GIT Bleeding Updated 5 PDF - University of Baghdad 2024-2025

University of Baghdad College of Medicine 2024-2025 Title:Gastrointestinal bleeding Grade:5 Module: Speaker: Assiss. Prof.Rabab Farhan Date:2024-2025 GIT BLEEDING IN PEDIATRICS Gastrointestinal (GI) tract is a highly vascularized organ with a large sur...

University of Baghdad College of Medicine 2024-2025 Title:Gastrointestinal bleeding Grade:5 Module: Speaker: Assiss. Prof.Rabab Farhan Date:2024-2025 GIT BLEEDING IN PEDIATRICS Gastrointestinal (GI) tract is a highly vascularized organ with a large surface area, thus any pathology involving the mucosa and the vasculature of the GI tract can lead to GI bleeding. (1) Gastrointestinal bleeding also known as gastrointestinal hemorrhage is one of the most alarming conditions encountered in pediatrics and can occur in any area of the gastrointestinal tract, from the mouth to the anus. Bleeding is typically divided into two main types: upper gastrointestinal bleeding and lower gastrointestinal bleeding , about 2/3 of all GI bleeds are from upper sources and 1/3 from lower sources. Obscure gastrointestinal bleeding (OGIB) is when the source is unclear despite GI bleeding symptoms including iron deficiency anemia, and positive occult blood test, no endoscopy or colonoscopy abnormalities are observed Types: Upper Gastrointestinal bleeding is from a source between the pharynx and the ligament of Treitz (commonly defined as bleeding arising from the esophagus, stomach, or duodenum), characterized by hematemesis (vomiting of frank blood or coffee grounds), melena (black, tarry stool containing altered blood) or both (hematemesis and melena). Lower Gastrointestinal Bleeding is typically from the colon, rectum or anus. It may be indicated by hematochezia (the passage of fresh red blood rectally). The presentation of bleeding depends on the amount and location of hemorrhage The etiology of UGIB can be categorized by age groups, but causative disorders overlap considerably between these. In neonates:— UGI bleeding True UGI bleeding in a neonate must be distinguished from swallowed maternal blood. Vitamin K-deficient bleeding (hemorrhagic disease of the newborn) should be considered in neonates who were not given vitamin K prophylaxis at birth Stress gastritis or ulcers are associated with critical illness but also may occur spontaneously even in the first few days of life. in rare instances. Congenital anomalies including intestinal duplications or vascular anomalies may present with gastrointestinal (GI) hemorrhage Coagulopathy in a neonate may also be caused by infection, liver failure, or a congenital coagulation factor deficiency.. Milk protein intolerance may present with UGI bleeding, although lower gastrointestinal (LGI) bleeding is much more common. Care must be taken to exclude other causes of UGI bleeding, as outlined below, because UGI bleeding or passage of blood per rectum alone is not diagnostic of milk protein intolerance. Infants, children, and adolescents — The spectrum of causes of UGI bleeding in children is similar to that in adults, although some risk factors vary with age Mallory-Weiss syndrome – Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations in the distal esophagus, usually developing after forceful retching. The bleeding is usually small and self-limited but occasionally is severe. Esophageal or GI foreign body – A foreign body can cause GI bleeding if it is sharp, caustic, and/or lodged in the esophagus. Clinical clues to this possibility include a history of a choking episode, even if it was transient or occurred days or even weeks before the bleeding episode. Rarely, ingestion of a button battery has led to severe UGI hemorrhage due to aortoesophageal fistula, which can be fatal Esophagitis – Esophagitis in this age group usually is caused by gastroesophageal reflux (GERD)disease or eosinophilic esophagitis(EOE) and occasionally or by caustic ingestion. Peptic esophagitis also may develop after recurrent vomiting from other causes. "Caustic esophageal injury in children" and "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)".) Bleeding from esophageal varices – Variceal bleeding is the most common cause of severe acute UGI bleeding in children. Esophageal varices (OV)are caused by portal vein hypertension. Clues to portal hypertension include splenomegaly and/or a history of thrombocytopenia, even in a patient without a history of liver disease. Peptic ulcers and gastritis – Gastritis and ulcers occasionally occur in all age groups, typically in the setting of critical illness or use of nonsteroidal antiinflammatory drugs (NSAIDs). Young children are particularly susceptible to developing UGI bleeding after NSAID use. Gastritis or peptic ulcers also may be related to Helicobacter pylori infection or, occasionally, to a viral infection including cytomegalovirus.In these disorders, epigastric discomfort and/or vomiting typically precede the hematemesis, Arterial bleeding – Rarely, severe acute UGI bleeding is from an artery, either from an overlying peptic ulcer or a Dieulafoy lesion Unusual causes of UGI bleeding have been described in case reports, including hemangiomas aortoesophageal fistulas hereditary hemorrhagic telangiectasia (Osler-Weber Rendu syndrome) Kasabach-Merritt syndrome duplication cysts parasites , vasculitis , gastric polyps, annular pancreas , antral or duodenal web , and systemic mastocytosis Lower GIT bleeding Neonatal period — The most common diagnoses to consider in newborns presenting with LGIB are: Swallowed maternal blood Anorectal fissures Necrotizing enterocolitis (NEC) Malrotation with midgut volvulus Hirschsprung disease with enterocolitis Coagulopathy Brisk upper GI bleeding Vascular malformations Gastric or duodenal ulcer GI duplication cyst Infants and toddlers — Causes of bleeding in infants and toddlers (one month to two years) include: Anal fissures (especially around the introduction of solid food or cow's milk) Milk- or soy protein-induced colitis (allergic colitis) Intussusception Infectious colitis Meckel's diverticulum GI duplication cyst Coagulopathy Eosinophilic GI disease Infantile and very early-onset inflammatory bowel disease (VEO-IBD). Clinical Manifestations of Gastrointestinal bleeding: Gastrointestinal (GI) bleeding can be occult or overt. When there is significant blood loss over a short time, symptoms may include vomiting red blood (hematemesis), coffee-ground emesis, bloody stool (hematochezia), or black tarry stool(melena). Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or syncope. Definition of some clinical problems that cause GI bleeding Swallowed maternal blood — In a newborn infant with oral or rectal bleeding, the rectal blood should be tested to determine whether it comes from the infant or whether it represents maternal blood, which may have been swallowed during delivery or ingested during breast feeding from cracked nipples. This is accomplished using the Apt test (hemoglobin alkaline denaturation test), which detects fetal hemoglobin (HbF) : Gastritis: is an inflammation of the lining of the stomach. Common causes include infection with Helicobacter pylori and use of Non-steroidal anti-inflammatory drugs. It can manifest with abdominal pain or vomiting (may be clear, green or yellow, blood streaked or completely bloody depending on the severity of the stomach inflammation) and less often refractory iron deficiency anemia or growth retardation Peptic ulcer disease: is the end result of inflammation caused by an imbalance between cytoprotective and cytotoxic factors in the stomach (gastric ulcer) and duodenum (duodenal ulcer). Hematemesis or melena is reported in up to half of the patients with peptic ulcer disease. School-aged children and adolescents more commonly present with epigastric pain, nausea and dyspepsia. Infants and younger children usually present with feeding difficulty, vomiting, crying episodes, hematemesis, or melena. In the neonatal period, gastric perforation can be the initial presentation Esophageal varices: are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. Presentation is with significant hematemesis and melena; most patients have liver disease. Any child with hematemesis and splenomegaly should be presumed to have esophageal variceal bleeding until proved otherwise Cow’s milk protein allergy: is an adverse immune reaction to one or more proteins in cow's milk. Symptoms can occur either rapidly or have a gradual onset. The former may include anaphylaxis, a potentially life-threatening condition which requires treatment with epinephrine among other measures. The latter can take hours to days to appear, with symptoms including atopic dermatitis, inflammation of the esophagus, enteropathy involving the small intestine and proctocolitis involving the rectum and colon causing bloody stool. Mallory–Weiss syndrome or gastro-esophageal laceration syndrome: refers to bleeding from a laceration in the mucosa at the junction of the stomach and esophagus. This is usually caused by severe vomiting because of bulimia, but can be caused by any condition which causes violent vomiting and retching such as food poisoning. The syndrome presents with hematemesis. The laceration is sometimes referred to as a Mallory-Weiss tear Gastroesophageal reflux disease: is the retrograde movement of gastric contents across the lower esophageal sphincter into the esophagus, which occurs physiologically every day in all infants, older children, and adults. Pathological GERD in infants and children who manifest or report bothersome symptoms because of frequent or persistent GER, producing esophagitis-related symptoms, or extraesophageal presentations, such as nutritional effects  Meckel's diverticulum. What is Meckel's diverticulum? Meckel's diverticulum is an outpouching or bulge in the lower part of the small intestine. The bulge is congenital (present at birth) and is a leftover of the umbilical cord. Meckel's diverticulum is the most common congenital defect of the gastrointestinal tract. It occurs in about 2% to 3% of the general population. The most common symptom in children under age 5 is painless bleeding, which is caused by ulcers that develop in the small intestine when the diverticulum secretes stomach acid. Bowel obstruction occurs more often in older children and adults. Diverticulitis can occur at any age, but is most common in older children Technetium scan: This test is a scan. Radioactive technetium is injected into the body. This substance is absorbed by stomach cells in the diverticulum and can be detected by a special camera. Colonoscopy: In this test, a small, flexible tube with a camera on the end is inserted into the rectum and colon to look for blockages and the cause of bleeding. Wireless capsule endoscopy: For this test, the patient swallows a small camera that can detect sources of bleeding in the small intestine. If your child is too young to swallow a pill, it can be placed in the stomach while your child is asleep. Management is surgical removal in symptomatic patients. Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease and Osler–Weber–Rendu syndrome: is a rare autosomal dominant genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain. It may lead to nosebleeds, acute and chronic digestive tract bleeding, and various problems due to the involvement of other organs. (27) (28) Angiodysplasia: is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places. Ulcerative colitis (UC): an idiopathic chronic inflammatory disorder, is localized to the colon and spares the upper gastrointestinal tract. Blood, mucus and pus in the stool as well as diarrhea are the typical presentation of UC. Constipation may be observed in those with ulcerative proctitis (when the disease is localized to the rectum). Symptoms such as tenesmus, urgency, cramping abdominal pain (especially with bowel movements). Infectious enterocolitis: is an inflammation of the digestive tract, involving enteritis of the small intestine and colitis of the colon. It may be caused by various infections, with bacteria, viruses, fungi, parasites, or other causes. Henoch–Schönlein purpura (HSP): also known as IgA vasculitis, is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children. Purpura, arthritis, and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura. Purpura occur in all cases, joint pains and arthritis in 80%, and abdominal pain in 62%. Some include gastrointestinal hemorrhage as a fourth criterion; this occurs in 33% of cases, sometimes, but not necessarily always, due to intussusception Crohn disease: an idiopathic, chronic inflammatory disorder of the bowel, involves any region of the alimentary tract from the mouth to the anus. Although there are many similarities between ulcerative colitis and crohn disease, there are also major differences in the clinical course and distribution of the disease in the GI tract. Symptoms often include abdominal pain, diarrhea (which may be bloody if inflammation is severe), fever, and weight loss Hirschsprung's disease (HD or HSCR): is a birth defect in which nerves are missing from parts of the intestine. The affected segment of the colon cannot relax and pass stool through the colon, creating an obstruction. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, bloody diarrhea with attacks of enter colitis leading to delayed growth. NORMAL HIRSCHPRUNG Diagnostic Approach: Diagnosis typically begins with a medical history and physical examination, along with blood tests. Upper intestinal bleeding is evaluated with esophagogastroduodenoscopy. Evaluation of the small intestine is facilitated by capsule endoscopy {The capsule is similar in shape to a standard pharmaceutical capsule, although a little larger, and contains a tiny camera and an array of LEDs (light emitting diode) powered by a battery After a patient swallows the capsule, it passes along the gastrointestinal tract taking a number of images per second which are transmitted wirelessly to an array of receivers connected to a portable recording device carried by the patient. The primary use of capsule endoscopy is to examine areas of the small intestine that cannot be seen by other types of endoscopy such as colonoscopy or esophagogastroduodenoscopy (EGD)}. Lower GI bleeding is investigated with a colonoscopy. Occult blood in stool is usually detected by using commercially available fecal blood testing cards, which are based on a chemical reaction between the chemical guaiac and oxidizing action of a substrate (hemoglobin), giving a blue color. The guaiac test is very sensitive, but random testing can miss chronic blood loss, which can lead to iron deficiency anemia Treatment: Supportive measures include stabilization of hemodynamic status, correction of any coagulation or platelet abnormalities, blood transfusion if necessary, and iron supplementation. Because both intravascular and extravascular volumes are reduced in acute GI bleeding, crystalloid (normal saline, Ringer lactate) is the solution of choice for initial intravenous resuscitation. Colloid solutions or blood are used only when blood loss is massive, in which case the patient is at risk for developing respiratory insufficiency or shock lung {ARDS: a form of fluid accumulation in the lungs not explained by heart failure (non-cardiogenic pulmonary edema)} because of a significant decrease in plasma oncotic pressure. Blood transfusion is the only method of restoring oxygen-carrying capacity during active GI bleeding. A number of medications and procedures may improve outcomes depending on the source of the bleeding: *Crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. Proton pump inhibitors (PPI) may reduce mortality in those with severe peptic ulcer as well as the risk of re-bleeding and the need for surgery among this group. For variceal bleeding, vasopressin and nitroglycerin are important to reduce portal venous pressures. This is in addition to endoscopic banding or sclerotherapy {is a procedure used to treat blood vessels or blood vessel malformations (vascular malformations) and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations} for the varices. If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding In those with upper GI bleeding endoscopy within 24 hours is recommended, in addition to medical management. A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. Colonoscopy is useful for the diagnosis and treatment of lower GI bleeding. A number of techniques may be employed including: clipping, cauterizing, and sclerotherapy. Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem. Thanx