Mommy, the toilet’s red!!

James Markowitz, MDDivision of Pediatric Gastroenterology

Cohen Children’s Medical Center of NYNew Hyde Park, NY

Objectives

• Definitions• Quick Cases

o Differential Diagnoseso Evaluation

• Treatment

Important Definitions

Hematochezia – passage of bright or dark red blood per rectum• in general, the redder the blood, the more distal the site

of bleeding

Melena – the passage of black, tarry stools• indicates likely UGI bleed (proximal to the ligament of

Treitz)

Hemetemesis – vomitus containing frank blood or brown-black “coffee grounds”

Red Emesis Does Not Always Mean an Upper GI Bleed!

• Nose bleed• Tooth extraction• Throat laceration• Hemoptysis• Food coloring

Not Every Red or Black Stool Contains Blood!

Common Materials Masquerading as Blood

Red Stool• Food coloring• Beets• Phenophthalein

laxatives• Phenytoin• Rifampin• Pyridium

Black Stool• Bismuth• Activated charcoal• Iron• Spinach• Blueberries• Licorice

None of these materials causes a positive Guaiac reaction

The Likely Causes of GI Bleeding Differ at Varying Ages

Case 1• 6 yr old boy complains that “my poop is

red”o No previous episodes of red colored stoolso Healthy child, no underlying conditionso No pain, fever, systemic symptomso No recent illness, travelo No prescribed or OTC medicationso No family history GI disease

• PE:o VS: Pulse 120/min; BP 70/40; + orthostasiso Exam otherwise unremarkable

Case 1: Evaluation

• Stool Guaiac positive• CBC: Hgb 9 mg/dl Hct 27% Platelets 360k• BUN 25 Creatinine 1.0

Impression: 1.Red blood pr = likely hematochezia• Orthostatic, anemic = significant bleeding• Painless

Case 1 – Differential DxHematochezia in a Child

• Anal fissure• Juvenile polyp• Nodular lymphoid hyperplasia• Infectious colitis• Hemolytic uremic syndrome• Inflammatory bowel disease• Intussusception• Henoch-Schonlein purpura• Meckel’s diverticulum• Intestinal duplication• Vascular malformations• Neutropenic colitis

FIGURE 59.8. Meckel Diverticulum. A small focus (arrow) of technetium-99-pertechnetate uptake gradually becomes visible in the ectopic gastric mucosa of a Meckel diverticulum in the midabdomen.

http://www.msdlatinamerica.com/ebooks/FundamentalsofDiagnosticRadiology/sid613328.html

Meckel Scan• Technetium-99-

pertechnetate• Concentrates in gastric

mucosa• Premedicate with H2

blocker to enhance uptake and minimize risk of stomach or bleeding obscuring the diverticulum

• Can also identify duplications

ONLY 50% OF PROVEN MECKEL’S HAVE A POSITIVE

SCAN

Case 1b• 6 yr old boy complains that “my poop is

red”o Healthy child, no underlying conditionso No pain, fever, systemic symptomso No recent illness, travelo No prescribed or OTC medicationso No family history GI disease

• PE:o VS: Pulse 100/min; BP 70/40; no orthostasiso Exam unremarkable

80 80/50

Case 1b: Evaluation• Stool Guaiac positive

• CBC: Hgb 9 mg/dl Hct 27% Platelets 360k

• BUN 25 Creatinine 1.0

12 36

5 0.6

Case 1 – Differential DxHematochezia in a Child

• Anal fissure• Juvenile polyp• Nodular lymphoid hyperplasia• Infectious colitis• Hemolytic uremic syndrome• Inflammatory bowel disease• Intussusception• Henoch-Schonlein purpura• Meckel’s diverticulum• Intestinal duplication• Vascular malformations• Neutropenic colitis

Juvenile Polyp

• May be single or a few, located throughout the colon; virtually always benign

• Occasionally multiple (juvenile poyposis coli)o In JPC, may have potential for adenomatous change

• Diagnosis: Colonoscopy• Treatment: Endoscopic Polypectomy

Case 1c – Painful hematochezia in the Child

• 6 yr old boy – Red blood in the stoolo Previously healthyo Cramps, vomiting (nonbloody)o Loose, stools mixed with blood and mucus

Case 1c – Differential DxPainful Hematochezia in a Child• Anal fissure• Juvenile polyp• Nodular lymphoid hyperplasia• Infectious colitis• Hemolytic uremic syndrome• Inflammatory bowel disease• Intussusception• Henoch-Schonlein purpura• Meckel’s diverticulum• Intestinal duplication• Vascular malformations• Neutropenic colitis

Infectious Enterocolitis• Bacterial infections

o Salmonella, Shigella, Campylobacter, E colio C. difficile – may not have clearcut history of

antibiotic exposure• Viral infections - only CMV in the

immunocompromised host• Parasitic - amebiasis

Inflammatory Bowel Disease• Both Crohn’s and UC can present with

bloody diarrhea• Exclude infectious causes before initiating

invasive diagnostic procedureso CT evidence of diffuse or segmental bowel

inflammation does not preclude an infectious etiology

Intussusception

Case 2: Painless Hematochezia in the Adolescent

• 17 year old girl with streaks of BRBPRo Healthy adolescent; not sexually activeo No weight loss, systemic symptomso Menses regularo Solid BM qod; not hard or largeo No prescription or OTC meds

• PE: Healthy appearing, VS normalo Normal abdominal examinationo No anal fissure or other perianal lesiono Normal sphincter tone, empty rectum, no

mass, secretions Guaiac positive

Case 2: Evaluation

• Stool Guaiac positive

• CBC: Hgb 12 mg/dl Hct 36% Platelets 285k

• BUN 8 Creatinine 1.0

Impression: Painless hematochezia

Case 2- Differential DiagnosisHematochezia in the

Adolescent• Anal fissure• Infectious colitis• Inflammatory bowel disease• Meckel’s diverticulum• Polyps• Intestinal duplication• Neutropenic colitis• Hemorrhoids

Proctitis/Proctosigmoiditis

• Most common presentation of colitis in adults• Typically, painless hematochezia is only symptom

o Tenesmus often mistaken for constipation• Laboratory evaluation often entirely normal

Anal Lesions

• Hemorrhoids are extremely uncommon in the child and adolescent

• Fleshy rather than vascular lesions should raise the suspicion of Crohn’s disease

External hemorrhoids Crohn’s anal tags

Polyps

• Polyps are unusual in adolescents• May indicate a polyposis syndrome, often malignant

o Familial Adenomatous Polyposis (FAP)o Hereditary Nonpolyposis Colon Cancer Syndrome

(HNPCC)

Case 3 – Hematochezia in the Infant• 6 week old girl with streaks of bright red

blood per rectumo Full term, no neonatal problemso Breast fed x 2 weeks but changed to intact

milk protein formula due to “constipation”o At 4 weeks, developed streaks of blood in

mucusy stool that persisted with change to casein hydrolysate formula

o Poor intake on all feeds except breast milk (“She didn’t like the taste”), and gained weight poorly

Case 3: Evaluation

• PE: Irritable but consolableo Temp 38o; other VS normal for ageo Weight 50% at birth → 25% nowo Benign abdomen, normal perineal anatomy

• Labs:o Guaiac positive

Case 3: Differential DxHematochezia in infants

• Dietary protein “allergy”

• Bacterial colitis

• NEC

• Hirschsprung’s enterocolitis

• Malrotation with volvulus

• Intestinal duplication

• Vascular malformation

• Vitamin K deficiency

• Maternal ITP• Maternal NSAID use

Primarily in newborn

X

X

X

Significant systemic toxicity

±

X

X

X

X

±

X

Milk Protein Allergy• Presentations

o Hematochezia – usually in first 3 months of life Diarrhea, irritability, ± poor weight gain

o Hypoalbuminemia, anasarcao “GE reflux”

• Labso Variable eosinophilia in blood and biopsyo Skin prick, RAST testing negative

• Treatmento Casein hydrolysate or amino acid based formula

Case 3b• 6 week old girl with streaks of bright red

blood per rectumo Full term, no neonatal problemso Breast fed x 2 weeks but changed to intact

milk protein formula due to “constipation”o At 4 weeks, developed streaks of blood in

mucusy stool, that persisted with change to casein hydrolysate formula

o Poor intake on all feeds except breast milk (“She didn’t like the taste”), and gained weight poorly

Case 3b: Evaluation

• PE: Irritable but consolableo Temp 38o; other VS normal for ageo Weight 50% at birth → 10% nowo Benign abdomen, normal perineal anatomy

• Labs:o Guaiac positiveo WBC 25k, Hgb 10, Plt 350k, Albumin 2.8

TachycardicHypotensive

Distended, firm tender

Case 3b: Differential DxHematochezia in infants

• Dietary protein “allergy”

• Bacterial colitis

• NEC

• Hirschsprung’s enterocolitis

• Malrotation with volvulus

• Intestinal duplication

• Vascular malformation

• Vitamin K deficiency

• Hemophilia

• Maternal ITP• Maternal NSAID use

Primarily in newborn

X

X

Significant systemic toxicity

±

X

X

X

X

±

X

Surgical Emergencies with Lower GI Bleeding

Malrotation and Volvulus

Hirschprung’s• Bloody stool

portends enterocolitis• May be mimicked by

severe GI allergy

Case 4• 18 year old male with episode of coffee ground

emesiso Graduated from high school 1 week before

Denied alcohol or NSAID useo 1 month history of postprandial epigastric paino Emigrated from Italy at 5 years of ageo Mother had recurrent ulcers as a young woman

• PE: Mildly dehydrated, minimally tender in epigastrium, no stigmata of chronic liver disease

• Labs: Hgb 10 Hct 30% Normal LFTs

Case 4: Differential DxHemetemesis/Melena

• Esophagitis• Gastritis (H. pylori)• Gastric/duodenal ulcer (H. pylori)• Mallory Weiss tear• Esophageal varices• Portal hypertensive gastropathy• Pill induced ulcers

o NSAIDs• Alcohol

Case 4: Evaluation

• Esophagogastroduodenoscopyo Diagnostico Potentially therapeutic

NSAIDs

Hemorrhagic Gastritis Duodenal Ulcer

Rx: 1. Supportive care2. Acid suppression (H2 blocker or PPI)

Reflux esophagitis

Rx: 1. Acid suppression (PPI)2. ? Prokinetic (eg metoclopramide)3. ? Fundoplication

Helicobacter pylori

Antral nodularity Duodenal ulcer

H. pylori• At least 50% of individuals is the world are

thought to be infectedo Frequency: developing > developed worldo Prevalence increased in areas of the world with

lower standard of living, increased population density

o Infection acquired at all ages• Therapy

o Triple therapy: PPI + 2 antibiotics (e.g. metronidazole, clarithromycin)

o Quadruple therapy: PPI + 2 antibiotics + bismuth

Case 5• 5 yr old male with 3 large, foul smelling,

tarry stoolso Ex-28 week premature infant, NICU x 4 weeks

• PE: o Mildly dehydratedo Liver not palpable, span ~6 cmo Spleen tip palpable 2 cm below left costal margino Anicteric, few petechiae

Case 5: Evaluation

• Labso WBC 2.2; Hgb 8 g/dl; Hct 24%; Plts 60Ko LFTs nl

Impression: 1. Acute upper GI bleed 2. Likely portal hypertension with hypersplenism

Case 5 – Differential Dx

Hemetemesis/Melena in a Child• Esophagitis• Gastritis (H. pylori)• Gastric/duodenal ulcer (H. pylori)• Mallory Weiss tear• Esophageal varices• Portal hypertensive gastropathy• Pill induced esophagitis

Esophageal Varices

Vascular Anatomy of Portal Hypertension

www.bio.ri.ccf.org

Portal Hypertension

• Intrahepatic (e.g. cirrhosis)• Post-sinusoidal

o Budd Chiari syndrome (hepatic vein thrombosis)• Presinusoidal

o Splenic vein thrombosiso Cavernous transformation of the portal vein

Sclerotherapy Band Ligation

Endoscopic Therapy for Varices

Case 6 -

• One day old full term male with bloody emesiso Unremarkable pregnancyo Complicated delivery: Apgars 4 and 8o Breast feeding, but taking poorly

• PE: o WD WN, weight appropriate for gestational ageo Anicteric, normal abdominal exam

Case 6 – Differential DiagnosisHemetemesis/Melena in the Infant

• Swallowed maternal blood• Stress gastritis• Intestinal duplication• Vascular malformation• Vitamin K deficiency• Hemophilia• Maternal ITP• Maternal NSAID use

Case 6 - Evaluation

• Apt test • Esophagogastroduodenoscopy

• Treatment: oSupportive careoH2 blocker

Hemorrhagic “stress” gastritis

Emergency Management of GI Bleeding: Overall Approach

• Assess hemodynamic status and stabilize as necessary

• Determine upper vs lower GI bleed

• Establish differential diagnosis

Clinical Assessment• Appearance of the patient

o Worrisome signs: pallor, diaphoresis, restlessness, lethargy, abdominal pain

• Hemodynamic status of the patiento tachycardia, hypotension, shock?o orthostatic changes in heart rate and blood pressure?

Drop of 10 mmHg or more in systolic BP and/or an increase of ≥20 beats/min in pulse when moved from supine to sitting

• Character of the bleeding• Estimate volume of blood lost• Hematocrit

o Remember: With an acute bleed, Hct will not drop significantly until intravascular volume is repleted!

Stabilize the Patient (1)

• Insert the largest bore IV catheter possible: the r4 factor

• A two-fold increase in IV radius augments flow by 16-fold

• A four-fold increase in IV radius augments flow by 256-fold

Stabilize the Patient (2)• Volume expand as necessary

o Crystalloids for initial volume expansiono PRBC for oxygen carrying capacityo Fresh frozen plasma

• Vasopressors as necessary• Initial laboratory studies

o Type and cross matcho CBC with plateletso PT/PTTo Comprehensive metabolic panel

Pharmacologic Agents• Ranitidine: H2-receptor antagonist

o Bolus infusion: 3-5 mg/kg/day divided q8ho Continuous infusion: 1 mg/kg bolus followed by

infusion of 2-4 mg/kg/day• Pantoprazole: proton pump inhibitor

o Children < 40 kg: 0.5-1 mg/kg IV qdo Children > 40 kg: 20-40 mg IV qd

• Octreotideo Decreases portal pressure by decreasing splanchnic

blood flowo Loading dose: 1 μg/kg bolus (maximum of 50 μg)o Continuous infusion of 1 μg/kg/hour; can be

increased gradually to 4 μg/kg/hour

Upper vs Lower GI Bleed: Role of Nasogastric Lavage

• Diagnostic: Establishes UGI bleed• Room temperature saline, not iced

o Iced saline may induce mucosal ischemia and worsen bleeding

• Lavage may reduce clots, allowing better visualization at endoscopy

• Lavage may remove clots, preventing hemostasis

Indications for Endoscopic AssessmentTest Indication

EGDHemetemesis, Melena

Sigmoidoscopy/Colonoscopy Hematochezia

Small bowel enteroscopy Occult GI bleeding

Video capsule endoscopy Occult GI bleeding

Therapeutic Endoscopic Interventions

For varices• Sclerotherapy

o Sodium morrhuateo Sodium tertadecyl

sulfate• Band ligation

For Mucosal Lesions• Injection therapy

o Epinephrine• Coagulation

o Heater probeo Bipolar probeo Laser

• Mechanicalo Hemoclipo Banding

Additional therapies to be considered when endoscopic techniques fail

• Angiographyo Embolizationo Selective vasopressin infusion

• Surgery

ALWAYS INVOLVE THE SURGEON EARLY IN THE COURSE OF

MANAGING A SEVERE GI BLEED