Gib in Infancy and Childhood

7/30/2019 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.

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Gib in Infancy and Childhood