Gastrointestinal bleeding in children -...
Transcript of Gastrointestinal bleeding in children -...
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Gastrointestinal bleeding
in children
รศ.นพ.เสกสิต โอสถากุลภาควชิากุมารเวชศาสตร ์ คณะแพทยศาสตร์
มหาวทิยาลยัสงขลานครนิทร์
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Gastrointestinal bleeding
Upper
Lower
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Upper GI bleeding (UGIB)
Bleeding from any point in the GI tract from the mouth to the Ligament of Treitz in the distal duodenum.
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Clinical presentations
UGIB
Hematemesis(vomiting of
blood or coffee
ground-like
material)
Hematochezia(Grossly bright
or dark red
bloody stools)
Melena
Anemia(Occult
bleeding)
LGIB
Bright red
blood mixed or
coating normalstool
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Is It Blood ?Conditions mistaken for blood in the stool
Squires RH, Pediatr Rev 1999.
Melena• Iron preparations
• Blueberries
• Beets
• Lead
• Dirt
Hematochezia• Menstruation
• Commercial dyes
• Licorice
• Spinach
• Bismuth (eg, Pepto-Bismol)
• Charcoal
• Swallowed non-human blood
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Occult bleeding
Diagnosed by fecal occult blood test
– Guaiac test
– Heme - porphyrin
– Immuno - chemical
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เด็กชายไทยอายุ 1 ปี
3 วนักอ่นมารพ. ถา่ยอุจจาระปนเลอืดสีแดงคล า้ ประมาณ ¼ แก้ว ไมม่ไีข้ ไมอ่าเจยีน ท้องไมอ่ดื รกัษาทีค่ลนิกิ แพทยว์นิจิฉัย anal fissure รกัษาดว้ยยาระบาย ถา่ยอุจจาระนิ่มขึน้แตย่งัคงถา่ยเป็นเลอืดสีแดงคล า้ปรมิาณมากจนผู้ป่วยหน้าซดี จงึพามารพ.สงขลานครนิทร์ประวตัอิดตีและครอบครวั : บุตรคนแรก แข็งแรงดมีาตลอด
ปฏเิสธโรคภมูแิพ้ตรวจรา่งกาย : ซดีมาก ซมึเล็กน้อย น ้าหนกั 10 กก.
ความยาว 75 ซม. Vital signs ปกติabdomen - no hepatosplenomegaly,
normal
Otherwise - normal
Hct 20%
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How to differentiate upper from
lower GI bleeding
Clinical
NG-tube aspiration for diagnosis of UGIB for non-hematemesis
sensitivity 42-84%, specificity 54-91%, NPV 61-78%
BUN/Cr > 30 (spec. 98%, sens 68.8%)
Urashima M, et al. JPGN 1992;15:89-92.
Palamidessi N, et al. Acad Emerg Med 2010;17:126-31.
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Etiology of GI bleeding : UGIB
โรคทารกแรกเกดิ(0-1 เดอืน)
ทารก(1-12เดอืน)
วยักอ่นเรยีน(1-6 ปี)
วยัเรยีน(6-14 ปี)
Hemorrhagic disease of newborn
+
Gastritis + + + +
Reflux esophagitis + +
Peptic ulcer +
Esophageal varices + +
Mallory-Weiss tear + + + +
Vascular anomaly (angiodysplasia)
+ + +
Coagulopathy +
Milk-protien hypersensitivity(induced gastritis)
+ +
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Disease Newborn Infant Preschool School
NEC +
Cow milk protein allergy
+ +
Malrotation with vulvulus
+ +
Allergic proctocitis
+ +
Hirschsprung + +
Anal fissure + + +
Etiology of GI bleeding : LGIB
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Disease Infant Preschool School
Infectious colitis + + +
Intussusception +
Meckel diverticulum + +
Lymphonodular hyperplasia
+ +
Polyp + +
Henoch-Schonlein purpura
+ +
Inflammatory bowel disease
+
HUS +
Etiology of GI bleeding : LGIB
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How to identify the cause of
GI bleeding
Age group
Clinical
Investigation
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Differential cause of GI bleeding base on
clinical presentation
• Hematochezia, Melena: intestinal ischemia, intussusception, mid-
gut volvulus, Meckel diverticulum, vascular malformation, PU
• Rectal bleeding with signs of colitis: NEC, Infectious colitis,
eosinophilic proctocolitis, IBD
• Rectal bleeding with normal stool pattern: nodular lymphoid
hyperplasia, juvenile polyp, vascular malformation
• Bright red blood coating normal or hard stool: anal fissure,
solitary rectal ulcer, Internal hemorrhoids
• Occult GI blood loss: eosinophilic colitis, celiac disease, polyp,
Meckel diverticulum, vascular malformation, PU
• Hematemesis with massive fresh blood: ruptured EV, vascular
malformation, PU
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Associated clinical features to predict the cause of GI bleeding
HistoryNSAIDSevere vomiting followed by hematemesis ➙ Mallory-Weiss syndromeChronic dyspepia ➙ PU, reflux esophagitisDiarrhea ➙ Mucosal inflammation (IBD, colitis)
PESkin
Purpura ➙ Henoch - Schonlein vasculitisHyperpigmentation ➙ Peutz - Jegher syndromeHemangioma ➙ vascular malformation
Hepatosplenomegaly ➙ portal HTAnus ➙ anal fissure, Crohn’s disease (fistula, fissure, tags)
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Peutz-Jeghler syndrome Crohn’s disease
Henoch - Schonlein vasculitis
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Investigations in GI bleeding
Endoscopy
– Gastroscopy
– Colonoscopy
Radiologic study
– Plain film abdomen
– Scintigraphic studies Meckel’s scan
Tc-99m labeled red cells scan (rbc scan)
– Angiography
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Useful in diagnosis of mucosal and vascular lesions of the GI tract.
Generally recommended for children with acute severe hemorrhage requiring blood transfusions or with unexplained low grade persistent or recurrent bleeding.
Indications for early endoscopy in children are not standardized.
Endoscopy in GI bleeding
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Radiologic study
Type IndicationPlain film abdomen GI bleeding caused by gut obstructionMeckel’s scan Suspected of Meckel diverticulumRbc scan Diagnosis of obscure GI bleeding
(rates >0.1 mL/min)Grossly localized the site of bleeding
Angiography Diagnosis of GI bleeding (rate >0.5 mL/min)Diagnosis of vascular malformationAlternative to endoscopy for treatment of massive GI bleeding by embolisation of bleeding vessel
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the presence of ectopicgastric mucosa in the right
lower quadrant
Technetium-99m pertechnetate radionuclide scanning
Meckel’s Scan
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General management
1. Assessment of severity and likelihood of ongoing bleeding
Amount of blood loss, Vital signs,
CBC, Hct
2. Identify the cause
Clinical data (Age, Hx/PE)
Appropriate investigation
3. Treatment
Initial Rx to maintain vital signs
Medications for EV, non-EV bleeding
Definite
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Significant GI bleeding is mostly
confined to UGIB
1. Esophageal varices (EV) bleeding
2. Non-EV bleeding
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Initial management of EV bleeding
1. Assessment of severity Amount of blood loss Vital signs CBC, Hb
2. NPO3. Semi-sitting position4. Fluid resustiation to maintain BP5. Cross-matching and blood component transfusion
(avoid over transfusion)6. Vit K 5-10 mg IV7. Serial Hct8. Close observe monitoring9. Supportive treatment : Oxygen supplement
10. Medication
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Pharmacotherapy for initial management of UGIB in children
Acute variceal bleedingDrugs that act by reducing portal blood flow
VasopressinAction : V1 receptor stimulation ➙ splanchnic
vasoconstrictionDose : 0.002 - 0.005 U/kg/min to max 0.01 U/kg/min
Curr Gastroenterol Rep 2011;13:10-16.
Side effects : HT, ischmic bowel, limb gangrene, etc.Terlipressin (a vasopressin analogue)
A longer half-life than vasopressin and less side effectsNo data for use in children
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Drugs that act by reducing portal
blood flow
Octreotide (somatostatin analogues)
Action : inhibit the release of vasodilator glucagon
and a local vasoconstrictive effect
Dose : bolus 1-2 g/kg followed by 1-2 g/kg/hr and
maintained for 2-5 days
Side effects : hyperglycemia, steatorrhea
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1. Assessment of severity Amount of blood loss Vital signs CBC, Hb
2. NPO3. Fluid resustiation to maintain BP4. Cross-matching and blood component transfusion5. Close observe/serial Hct6. Retain NG tube in severe active bleeding7. Supportive treatment : Oxygen supplement8. Medication
Initial management of acute significantnon - EV bleeding
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Acute non-variceal bleeding
Drugs that act by inhibit acid secretion
Effects of gastric acid
Decreased platelet aggregation
Increased clot lysis and fibrinolytic activity
A pH of 6.0 - 6.5 is targeted to reverse these
effects
Pharmacotherapy for initial
management of UGIB in children
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H2-receptor antagonists are not efficacious in
suppression of gastric acid
Controlled studies in adults have shown no overall benefits of H2-receptor antagonists in patients with
peptic ulcer bleeding
Levine JE, et al. Aliment Pharmacol Ther 2002;16:1137-42.
Netzer P, et al. Am J Gastroenterol 1999;94:351-7.
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High dose of intravenous PPI in children
BW ≥ 40 mg : 80 mg IV. bolus and 8 mg/hr IV continuously
BW < 40 mg : 2 mg/kg IV. bolus and 0.2 mg/kg/h IV. continuously
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Endoscopic therapy for
upper GI bleeding
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Endoscopic hemostasis for
upper GI bleeding
Variceal bleeding
Non-variceal bleeding
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Sclerosing injection Rubber band ligation
Endoscopic hemostasis for variceal
bleedinging
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Endoscopic rubber band ligation
Band ligation is limited in young children (< 4 years)
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Endoscopic hemostasis for non-variceal
hemorrhage
Injection Mechanism– Adrenelin 1 : 10,000 Pressure effect,
vasoconstriction
– Absolute alcohol Dehydrated and coagulation
– Polidocanol (1-1.5%) Sclerosis
Coagulation– Heater probe Tamponade/Direct thermal
– Bipolar/Multipolar probe Tamponade/Electrical thermal
– Argon plasma coagulation Ionized gas thermal
Clipping– Endoclip Mechanical pressure
Banding– Endoloop Mechanical pressure
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Injection
Side effects depend on type of injection agents
Bowel ischemia
Perforation
Tachycardia, hypertension
Adrenelin injection combined with secondendoscopic hemostasis is recommended
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Thermocoagulation
Target lesion : bleeding peptic ulcer
Side effects : deep necrosis, perforation, delayed bleeding
Heater probeElectrocoagulation
Target lesion : vascular ectasias
Side effects : gaseous distension, pneumatosis intestinalis,
pneumoperitoneum
Argon plasma coagulation
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Mechanical hemostasis
Target lesion : bleeding peptic ulcer, Dieulafoy lesion, post
polypectomy bleeding prophylaxis
Side effects : rare
Endoclips Endoloop
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The choices of techniques for
endoscopic hemostasis depends on
the nature of bleeding lesion, the
availability of equipment and the
experience of endoscopist
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Case demonstration of
significant GIB
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Case 1 เด็กหญงิอายุ 5 ปี
ถา่ยเป็นเลอืดสดปรมิาณ ½ แก้ว 3 ครัง้ ไมม่อีาการปวดท้อง รกัษา รพ.ใกลบ้้าน ตรวจ Hct 23% ได้รบั PRC 2 ยูนิต แพทยส์งสัยโรค Meckel diverticulum จงึไปผา่ตดัแตพ่บวา่ปกต ิ จงึส่งตอ่มา รพ.สงขลานครนิทร์ประวตัอิืน่ ๆ และครอบครวั : บุตร 2/3 ไมม่โีรคประจ าตวั
ตรวจรา่งกาย : น ้าหนกั 15 กก., สูง 98.5 ซม., vital signs ปกติAbdomen – normal, no hepatosplenomegalyOtherwise – normalCBC, Coagulogram - WNL
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Case 1 Colonoscopy
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Case 2 เด็กชายไทยอายุ 12 ปี
3 ปีกอ่นมา รพ. อาเจยีนเป็นเลอืดด าปนแดง ปรมิาณ 2 แก้ว ประมาณ 3 ครัง้ และทุกครัง้ไดร้บัการรกัษาจากรพ.ใกลบ้า้นโดยการไดร้บัเลอืดและให้กลบับ้าน3 สัปดาหก์อ่นมารพ. อาเจยีนเป็นเลอืดสด ครัง้ละ 2 แก้ว 2 ครัง้ ซดี Hct 10% แพทยร์พ.ใกลบ้้านให้ PRC 2 unit แล้วส่งตวัมารพ.สงขลานครนิทร์ประวตัอิืน่ ๆ และครอบครวั : ปกติตรวจรา่งกาย : น ้าหนกั 34 กก, สูง 145 ซม. Vital signsปกติAbdomens - spleen 18 cm, below LCM, no hepatomegaly, no ascitesOther wises - normal
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Case 2 (cont.)
Problem 1. Significant hematemesis2. Splenomegaly
CBC : Hct 27 g/dL, WBC 1,060 (PMN 41%, L 40%, Mo 20%), plts 41,000
Coagulogram : normalLFT : TB/DB 0.8/0.2 g/dL, ALT/AST 50/40, ALK 250,
TP/Alb 6.5/3.8 g/dLImp : Extra hepatic venous obstruction with variceal
bleeding
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Case 2 (cont.)
ระหวา่ง admit ในรพ.สงขลานครนิทร ์ เพือ่รอ investigate ผู้ป่วยอาเจยีนเป็นเลอืดสด 400 มล.PE : Good concious, BP 110/70 mmHg, PR 100/min Hct 18%Initial treatment
1. NPO2. IV. Fluid3. PRC Hct 27%4. IV. Octreotide5. Gastroscopy
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Case 2 Gastroscopy
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Case 3 เด็กชายไทย อายุ 5 ปี
2 สัปดาหก์อ่นมารพ. มไีข้ต า่ ๆ อาเจยีนและปวดท้อง
9 วนัตอ่มา อาเจยีนเป็นเลอืดสด ถา่ยอุจจาระสีด าปรมิาณมากรกัษารพ.ใกลบ้้าน Hct 13% รกัษาโดยให้เลอืดและให้กลบับ้าน
1 วนั PTA อาเจยีนเป็นเลอืดสดปรมิาณมากจนซดี Hct 6%
ได้รบัเลอืดและถกูส่งตอ่มารพ.สงขลานครนิทร์ประวตัอิดตีและครอบครวั : Unremarkable
PE : รู้ตวัด ี ซดี BP 65/50, PR 140 เบาเร็ว, BW 20 kg
NG tube – coffee ground
ถา่ย melena ปรมิาณ 100 มล.ระหวา่งตรวจAbdomen normal
Otherwise normal
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CBC : Hct 8.7%, WBC 12,460 (PMN 70%, Lymph 26%, Eo 1%, Mono 3%, plts normal
Coagulogram normalInitial treatment
- fluid resusitate- PRC transfusion- Omeprazole 2 mg/kg/v bolus then 0.2 mg/kg/h iv.
continuously- emergency gastroscopy
Case 3 (cont.)
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Case 3 Gastroscopy
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SummaryGIB
UGIB LGIB
Hx, PENG tube aspiration
Refer
Not improved orunknown cause
Supportive RxRx accordingto the cause
Supportive RxHigh dose PPI
Supportive RxOctreotide IV
Portal HT
Severe Not severe
Non-portal HT
Refer
Supportive RxRx accordingto the cause
Not severeSevere
Supportive Rx
Hx, PE
Not improved orunknown cause
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Thank You