Gastro-intestinal Bleeding Flashcards
What is important when caring for children with gastrointestinal bleeding?
It requires knowledge of the many aetiologies and differentiating symptoms and signs. A detailed history and examination are necessary.
What are the two important differentiating factors in assessing gastrointestinal bleeding?
The patient’s age and the nature of the bleed.
How is gastrointestinal bleeding classified?
Bleeding from sites proximal to the DJ flexure is upper GI bleeding, while bleeding from below the DJ flexure is lower GI bleeding.
What are the typical signs of upper GI bleeding?
Upper GI bleeding typically presents with haematemesis (vomiting blood) or melena (black, tarry stools).
How does lower GI bleeding typically present?
Lower GI bleeding may present with bloody diarrhoea, haematochezia (bright red blood in stool), blood streaks, or clots mixed with stool.
What symptoms may indicate occult gastrointestinal bleeding?
Occult bleeding may present with fatigue, pallor, or anaemia.
What should be assessed in a child with gastrointestinal bleeding?
Efforts should be made to determine if the child is actively bleeding, considering factors like swallowed maternal blood, coloured foods, or medications that can be misleading.
How can swallowed maternal blood be differentiated in a child?
Swallowed maternal blood can be differentiated using the APT test.
What should be examined if blood from the nasal mucosa is suspected?
The oropharynx, nasopharynx, and nares should be examined as blood from the nasal mucosa can be swallowed.
What is the first step in managing unstable patients with gastrointestinal bleeding?
Unstable patients require urgent resuscitation according to APLS (Advanced Pediatric Life Support) guidelines.
How should diagnostic tests and therapeutic interventions be guided?
The urgency of diagnostic tests and interventions will be guided by the child’s condition and their response to resuscitation.
How should small bleeds without haemodynamic instability or abdominal signs be managed?
Small bleeds without haemodynamic instability or abdominal signs are usually not life-threatening, and investigations can be planned and executed systematically.
What should be inquired about during the history of a child with gastrointestinal bleeding?
Enquire about:
• Previous nosebleeds
• Blood in vomitus or stool
• Colour of the bleed/stool
• Location of blood in stool
• Time, duration, and previous history
• Amount of blood
• Bleeding disorders
• Liver disease, varices, medication
• Dysphagia, dyspeptic symptoms, abdominal pain
• Fever, weight loss, irritability
What should be examined in a child with gastrointestinal bleeding?
Examinations should assess:
• Vital signs, mental status
• Skin colour, capillary refill
• Bruising or jaundice
• Abdominal distension, tenderness, veins, or masses
• Rectal/perianal examination
What are the common causes of upper gastrointestinal bleeding in newborns (<1 month)?
Common causes in newborns include swallowed blood.
What are the common causes of upper gastrointestinal bleeding in infants (1 month – 2 years)?
Common causes in infants include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, and varices.
What are the common causes of upper gastrointestinal bleeding in preschool-aged children (2 – 5 years)?
Common causes in preschool-aged children include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, and Dieulofoy’s lesion.
What are the common causes of upper gastrointestinal bleeding in school-aged children (>5 years)?
Common causes in school-aged children include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, and Dieulofoy’s lesion.
What are some causes of upper gastrointestinal bleeding specific to certain age groups?
• Newborns (<1 month): Swallowed blood
• Infants (1 month – 2 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices
• Preschool (2 – 5 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, Dieulofoy’s lesion
• School age (>5 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, Dieulofoy’s lesion
What are some causes of upper gastrointestinal bleeding that may occur across multiple age groups?
Causes that may occur across multiple age groups include oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, and varices.
What are some causes of upper gastrointestinal bleeding specific to older children or adults?
Causes like congenital malformations, intestinal duplication, coagulopathy, liver disease, haemangiomas, and Dieulofoy’s lesion may occur in specific age groups but are less common in younger children.
What are the common causes of lower gastrointestinal bleeding in newborns (<1 month)?
Common causes in newborns include swallowed blood and necrotizing enterocolitis.
What are the common causes of lower gastrointestinal bleeding in infants (1 month – 2 years)?
Common causes in infants include allergic enteritis, necrotizing enterocolitis, malrotation with volvulus, intussusception, Meckel’s diverticulum, AVM’s, and infectious colitis.
What are the common causes of lower gastrointestinal bleeding in preschool-aged children (2 – 5 years)?
Common causes in preschool-aged children include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, and inflammatory bowel disease.
What are the common causes of lower gastrointestinal bleeding in school-aged children (>5 years)?
Common causes in school-aged children include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, and inflammatory bowel disease.
What are some causes of lower gastrointestinal bleeding specific to certain age groups?
• Newborns (<1 month): Swallowed blood, necrotizing enterocolitis
• Infants (1 month – 2 years): Necrotizing enterocolitis, malrotation with volvulus, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis
• Preschool (2 – 5 years): Intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, inflammatory bowel disease
• School age (>5 years): Intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, inflammatory bowel disease
What are some causes of lower gastrointestinal bleeding that may occur across multiple age groups?
Causes that may occur across multiple age groups include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, and juvenile polyps.
What are some causes of lower gastrointestinal bleeding specific to older children or adults?
Causes like Hirschsprung’s enteritis, coagulopathy, liver disease, anal fissure, intestinal duplication, and inflammatory bowel disease may be more common in older children or adults.
How are investigations for gastrointestinal bleeding directed?
Investigations are guided by the patient’s state, demographics, nature of the bleed, and examination findings.
What investigations should be done for patients with signs of liver disease?
A full blood profile, including a full blood count, clotting investigations, liver function tests, electrolytes, and renal function should be conducted.
What is the investigation of choice for upper gastrointestinal bleeding?
Oesophagogastroduodenoscopy is the investigation of choice for upper GI bleeding as it allows for both diagnosis and treatment of some conditions.
When should upper gastrointestinal endoscopy be performed?
Upper GI endoscopy is required in cases of liver disease, and in patients with epigastric pain, coffee ground vomiting, or melena stools.
What is the first step in diagnosing a neonatal patient with abdominal distension and blood per rectum?
Neonates with these symptoms may require an x-ray to diagnose necrotizing enterocolitis (NEC).
When is colonoscopy useful in cases of lower gastrointestinal bleeding?
Colonoscopy is useful in patients with frank fresh red blood or ongoing bloody diarrhoea to assess for polyps, inflammatory bowel disease, or infective or allergic colitis.
What is the appropriate investigation for a child with painful constipated stools and red blood on the outside of the stool?
An examination under anaesthetic is more appropriate to confirm an anal fissure in such a case.
How should a child in the 6 to 18-month group, with a history of viral infection or gastroenteritis, and a sausage-shaped abdominal mass be investigated?
An ultrasound should be performed to rule out intussusception.
What investigation may be indicated for a patient with maroon-coloured PR bleeding and a normal colonoscopy?
A Meckel’s scan may be indicated for such patients.
What investigations may be required for patients with occult blood in the stool?
Both upper and lower GI endoscopy may be required to find the cause of occult blood in the stool.
What is the general management approach for patients presenting with gastrointestinal bleeding?
The management focuses on restoring haemodynamic status, raising haemoglobin with haematinics or transfusion if needed, and managing the underlying condition.
How is gastritis or oesophagitis treated in patients with gastrointestinal bleeding?
Gastritis or oesophagitis is treated with a proton pump inhibitor (PPI), and investigations and management of underlying gastro-oesophageal reflux disease (GORD) and Helicobacter pylori are also required.
How are bleeding gastric or duodenal ulcers managed?
Bleeding gastric or duodenal ulcers are managed with IV proton pump inhibitors and may require injection of the bleeder with vasoconstrictors.
How is portal hypertension managed in patients with gastrointestinal bleeding?
Management of portal hypertension may include banding or injection sclerotherapy, progressing to a Sengstaken-Blakemore tube for life-threatening bleeds, along with beta blockers and Octreotide to reduce portal pressure. In severe cases, porto-systemic shunting or liver transplantation may be required.
How is intussusception managed in patients with gastrointestinal bleeding?
Patients with intussusception undergo air reduction or surgical correction as discussed in the relevant section.
What is the management for isolated colonic polyps in children?
Isolated colonic polyps, usually hamartomas, are not premalignant and can be snared endoscopically.
How are polyps related to familial polyposis syndromes managed?
Polyps related to familial polyposis syndromes have their own management algorithms and should be referred to specialist centres for lifelong follow-up.
What is the most common cause of lower GI bleeding in all ages, and how is it managed?
Fissure in ano is the most common cause of lower GI bleeding. Management includes breaking the vicious cycle of stool withholding by using stool softeners, anti-constipation diets, a stooling routine, and topical local anaesthetic mixed with topical isosorbide mononitrate or calcium channel blockers to relieve anal spasm and improve blood flow for healing.
What is the common cause of painless bleeding with stools in children, and how is it managed?
Painless bleeding with stools is often caused by a juvenile “mucous retention” polyp. Treatment involves addressing associated constipation with stool softeners and diet modification. Polyps may be snared on sigmoidoscopy or colonoscopy, and biopsies should be taken if there are more than five polyps or a family history of polyposis.
How is a prolapsed rectal polyp managed?
A prolapsed rectal polyp, which looks like a “red cherry,” is often mistaken for haemorrhoids (rare in children). Management involves reducing the polyp and buttock strapping along with stool softeners. Sclerotherapy is used if it recurs or persists for more than three months despite treatment, and rectopexy may be necessary for severe, refractory cases.
How is rectal prolapse treated in children?
Rectal prolapse, which may be mucosal or full-thickness, is managed conservatively with reduction, buttock strapping, and stool softeners, or resolution of diarrhoea. If recurrent and lasting more than three months, sclerotherapy is used, and rectopexy is considered for severe cases.
How do you distinguish between rectal prolapse and rectal prolapse due to intussusception?
Rectal prolapse due to intussusception can be distinguished by a side-wards curl (can form a “pigtail” twist), the ability to pass an examining finger between the mass and rectal wall, and associated vomiting (usually bilious) and palpable abdominal mass. Management involves addressing bowel obstruction.
