Normal AXR Normal Abd

Ultrasound Previously normal

barium swallow (done for reflux as infant)

Meckel’s Diverticulum 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

Sloughed Juvenile Polyp 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

Henoch Schonlein Purpura (HSP) IgA mediated small

vessel vasculitis affecting skin, kidney, GI tract and joints

May have guaiac postive stools

• Tx - Supportive

Bloody Diarrhea - DDx

Infectious Ulcerative colitis Crohn’s disease Allergic colitis

Infectious

Salmonella EHEC (O157:H7) Campylobacter Shigella Yersinia

C. Diff

Amox, TMP-SMX Supportive Erythromycin TMP - SMX Supportive, TMP-

SMX, aminoglycosides

Metronidazole or PO Vancomycin

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%

Ulcerative colitis Presents with bloody

diarrhea and tenesmus

p-ANCA Mucosa inflammation Continuous Rectum involved and

progresses proximally

Allergic Colitis Inflammatory

enteropathy caused by the ingestions of cow milk protein

Stools often loose with occult or frank blood present

Tx – Elimination diet Soy formula may

have up to 50% cross reactivity

Usually resolves by 1 year of age

When to consult GI?

True UGBI bleed r/o swallowed blood Mallory Weis tear

may not need consult

LGIB r/o Meckel’s r/o Infectious r/o CMPA

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

FHx – Dad also gets lots of nose bleeds and ‘lung problems’, paternal grandfather died of stroke

no IBD, no celiac, no FHx of hemophilia L – This morning at 08:00 E – GP referred to GI

On Exam 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

Hypochromic microcytic

Endoscopy finding

Hereditary Hemorrhagic Telangiectasia

Also known as Osler-Weber-Rendu Diease

Autosomal dominant mutation in transforming growth factor beta signalling pathway

Important for vascular growth and repair

Triad = Telangiectasia, affected first degree relative and epitaxis

Dx – 3 of 4 Criteria

Epistaxis - Spontaneous, recurrent nosebleeds

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

Boyle 2008

References

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/diagnostic-approach-to-lower-gastrointestinal-bleeding-in-children?source=search_result&search=lower+gi+bleed&selectedTitle=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/957067-overview. 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/approach-to-upper-gastrointestinal-bleeding-in-children?source=search_result&search=upper+gi+bleed&selectedTitle=2%7E150. Accessed October 12, 2011

Thanks!

Special Thank You to Dr. C. Waterhouse