Gib in Infancy and Childhood
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Transcript of Gib in Infancy and Childhood
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Intestinal bleeding in the
child
SURGICAL ASPECTS
Dr EW Muller
Block 8
2013
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Definition - UpperGIB (UGIB)
Bleeding proximal tothe ligament of
Treitz Source:
Oesophagus
Stomach
DuodenumLigament ofTreitz
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Bleeding is located distal to ligament of
Treitz Source: - Small bowel
- Colon
- Rectum
Definition - Lower GIB (LGIB)
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Relevant history in a bleeding child
Vomiting, diarrhoea, fever: Infectious cause
Recurrent forceful vomiting: Mallory - Weiss
Drugs: NSAIDS, tetracyclines, caustics or foreign
bodies: Damage of gastric mucosa
Jaundice, bruising, change in stool color: Liverdisease
Drugs and foods which might imitate bloodystools: Certain antibiotics, iron supplements,bismuth containing products
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Physical examination
Look for signs of shock: Heart rate, BP, capillaryrefill
Rule out epistaxis, nasal polyps, oropharyngeal
erosions or the lung as the source of bleeding Abdominal scars: What was reason for surgery?
Bowel sounds: Often hyperactive in upper GI
bleeding Abdominal tenderness: Intussusception,
Ischemia, Ulcer, Gastro-oesophageal reflux
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Physical examination
Hepatomegaly, splenomegaly, jaundice:Liver disease and portal hypertension
Inspection of the anal area: Fissures,fistulas, skin breakdown, trauma
Digital rectal examination: Polyps, masses
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Haematemesis Red blood + clots: ongoing bleeding Dark coffee-ground (denatured blood) vomitus:
Slow bleeding or bleeding has stopped No haematemesis if source of bleeding is in distal
duodenum
Melaena (= tarry black stools) passed
per rectum Melaena = Altered blood (oxidized haemoglobin)
after prolonged passage(>14 hours) throughbowel
CLINIC - UGIB
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CLINIC - LGIB
Haematochezia: Passage of bright redrectal blood on top or in stool: Source: Usually distal bowel, but:
Severe haemorrhage from oesophagus,stomach or duodenum can also causehaematochezia
Rectorrhagia: Passage of rectal blood,without stool: Source: rectum, anus
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RESUSCITATION
Assess the Location, high or low - Place NGT:Aspiration of blood: UGIB. Aspiration of bile withoutblood rules out UGIB.
Assess severity: Shock, haematemesis, ongoing
drainage of blood from NGT or rectum. Oxygen mask 2 good peripheral lines; Ringers lactate bolus
20ml/kg If bleeding continues: Blood 10 15 ml/kg; give
somatostatin analogue Urgent referral for therapeutic gastroscopy (UGIB) or
colonoscopy (LGIB), but Patient should be stabilisedfor transport
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COMMON CAUSES OF GIB INCHILDHOOD
Age Group UGIB LGIB
Neonates Haemorrhagic disease ofthe Newborn (Vit K)
Swallowed maternal blood
Stress Gastritis (ICU set up)
Necrotizing Enterocolitis(immature infants)
Anal fissure
Malrotation with volvulus
Infants 1month to1 year
Oesophagitis (Reflux)
Stress Gastritis
Anal fissure
Intussusception
Milk protein allergy
Infants 1 2years
Peptic Ulcer disease (HP -or non HP - related)
Gastritis
PolypsMeckel Diverticulum
Children olderthan 2 years
Oesophageal varices
Peptic Ulcer disease
Polyps
Inflammatory bowel disease
Infectious diarrhoea
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Necrotizing Enterocolitis (NEC)
Occurs in premature brittle newborns Aetiology: Bowel wall bacterial infection due to
immature mucosal barrier Immunoglobulins in breast milk protect against
NEC - Formula fed newborns are at risk Clinic: Sudden feeding intolerance in premature
baby: Abdominal distension, vomiting, sepsis,acidosis, shock
Diagnosis: Pneumatosis intestinalis on AXR Treatment: NPO, Antibiotics, parenteral feeds. If
necrotic bowel or perforation: Operation
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Anal fissure
History of painful passage of bright red
blood which is not mixed with stool Baby usually in good condition
Sometimes associated with constipation
Rectal examination: Small very painfulanal tear visible, +/- hard stool
Treatment: Stool softeners, wait and see
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Polyps in Children
2 types: Hamartomas (common) and adenomas (rare)
Present with painless red bleeding or can protrudethrough anus
Usually in distal colon
Hamartomas: Sporadic, single: with no malignantpotential; also called hyperplastic polyps
Adenomas associated with familial polyposis syndrome,
high cancer risk: Colectomy in early adolescencerequired
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Familial adenomatous polyposis coli
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Meckels Diverticulum
Embryology: Remnant of omphalo-mesenteric duct
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MeckelsDiverticulum
Located in terminal
ileum, 60 70 cm
proximal to ileocolic
juntion
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Meckels Diverticulum
Complications associated withectopic gastric tissue:
Ulceration, perforation, bowel
obstruction Bleeding (most common
complication): usually painless, can be
massive, transfusion often necessary
Treatment: Must be surgically excised
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Meckels Diverticulum: Diagnosis
Technetium Scan
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Intussusception
Condition where the proximal bowel moves into
the distal bowel like an inverted sock
Proximal bowel = Intussusceptum
Distal bowel = Intussuscipiens
Intussusception can be ileo-ileal, ileo-colonic (by
far the most common presentation) or colo-
colonic The intussusceptum might even protrude
through the anus mimicking a rectal prolapse
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Intussusception: Pathophysiology
Caused by lead point which is pulled into thelumen by peristalsis
Age group 5 9 months: lead point caused by
enlarged bowel lymphoid tissue (Peyersplaques) following viral infection: this is by farthe most common reason for intussusception
Older age group: Lead point might be Meckels
diverticulum, polyps, lymphoma, worms or otherforeign bodies
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Intussusception: symptoms
Well fed baby who might have a history of
recent upper respiratory tract infection or
gastro-enteritis
Bloody, slimy stool (red currant jelly stool)
Signs of bowel obstruction (vomiting,
abdominal distension)
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Intussusception: Signs
The child might be dehydrated
Abdominal tenderness
A sausage-shaped mass can often bepalpated in the region of the colon
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Intussusception: Special
investigations
Biochemistry: Electrolyte disturbances and
high urea in case of dehydration due to
vomiting
AXR: Multiple air fluid levels indicating
bowel obstruction. Mass effect in the
region of the colon. No air in colon. Free
air if perforation
Sonar: Imaging of choice: Mass visible
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Intussusception: Management
Nil per os, nasogastric tube, iv fluids (rehydrationand maintenance)
Pneumatic reduction should be attempted if Child fully resuscitated
Abdomen without peritonitis No free air on AXR
Laparatomy If pneumatic reduction is contraindicated
If pneumatic reduction has failed Intraoperatively: Trial of manual reduction. If this
maneuver fails: Resection of intussusception andprimary anastomosis.