The Child with Gastrointestinal Bleeding

Question 1

What is the rule of twos re: Meckel’s diverticulum?

Answer 1

• 2 feet from IC valve, 2 cm wide, 2% of the population, presents before 2, twice as likely to occur in boys

Question 2

What isthe pathophysiology of Meckel’s diverticulum?

Answer 2

• Incomplete obliteration of the vitelline duct
• Duct can contain ectopic gastric mucosal tissue (painless bleeding as it ulcerates) and can become obstructed
• Occurs on the anti-mesenteric border of the ileum about 40-60 cm from the ileocaecal valve

Question 3

What is the best modality for diagnosing a Meckel’s diverticulum? What is the definitive treatment?

Answer 3

• Scintigraphy (best if mucosal complications like bleeding)
• Ultrasound (best if anatomic complications i.e. obstruction)
• Surgical excision

Question 4

What is the general presentation of an infant with cows-milk protein proctitis?

Answer 4

• Generally healthy infant with blood-tinged stools and mucus

Question 5

Outline a management plan for a child with cow’s milk protein proctitis

Answer 5

• Investigations
  
  • Stool MCS - polymorphs
  • FOBT
• Dietary changes
  
  • Exclude dairy from maternal diet if breastfed
    
    • Then soy then egg if no response
  • Hydrolysed formula if formula-fed
  • Amino acid formula if no response
• Reintroduce milk at 1 year if FOBTs negative