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Approach to GI BleedingSimon Lam
October 13, 2011
ACH Resident Academic Half Day
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Overview Case 1 and Case 2 Presentation History Physical Labs Classification DDx – UGIB Case 1 – Cont’d Initial Management DDx –LGIB Case 2 – Cont’d Case 3
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Case 1
A. S. - 23 mo male with GDD presents with “a cup” of bright red hematemsis
ABC stable S – No other symptx, no melena/hematochezia. A – No allergies M – Vit D and Iron supplements P – Ex 32 wk, had a UVC placed as neonate and 1
episode of CONS sepsis in NICU. L – Last meal 2 hours ago E – “Just happened all of a sudden”
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Case 2
2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting
ABC stable S – 2 day history of periumbilical pain A – No allergies M – Vit D P – Had severe reflux as an infant, resolved by 12
mos L – Last meal 2 hours ago E – Has had about 3 BM today, all full of blood.
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Presentation
Hematemesis Coffee ground emesis Melena stool Hematochezia Normal stools with blood Bloody Diarrhea
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History
Onset, duration, volume and associated symptoms
Colour of blood/emesis/stool Consistency of accompanying stool Blood coating or mixed into stool Hx of dyspepsia, heartburn, abdominal pain,
constipation, diarrhea or weight loss Hx of jaundice, easy bruising may suggest liver
disease Hx of NSAID use
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On Exam
ABC Vitals HEENT CVS RESP ABD
Must include DRE! GU
Worrisome Signs Pallor Diaphoresis Restlessness Increased HR Decreased BP Orthostatic changes
Increase HR 20 bpm Decrease BP 10
mmHg
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Labs CBC
Hct MCV Plts
Iron studies Creatinine Alb CRP/ESR ALT/AST INR/PTT Stool WBC, C+S,
O+P
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Guaiac Test
Used to confirm the presence of hemoglobin
False positives Ascrobic acid (Vit C) Animal
myoglobin/hemoglobin
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Apt Test
Differentiates maternal vs infant blood
Maternal = 2α2β Fetal/infant = 2α2γ NaOH will denature
maternal blood and not fetal/infant
Positive test = Pink
Negative test = Yellow/Brown
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Classification
Commonly classified based on location
Above Ligament of Treitz = UGBI
Below Ligament of Treitz = LGIB
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May try to pass NG into stomach and aspirate. If + blood, likely UGBI. However if negative, does not exclude UGBI
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Upper Gastrointestinal Bleed DDx
Swallowed blood Mallory-Weiss tear Variceals Gastritis* Peptic ulcer AV malformations
Hemangiomas Angiodysplasia Dieulafoy lesion
Hemobilia Vitamin K deficiency Thrombocytopenia
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Case 1
A. S. - 23 mo male with GDD presents with “a cup” of bright red hematemsis
ABC stable S – No other symptx, no melena/hematochezia. A – No allergies M – Vit D and Iron supplements P – Ex 32 wk, had a UVC placed as neonate and 1
episode of CONS sepsis in NICU. L – Last meal 2 hours ago E – “Just happened all of a sudden”
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On Exam
HR 150 BP 80/62 HEENT – No scleral icterus, mild conjunctival
pallor CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT
= 3 Resp – N Abd – Soft non tender. Spleen ~14cm below CM
on MCL. No hepatomegaly, No sigmata of chronic liver diease
MSK N CNS – Playful during exam
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Labs
Hb – 80 MCV 90 Plts -150
INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N
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DDx?
Sounds like UGBI Esophagel varicies Congestive
gastropathy Dieulafoy lesion Peptic ucler
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Initial Management
ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood,
FFP, Cryoprecipitate Proton Pump
Inhibitors Octreotide
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PPI Helpful for gastric
mucosal bleeds
Thought to decrease the activation of pepsinogen to pepsin which may degrade the fibrin clot
pH greater than 6 allow for better platelet aggregation
CHILDREN <40 kg: 2 mg/kg IV loading dose over 15 minutes 0.2 mg/kg/hour for
72 hours
CHILDREN ≥40 kg: 80 mg IV loading dose over 15 minutes 8 mg/hour for 72
hours
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Octreotide
Decreases splanchnic blood flow
Decreases bleeding from esophageal and gastric varices
S/E is hyperglycemia, angina, arrhythmias, and headache
1-2 mcg/kg (Max 50mcg) initial I.V. bolus followed by 1-2 mcg/kg/hour (max 50mcg/hr) one hour after loading dose continuous infusion
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Endoscopy Bleeding varicies Banding
Sclerotherapy – small percentage will have esophageal ulcerations leading to strictures
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Sengstaken-Blakemore tube
If unable to stablize, may need to use in PICU setting
Patient will to be sedated
ETT to secure airway Stabilize before
going into endoscopy
Consider angiography
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Swallowed Blood
Infant – Maternal blood Apt test
Child – epitaxis, recent dental extraction or tonsillectomy
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Mallory – Weiss Tear Repeated vomiting
or retching Acute mucosal
laceration of the gastroesophageal junction
Tx – Up to 50 – 80% stop before time of endoscopy Electrocoagulation,
heater-probe application, or sclerotherapy
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Gastritis
Diffuse Trauma Burn Surgery Severe medical
problems
Locailzed NSAID H. pylori EtOH Bezoar
Tx – Proton Pump Inhbitors, may need antibiotics in certain situations
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AV Malformation
Hemangiomas Angiodysplasia Dieulafoy lesion Tx – Endoscopy
Thermal ablation
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Lower Gastrointestinal Bleed
DDx Anal fissure Sloughed polyp Meckel’s
Diverticulum Vasculitis Vascular
malformation UGBI
Don’t want to miss Necrotizing
entercolitis Malrotation/
Volvulus Intussusception Incarcerated
hernia Hirschsprung
entercolitis
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Case 2
2 yo male presents with 1 day history of dark red “bloody diarrhea”. The diaper is full of blood and very little stool. No vomitting
ABC stable S – 2 day history of periumbilical pain A – No allergies M – Vit D P – Had severe reflux as an infant, resolved by 12
mos L – Last meal 2 hours ago E – Has had about 3 BM today, all full of blood.
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On Exam HR 150 BP 80/62 HEENT – No scleral
icterus, mild conjunctival pallor
CVS – S1S2 No S3S4, SEM noted, ppp, mmm, CRT = 3
Resp – N Abd – Soft, slightly
tender in RLQ with deep palpation. No masses. BRBPR on DRE
MSK N CNS – responsive to
exam
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DDx?
Meckel’s Diverticulum
Massive UGIB Malrotation with
Volvulus Intussusception
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Initial Management
ABCs 2 large bore IV O2 and monitors Type + Screen Crossmatch May consider Blood,
FFP, Cryoprecipitate
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Labs
Hb – 80 MCV 90 Plts -150
INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP - N
Normal AXR Normal Abd
Ultrasound Previously normal
barium swallow (done for reflux as infant)
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Meckel’s Diverticulum Remnant of the
omphalomesteric duct
Rule of 2s – 2% of population, 2% of affected become symptomatic, 50% present before the age of 2, 2 inches long and 2 feet from ileocecal valve
May contain acid secreting cells which erode the mesenteric side of lumen causing profuse bleeding
Tx – Surgical excision
Technetium 99 absorbed by gastric mucosa
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Anal Fissure
Usually associated with constipation or recent history of passing large stool
Painful defecation Spotting on toilet
paper Resolves with
regular soft stooling
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Sloughed Juvenile Polyp Intermittant painless
rectal bleeding Ages 1 – 10 Maybe bright red,
streaked on stools or mixed in
May get intermittent abdominal pain, colocolonic intussusception and prolapse through anal canal
Often out grow their vascular supply and will auto-amputate
May be seen in stool
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Vasculitis
Henoch Schonlein Purpura (HSP) IgA mediated small
vessel vasculitis affecting skin, kidney, GI tract and joints
May have guaiac postive stools
• Tx - Supportive
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Bloody Diarrhea - DDx
Infectious Ulcerative colitis Crohn’s disease Allergic colitis
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Infectious
Salmonella EHEC (O157:H7) Campylobacter Shigella Yersinia
C. Diff
Amox, TMP-SMX Supportive Erythromycin TMP - SMX Supportive, TMP-
SMX, aminoglycosides
Metronidazole or PO Vancomycin
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Inflammatory Bowel Disease
Crohn’s Disease Insidious, may
present with abdo pain, growth delay, delayed puberty
ASCA Transmural
inflammation Skip lesions,
Terminal Ileum involved 60%
Ulcerative colitis Presents with bloody
diarrhea and tenesmus
p-ANCA Mucosa inflammation Continuous Rectum involved and
progresses proximally
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Allergic Colitis Inflammatory
enteropathy caused by the ingestions of cow milk protein
Stools often loose with occult or frank blood present
Tx – Elimination diet Soy formula may
have up to 50% cross reactivity
Usually resolves by 1 year of age
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When to consult GI?
True UGBI bleed r/o swallowed blood Mallory Weis tear
may not need consult
LGIB r/o Meckel’s r/o Infectious r/o CMPA
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Case 3 14 year old male with recurrent blood mixed in
with stool x 1 year. Feeling tired all of the time. Occasional dark stools, no hematemesis. +FOBT by GP. Negative celiac screen
A – No allergies M – Ventolin P – Epitaxis, exercise induced asthma
FHx – Dad also gets lots of nose bleeds and ‘lung problems’, paternal grandfather died of stroke
no IBD, no celiac, no FHx of hemophilia L – This morning at 08:00 E – GP referred to GI
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On Exam See 5mm red/purple
stains on skin over face, upper trunk, arms. Also noted on buccal mucosa and tongue.
Lesions blanch with pressure
Some look like they branch out from centre
DRE revealed some frank blood
Exam otherwise normal
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Labs
Hb – 90 MCV 70 Plts -200
Retics 5% INR – 1.0 Alb – 35 ALT/AST – N ESR/CRP – N Ferritin – Low TIBC - High
Hypochromic microcytic
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Endoscopy finding
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Hereditary Hemorrhagic Telangiectasia
Also known as Osler-Weber-Rendu Diease
Autosomal dominant mutation in transforming growth factor beta signalling pathway
Important for vascular growth and repair
Triad = Telangiectasia, affected first degree relative and epitaxis
Dx – 3 of 4 Criteria
Epistaxis - Spontaneous, recurrent nosebleeds
Telangiectases - Multiple at characteristic sites (lips, oral cavity, fingers, nose)
Visceral lesions - Such as gastrointestinal (GI) telangiectasia (with or without bleeding), pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM
Family history - A first-degree relative with HHT
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Treatment – GI standpoint
Estrogen-progesterone therapy
Transfusion Aminocaproic acid Endoscopic
photoablation or electrocautery
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Boyle 2008
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References
JT Boyle. 2008. Gastrointestinal Bleeding in Children and Infants. Pediatrics in Review. (2) 39 – 51
C Ramsook and EE Endom. 2011. Diagnostic approach to lower gastrointestinal bleeding in children. Up to date. http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/diagnostic-approach-to-lower-gastrointestinal-bleeding-in-children?source=search_result&search=lower+gi+bleed&selectedTitle=3%7E102. Accessed October 12, 2011
Soares et al 2010. J Port Gastrenterol. v.17 n.5 Lisboa set A. Panigrahi. 2011. Pediatric Osler-Weber-Rendu Syndrome.
Medscape reference. http://emedicine.medscape.com/article/957067-overview. Accessed October 12, 2011
X Villa. 2011. Approach to upper gastrointestinal bleeding in children. Up to date. http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/approach-to-upper-gastrointestinal-bleeding-in-children?source=search_result&search=upper+gi+bleed&selectedTitle=2%7E150. Accessed October 12, 2011
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Thanks!
Special Thank You to Dr. C. Waterhouse