15.4.3 GI Bleeding

Question 1

Define haematemesis

Answer 1

passage of bloody or dark “coffee grounds” material from the mouth typically associated with bleeding above the ligament of Trieitz

Question 2

Define Haematochezia

Answer 2

passage of bright red blood or maroon-coloured material from the rectum

Question 3

Define malaena

Answer 3

passage of dark, black, tar-coloured stool usually associated with oesophageal, gastric or upper small intestinal haemorrhage

Question 4

Upper GI bleeding: presentation

Answer 4

Remember: swallowed blood from nose, throat or coughed up from lungs and swallowed can also present with these symptoms – or mother’s cracked nipples if breastfeeding infant! (Take a good history!!)

• Hypovolaemic shock (hypotension, tachycardia, collapse)
• Vomiting fresh blood or coffee grounds (gastric acid in blood that is partially digested blood)
• Malaena

Also:
- Dizziness, weakness, syncope, heartburn, epigastric pain or tenderness
- Iron deficiency anaemia (from chronic blood loss) -> bleed very slow over long period of time
- Stool occult blood positive

-> think of breastfeeding nipples in completely well baby, vomiting blood
# Not everything that is red-coloured is blood (eg beetroot, food dyes, rifampicin) -> test if it is blood

Question 5

Lower GI bleeding: presentation

Answer 5

• Haematochezia
• Iron deficiency anaemia (from chronic blood loss)
• Important to differentiate: is the blood mixed in with the stool? Is it fresh or altered? Is the blood on the surface of the stool? Is the blood present in the toilet bowl not the stool? Is the blood only present on toilet paper?
• Fresher the blood; the lower the bleeding in Gut

Question 6

Mechanism of GIT bleeding

Answer 6

Mucosal injury – injury from gastric acid, infectious agents, ingestion of caustic agent, foreign body, inflammation

Blood vessel disruption - raised pressure eg chronic liver disease with cirrhosis leads to portal hypertension and bleeding from oesophageal varices

Question 7

Portal hypertension

Answer 7

• Develops due to cirrhosis of liver or portal vein thrombosis➡️back pressure in portal vein
• Collaterals develop at anastomotic sites where portal and systemic venous systems meet ➡️development of varices = abnormal dilated veins

Slide 9 notes

Question 8

Oesophageal varices

Answer 8

• Abnormal dilated veins at lower end of oesophagus
• Develop secondary to portal hypertension
• caused by portal hypertension and the blood trying to find varices to get back to systemic circulation

Question 9

Oesophagitis

Answer 9

Infections:
- oesophageal candidiasis,
- herpes simplex, cytomegalovirus (pt very immunocompromised)

Noninfectious:
- reflux oesphagitis,
- pill oesophagitis (pt swallow pill and it gets stuck)
- eosinophilic oesophagitis

Question 10

Gastric and duodenal bleeds

Answer 10

• Helicobacter pylori infection (most common cause)
• Inflammation
• Gastritis(common causes; helicobacter and PUD)
• Duodenitis
• Peptic ulcer disease
• Erosion into submucosal blood vessels or artery

Question 11

Foreign body

Answer 11

• causes GI bleed
• common: button batteries (can go to aorta within hours), magnets (stick together in babies intestines)
• always take chest X-ray

Question 12

Mallory Weiss tear

Answer 12

• Tear in the mucosa at the gastro-oesophageal junction
• Due to repeated forceful vomiting or retching

Question 13

Other causes of upper GI bleeding

Answer 13

• Bleeding disorder eg haemophilia, vitamin K deficiency, stress ulcer in critically ill child
• Vascular malformation of gut
• Drug side effect eg NSAIDs inhibit prostaglandin synthesis, which is protective to the gastric lining; allows stomach acid to damage the mucosal lining

Question 14

Lower GI bleeding

Answer 14

• Bleeding that arises beyond the ligament of Treitz
• Suspensory ligament of the duodenum – arises from right crus of diaphragm and suspends duodenojejunal flexure

Question 15

Anorectal pathology

Answer 15

• Anal fissures/tears (enquire about sexual abuse)
• Haemorrhoids
• Fistulas
• A small tear may occur due to passing hard stool in children with constipation
• NB: always consider INFLAMMATORY BOWEL DISEASE if there is significant perianal disease
• think of chromes disease

Question 16

Lower GI bleeding: polyp

Answer 16

• Most polyps in children are juvenile polyps
• No malignant risk
• Cured once removed
• Diagnosis confirmed by histology
• Also polyposis syndromes (large numbers of polyps)

Question 17

Lower GI bleed: colitis causes

Answer 17

• Infectious: bacterial dysentery, amoebic colitis
• Noninfectious: ulcerative colitis, Crohn’s colitis, allergic, other

Question 18

Lower GI bleed: surgical causes (needs surgical management)

Answer 18

Ischaemic bowel – bleeding with signs of intestinal obstruction:
- Intussusception
- *Malrotation and midgut voluvulus
- Incarcerated strangulated hernia
- Meckel’s diverticulum

*Watch a video regarding malrotation!

Question 19

Intussusception
General
Causes
Lead point

Answer 19

• Usually infants 3mo – 3 yrs
• This happens when one part of the intestine slides into another
• Often happens where the small and large intestine meet
  mesentery of the proximal bowel is compressed, resulting in venous obstruction and bowel wall oedema
• If prolonged arterial insufficiency will ultimately lead to ischaemia and bowel wall necrosis

Causes
IDIOPATHIC:
- Commonest form
- Lymphoid hyperplasia - due to an increase in the lymphoid tissue mass (“Peyers patches”) in the bowel wall of the terminal ileum is thought to be the most likely cause
Other possible causes:
- ? viral association - usually occurs about 10 days after a respiratory infection or gastroenteritis
- there is a seasonal variation (higher in spring and summer)

• Ileo-colic (ileum into colon) intussusception is usually found (MOST COMMON)

Lead point
- Less common
- Usually seen in the older child and adults (must be ruled out in older children)
- Lead points include:
➡️Meckel’s diverticulum
➡️Enlarged lymph nodes due to lymphoma
➡️Intestinal polyp

Question 20

Enterocolitis

Answer 20

• Neonates: necrotising enterocolitis in preterm neonates
• Other diseases of intestine Eg Hirschsprung’s disease

Question 21

Take Home Message

Answer 21

• Gastrointestinal bleeding is a serious clinical problem
• Presentation is variable depending on site of bleeding, how much bleeding occurs and over what time period
• Common mechanisms:
  o Mucosal injury
  o Bleeding from dilated blood vessels - most commonly oesophageal varices due to portal hypertension (due to cirrhosis of liver or portal or splenic vein thrombosis)