HEMATOCHEZIA

Question 1

Approach to the Critical GI Bleed

Answer 1

If unstable assume GI upper GI bleeding OR bleeding from Meckel’s Diverticulum

AIRWAY
NG Tube to Suction
Consider ET Tube

BREATHING
Consider pRBC if saturations are low

CIRCULATION
20 ml / kg bolus of NS IV

Stat CBC, PT / PTT, Type & Screen

Bedside POCUS to assess for IVC volume

If Hgb < 8 and patient is symptomatic OR active bleeding with a normal Hgb, transfuse pRBC 10 mL / kg for patients < 25 kg OR 1-2 units over 1-2 hr

Massive GI Bleed: Massive Transfusion Protocol
If 4 U pRBC: 1 U FFP
1 U Platelets if < 50,000
INR > 2 transfuse 1 U / 10 kg Cryoprecipitate

Pantoprazole 1 mg / kg loading dose (max 80 mg) over 30 min followed by 0.1 mg / kg / hr (max 8 mg / hr) for 72 hrs

If Variceal:

Octreotide 1 ug / kg IV bolus (max 50 ug) followed by 1 ug / kg / hr infusion

Cetriaxone 50 mg / kg q 24 h for children, 2 g for adult sized patients

STAT GI or Surgical Consult

Question 2

History & Physical

Answer 2

Ask About:

Acute vs. Chronic (> 3 days)

Stool description

Timing:

Local trauma

Foreign Body Ingestion

Caustic Ingestion / New Drugs / Heavy EtoH

Ingestions of beets, copious food colouring

Infectious symptons / recent sick contacts / recent travel / recent food exposures

Associations:
Fever
Weight loss
Fatigue
Dyspnea on Exertion
Hematemesis
Nose Bleed
Abdominal Pain
Tenesmus
Diarrhea / Bloody Diarrhea
Nighttime Stooling
Hematuria
Rashes

History of liver dz, CHF, IBD, bleeding diathesis, ho intestinal surgery

Family History of GI Chron’s / Ulcerative Colitis

Medications: antithrombotics, NSAIDs, steroids

Look for:
Tachycardia
Hypotension
Pallor
Cap Refill
Petechiae / Bruising
Jaundice
Abdominal Tenderness
Anal Fissures, Fistulae, Hemorrhoids, Hard Stool
Check for hemoccult

Question 3

Investigations

Answer 3

CBC
Blood Type and Crossmatch
Coagulation Profile
Lactate
Stool Hemoccult

CT Angio
NG to suction

Question 4

Urgent DDx

Answer 4

Upper GI Bleed

Vascular Malformation

Intussusception

Meckel’s Diverticulum

Hemolytic Uremic
Syndrome

Typhlitis or Graft Vs. Host Dz if undergoing Chemotherapy or Stem Cell Transplant

Anastomotic Ulceration or Watershed Ischemia if recent GI Surgery

Question 5

Most Common DDx

Answer 5

Anal Fissures
Allergic Colitis / Protein Allergy
Enteric Infections
Juvenile Polyps

Question 6

DDx: Hematochezia with Abdominal Pain

Answer 6

Henoch-Schonlein Purpura
HUS
Infectious Acute Gastreenteritis
Inflammatory Bowel Disease
Intussusception
Necrotizing Enterocolitis

Question 7

DDx: Painless Hematochezia

Answer 7

Allergic Colitis / Milk Protein Allergy
Meckel’s
AVM