Approach To GIT Bleeding Flashcards
What should be the first step in evaluating suspected GIT bleeding?
Confirm that it is really blood, as several substances can mimic GIT bleeding.
What is coffee-ground vomitus, and what can mimic it?
Coffee-ground vomitus is blood altered by heme oxidation from gastric acid. It can be mimicked by coffee, iron, or food coloring.
What is hematochezia, and what substances can mimic it?
Hematochezia is fresh, unaltered blood passed per rectum, possibly mixed with stools. It can be mimicked by food coloring, beetroot, gelatin desserts, sweets, antibiotics, and iron tablets.
What is melena, and what can mimic it?
Melena is altered, partially digested blood with a tarry black color and sticky consistency. It can be mimicked by iron, bismuth, dark chocolate, spinach, blueberries, and liquorice.
What special test can confirm the presence of blood in the stool?
Faecal occult blood tests, including bedside tests.
What does the guaiac test detect, and when is it particularly useful?
The guaiac test detects heme and is particularly useful for upper GIT bleeding, as gastric juice may denature globin.
What does the immunochemical test detect, and when is it typically used?
The immunochemical test detects antibodies to globin and is used to screen for distal intestinal or colonic bleeding.
What should be assessed to determine if a bleeding disorder is present in a child with GIT bleeding?
- Previous bleeding episodes (e.g., recurrent nosebleeds, persistent bleeding after minor trauma or circumcision).
- Family history of bleeding disorders (e.g., Haemophilia, Peutz-Jegher’s syndrome, Hereditary Haemorrhagic Telangiectasia).
What special investigations should be performed in all patients presenting with GIT bleeding?
- Full blood count (FBC).
- Clotting screen (INR/PTT).
- Urea and creatinine levels.
What could low platelet counts indicate in the context of GIT bleeding?
- Sepsis.
- Hypersplenism due to portal hypertension
What might renal failure cause in terms of bleeding risk?
Dysfunctional platelets.
What does a raised reticulocyte count indicate in GIT bleeding?
Chronic bleeding
Why is it important to obtain baseline coagulation studies before transfusion?
Transfusion can alter coagulation results, delaying accurate testing for a month or more.
What amount of blood loss is associated with signs of shock?
Greater than 40 mL/kg.
What vital signs indicate shock from significant blood loss?
- Tachycardia (increased pulse rate)
- Decreased pulse volume
- Hypotension (late sign)
- Signs of poor end-organ perfusion (e.g., confusion, lethargy)
- Cold and clammy peripheries
What urgent baseline investigations should be performed in suspected massive blood loss?
- Full blood count (FBC)
- Urea and electrolytes (U&E)
- INR/PTT (clotting screen)
- Crossmatch for blood transfusion
What are the key resuscitation steps for a child with massive GIT bleeding?
- Administer oxygen
- IV fluids (Ringer’s lactate, 10 mL/kg boluses)
- Tranexamic acid (15 mg/kg)
- Emergency O-negative blood after taking baseline investigations and crossmatch
How should coagulopathy be corrected in massive GIT bleeding?
- Transfuse packed red cells
- Administer fresh frozen plasma (FFP) and/or platelets as per the massive transfusion protocol
- Give additional calcium
What additional considerations are necessary if oesophageal varices are suspected?
- Broad-spectrum antibiotics
- Propranolol
- Possible use of a Sengstaken-Blakemore tube and somatostatin
- Refer to the portal hypertension management flowchart
How can anaemia be rapidly assessed while awaiting FBC?
Check haemoglobin (Hb) using a finger-prick test or blood gas analysis.
Why might haemoglobin levels be deceptively high in acute GIT bleeding?
Acute volume loss can cause haemoconcentration, especially if associated with vomiting and dehydration.
How should haemoglobin levels be interpreted in the context of vital signs?
Correlate the Hb level with the patient’s vital signs to assess the degree of blood loss accurately.
When is lower GIT endoscopy indicated in GIT bleeding?
After bowel preparation to detect GIT lesions.
What condition should be suspected if there is high-grade fever and an acute abdomen with generalized peritonitis?
Amoebic colitis.
What are the urgent management steps for amoebic colitis?
- Urgent surgery.
- High-dose metronidazole (15 mg/kg).
- Fresh stool sample for ova/histology.
What are common signs of portal hypertension in children?
Signs include upper gastrointestinal bleeding, enlarged spleen (splenomegaly), jaundice, ascites, and abdominal wall varices.
How is Meckel’s diverticulum diagnosed in children?
Diagnosis involves imaging studies and, in cases of significant bleeding, procedures like bleeding scans, colonoscopy, or angiography.
What is the primary treatment for bleeding caused by Meckel’s diverticulum?
The main treatment is surgical removal of the diverticulum (diverticulectomy), which is effective in controlling bleeding
How should a child with significant bleeding from Meckel’s diverticulum be managed preoperatively?
Management includes restoring blood volume, obtaining adequate intravenous access, correcting electrolyte abnormalities, and preparing for emergency surgery.
What surgical approach is typically used to treat bleeding from Meckel’s diverticulum?
Laparoscopic surgery is commonly used to remove the diverticulum, offering benefits like smaller incisions and quicker recovery
What are potential complications of untreated portal hypertension in children?
Complications can include gastrointestinal bleeding from varices, ascites, encephalopathy, and edema
Why is early detection of portal hypertension important in pediatric patients?
Early detection allows for timely interventions to manage symptoms, prevent complications, and improve quality of life.
What role does imaging play in diagnosing portal hypertension in children?
Imaging studies help assess liver structure, detect varices, and identify other complications associated with portal hypertension.
Can Meckel’s diverticulum cause other symptoms besides bleeding?
Yes, it can cause obstruction, inflammation (diverticulitis), or rarely, tumors
What is the prognosis for children after surgical treatment of Meckel’s diverticulum?
Prognosis is generally excellent, with most children recovering fully without long-term issues.
What are the key considerations in evaluating the underlying cause of massive gastrointestinal (GIT) bleeding in children?
When assessing massive GIT bleeding in children, it’s crucial to conduct a thorough history and physical examination to identify potential underlying causes, including:
• Portal Hypertension with Gastro-oesophageal Varices: Look for signs such as jaundice, ascites, abdominal wall varices, hepatosplenomegaly, petechiae, purpura, ecchymoses, spider naevi, and clubbing. An abdominal ultrasound can help confirm the diagnosis.
• Meckel’s Diverticulum with Ectopic Gastric Mucosa: Typically presents in children aged 18 months to 5 years with painless bright red or maroon blood per rectum and no other symptoms.
• Epistaxis: Consider if there’s a history of significant nosebleeds, as swallowed blood can be vomited or passed per rectum.
• Pulmonary Haemorrhage: Evaluate for risk factors and symptoms of conditions like tuberculosis.
• Gastritis/Peptic Ulcer Disease: Particularly in hospitalized patients, especially those in ICU, with burns, or on non-steroidal anti-inflammatory drugs.
• Peutz-Jeghers Syndrome: Characterized by oral mucosal freckling and, in older children, axillary freckling; bleeding may result from hamartomatous polyps.
• Hereditary Haemorrhagic Telangiectasia: May present with mucocutaneous lesions and a family history; abdominal ultrasound can detect large solid organ arteriovenous malformations.
• Amoebic Colitis: Presents with high-grade fever and acute abdomen with generalized peritonitis; requires urgent surgery and high-dose metronidazole (15 mg/kg), along with a fresh stool sample for ova and histology.
Identifying the specific cause is essential for appropriate management and improving patient outcomes.
What is the first step in evaluating chronic or recurrent gastrointestinal bleeding in a child?
Check hemoglobin (Hb) and reticulocyte count, and perform a fecal occult blood test (FOB) if there is no clear history of per rectum (PR) bleeding.
What is the approach to anemia with slow, chronic blood loss in children?
In cases of slow, chronic small-volume blood loss, physiological adaptation may occur, allowing Hb levels <6g/dL without needing transfusion if the child is hemodynamically stable.
How should anemia of unknown cause be evaluated in children?
Always screen for gastrointestinal (GI) sources of bleeding, starting with fecal occult blood testing (FOB).
How can parasitic infections be ruled out as a source of chronic GI bleeding?
Send stool samples for microscopy to test for helminth infections.
How can hemangiomas be diagnosed in cases of chronic GI bleeding?
Perform routine upper and/or lower GI endoscopy, possibly adding capsule endoscopy, and abdominal ultrasound to check for associated hepatic hemangiomas.
What is the diagnostic approach for intestinal polyps in children with chronic GI bleeding?
Perform upper and/or lower GI endoscopy, push endoscopy for the small bowel (in older children), double-contrast enema, and capsule endoscopy to assess the small bowel.
How is gastritis evaluated in children with chronic GI bleeding?
Discontinue any precipitating causes (e.g., NSAIDs), trial a proton pump inhibitor if acute with risk factors, or perform upper GI endoscopy with biopsies and Helicobacter pylori testing.
How can you differentiate between maternal and neonatal gastrointestinal bleeding?
Use the Apt test to distinguish between fetal hemoglobin (baby’s blood) and maternal blood. If the test is positive, the blood is from the mother; if negative, it’s from the baby.
What is a common cause of neonatal gastrointestinal bleeding related to vitamin deficiency?
Haemorrhagic disease of the newborn due to vitamin K deficiency.
What are possible causes of neonatal gastrointestinal bleeding related to birth complications?
Placenta praevia, placental abruption, birth trauma (e.g., liver trauma with haemobilia), and caesarean section.
What condition can cause neonatal gastrointestinal bleeding associated with infection and clotting issues?
Disseminated intravascular coagulopathy (DIC), which can occur due to sepsis.
What is necrotizing enterocolitis (NEC) and how can it cause bleeding?
NEC is an inflammatory condition affecting the neonatal intestine, which can lead to gastrointestinal bleeding.
How does midgut volvulus present in a previously well child with gastrointestinal bleeding?
Midgut volvulus typically presents as sudden, severe abdominal pain and vomiting in a previously well child, and it can cause gastrointestinal bleeding.
Causes of bleeding due to neonatal factors
Haemorrhagic disease of newborn (Vit K)
NEC (necrotizing enterocolitis)
DIC (disseminated intravascular
coagulopathy): from sepsis
Midgut volvulus (previously well child)
Birth trauma e.g. causing liver trauma with
haemobilia (blood in biliary tree)
How can you determine if blood is coming from the nasopharynx?
Look for signs such as blood in the nose or mouth, often due to trauma or an upper respiratory infection, which can lead to nasal bleeding.
How is blood from the respiratory tract identified?
Blood from the respiratory tract can be identified by the presence of blood in the sputum or coughing up blood (hemoptysis), which is often due to respiratory infections, pulmonary hemorrhage, or trauma.
How do you differentiate vaginal bleeding from gastrointestinal bleeding?
Vaginal bleeding, typically due to trauma or menstruation, can be distinguished by the absence of digestive symptoms and the presence of menstrual history or trauma.
What are the characteristics of haematemesis (vomiting blood)?
Haematemesis can be fresh (if large volumes) or coffee-ground (if gastric acid has altered the blood). Swallowed blood from nasal or oral bleeding may also present as vomited blood.
What does melena indicate and where is the bleeding source?
Melena refers to tarry stools, which are altered by digestion. It indicates bleeding from the upper gastrointestinal tract, typically from conditions like ulcers, varices, or gastritis.
How does a massive gastrointestinal bleed with shock present?
A massive GI bleed may present with fresh blood per rectum (e.g., from esophageal varices) along with vomited blood. It requires urgent attention and possible referral to manage esophageal varices and their complications.
How is upper gastrointestinal bleeding diagnosed?
Upper GI bleeding can be diagnosed by nasogastric tube insertion and stomach lavage to confirm bleeding above the ligament of Treitz. Oesophagogastroduodenoscopy (OGD) is performed once the patient is stable, and therapies such as adrenaline injection, sclerotherapy agents, or variceal banding may be used.
What are common signs and treatments for portal hypertension in upper GI bleeding?
Signs of portal hypertension include liver function abnormalities and abdominal ultrasound findings. Treatment may involve endoscopic procedures like variceal banding for children over 10kg or 2 years old.
What does altered blood in the lower gastrointestinal tract indicate?
Maroon clots may indicate Meckel’s diverticulum or intestinal polyps, while haematochezia (fresh rectal blood) may suggest lower GI bleeding.
What is red currant jelly stool a sign of
Red currant jelly stool, mixed with mucus, is typically a sign of intussusception.
What is haemobilia and what causes it?
Haemobilia refers to blood in the bile, often caused by liver trauma, including birth trauma.
How do you differentiate blood-streaked stool from infectious diarrhoea?
Blood-streaked stool typically suggests anal canal or rectal issues, while infectious diarrhoea may have mixed blood within the stool.
What could intermittent, painful stool bleeding indicate?
Painful stool bleeding is often caused by a fissure in ano (anal fissure).
What does painless, intermittent bleeding with stool suggest?
Painless bleeding with stool is often associated with juvenile mucous retention polyps.
What causes protrusion of a mucosalized mass during stool passage?
Protrusion of a mucosalized mass can be due to rectal prolapse or a prolapsed rectal polyp.
What is the role of digital rectal examination in gastrointestinal bleeding?
Digital rectal examination helps assess for signs of anal fissures (blood on glove), rectal polyps, hard stool balls (constipation), and tenderness, which may suggest an anal fissure.
What are the indications for endoscopy in gastrointestinal bleeding?
Proctoscopy, sigmoidoscopy, or colonoscopy is used for polypectomy, mucosal biopsy (e.g., for inflammatory bowel disease), or evaluating polyps in cases of juvenile polyposis.
When is a double contrast study used in GI investigations?
A double contrast study may be used in juvenile polyposis to assess polyp burden, although it is rarely performed due to radiation risks and non-therapeutic nature.
What role does a nuclear medicine scan play in gastrointestinal bleeding?
A nuclear medicine scan is used to detect ectopic gastric mucosa, such as in suspected Meckel’s diverticulum or duplication cyst.
How does an angiogram help in GI bleeding cases?
An angiogram helps locate the source of bleeding, such as in liver trauma (hemobilia) or rare lesions like Dieulafoy lesion in the duodenum, and can guide embolization.
What stool investigations should be conducted in cases of gastrointestinal bleeding?
Stool investigations include microscopy for red and white cells (inflammation), parasites, stool culture (for EHEC, EIEC, salmonella, shigella, campylobacter), and faecal occult blood tests.
Altered blood/ clots passed per rectum/ Neonate
Enterocolitis (NEC, Hirschsprung’s disease)
Foregut duplication cysts (ectopic gastric mucosa)
Swallowed maternal blood
Altered blood/ clots passed per rectum: Toddler
Intussusception
Meckels diverticulum
Hirchsprung’s enterocolitis
Duplication cyst
Colonic polyp
Colitis: infectious e.g.
pseudomembranous (Cl
difficile)/ radiation:
oncology
Altered blood/ clots passed per rectum: older chid
- Intussusception (lead
point >3-5 years usually
pathological - Meckel’s diverticulum
- Duplication cyst
- Colonic polyp
- Colitis (infectious etc.)
- Inflammatory bowel
disease: Ulcerative colitis,
Crohn’s disease
