Introduction. Digestive system Hemorrhage

Digestive system Hemorrhage

Inflammatory adhesions

Episodes of intra-abdominal inflammation, including, but not limited to ovarian torsion, ventriculoperitoneal shunt infection, Crohn's disease, acquired immunodeficiency syndrome, and pelvic inflammatory disease, can lead to adhesion formation and subsequent intestinal obstruction in the absence of previous surgical procedures.

Gastrointestinal bleeding accounts for at least 3 of every 1,000 pediatric emergency room visits.

Gastrointestinal bleeding is usually classified based on the anatomic relationship between the suspected site of bleeding and the ligament of Treitz. Bleeding from sites proximal to the ligament of Treitz is considered upper gastrointestinal bleeding and bleeding from sites distal to the ligament of Treitz is considered lower gastrointestinal bleeding.

Occult gastrointestinal bleeding refers to an initial presentation with a positive fecal occult blood test or iron deficiency anemia without visible evidence of blood loss. Patients with upper gastrointestinal bleeding typically present with melena, hematemesis, or blood clots mixed with emesis. Patients with lower gastrointestinal bleeding sometimes report bloody diarrhea, hematochezia, blood seen on toilet paper or blood streaks or clots mixed with stool. Patients with occult gastrointestinal bleeding sometimes present with non-specific signs and symptoms including fatigue, pallor, or anemia.

Certain types of gastrointestinal bleeding occur in children of any age; however, many etiologies are age-specific and warrant additional distinction (Tables 4.1 and 4.2).

The patient's age and clinical presentation are the most useful pieces of information in determining the likely cause of bleeding and for directing the diagnostic and treatment algorithm.

The approach to any patient with gastrointestinal bleeding should begin with an assessment of hemodynamic stability and overall clinical status followed by resuscitation, diagnosis, and therapy.

After resuscitation, the level of bleeding must be established and a list of potential diagnoses generated based on the child's age and clinical presentation.

A nasogastric tube lavage helps to confirm or exclude an upper GI source of bleeding (proximal to the ligament of treitz) and to remove particulate matter and clots from the stomach to facilitate endoscopy. For patients with a suspected upper GI bleed, EGD helps identify the bleeding source, permits treatment of the identified bleeding lesions, and allows for stratification of the risk for rebleeding.

For patients with a suspected lower GI bleed, the diagnostic workup depends on the suspected diagnosis based on the patient's age and presentation.

Adjunct treatments for upper gastrointestinal bleeding may include intravenous proton pump inhibitors or octreotide.

Table 4.1

Age-based differential diagnosis of gastrointestinal bleeding (by Jay L. Grosfeld, 2006).

Age	Upper gastrointestinal bleeding	Lower gastrointestinal bleeding
Newborn (<1 month)	· Hemorrhagic disease of the newborn · Swallowed maternal blood · Stress gastritis · Coagulopathy · Septicemia · Vascular malformations	· Anal fissure · Necrotizing enterocolitis · Malrotation with volvulus · Hirschsprung's disease with enterocolitis
Infancy (1 month- 2 years)	· Gastritis · Esophagitis · Hypertrophic pyloric stenosis · Trauma secondary to gastrostomy tube · Foreign body · NSAIDs	· Anal fissure · Milk protein allergy (allergic proctocolitis) · Intussusception · Lymphonodular hyperplasia · Intestinal duplication · Gangrenous bowel · Infectious diarrhea · Eosinophilic gastroenteropathy · Acquired thrombocytopenia
Child (>2 years)	· Peptic ulcer · Esophageal varices · Gastric varices · Gastritis · Esophagitis · Mallory-Weiss tear · Trauma secondary to gastrostomy tube · Eosinophilic gastroenteropathy · Munchausen syndrome by proxy · NSAIDS · Foreign body · Chemotherapy	· Polyps · Lymphonodular hyperplasia · Meckel's diverticulum · Hemolytic uremic syndrome · Henoch-Schonlein purpura · Infectious colitis · Anal fissure · Eosinophilic gastroenteropathy · Inflammatory bowel disease · Vascular lesions

Table 4.2

Common presentation and workup of specific causes of gastrointestinal bleeding (by Peter Mattei, 2011)

Diagnoses	Suggestive history/physical findings	Age groups	Diagnostic test
Upper gastrointestinal bleeding
Esophagitis, gastritis or gastroduodenal ulcers	Vomiting, GERD, epigastric pain, dysphagia, indwelling NGT or gastrostomy tube, critical illness, NSAIDs, alcohol, caustic ingestion	All age groups	EGD
Mallory-Weiss tear	Hematemesis after forceful vomiting	All age groups	EGD
Varices	Hematemesis with hepatomegaly, splenom­egaly, jaundice or ascites	Infancy and older	EGD
Lower gastrointestinal bleeding
Anorectal fissure	Painful defecation with streaks of red blood on stool	All age groups	Physical exam
Allergic colitis	Blood stained vomiting or diarrhea within 48 h of introducing formula	Neonates and infants	History
Necrotizing enterocolitis	Non-specific systemic signs of toxicity with abdominal distention, tenderness, vomiting, thrombocytopenia, or diarrhea with enteral feeding	Neonates (especially preterm)	KUB
Malrotation with midgut volvulus	Melena with abdominal distention and bilious emesis	Neonates	Upper GI series
Hirschsprung disease	Delayed meconium passage (>48 h) or progressive constipation with abdominal distention	Neonates	Contrast enema and suction rectal biopsy
Intussusception	Sudden onset, severe, colicky pain with vomiting and bloody mucoid stool; possible abdominal mass	Infants, preschool	Contrast enema or ultrasound
Meckel's diverticulum	Well child with large volume painless bleed	Infants, preschool	Meckel's scan
Lymphonodular hyperplasia	Painless bleeding after viral illness or allergic colitis	Infants, preschool	Colonoscopy
Juvenile polyp	Painless rectal bleeding with blood on top of the stool	Preschool, school age (up to 8 years old)	Colonoscopy
Infectious diarrhea	Bloody diarrhea with fever, pain, or tenesmus	Preschool, school age	History, stool cultures
Inflammatory bowel disease	Chronic bloody diarrhea with weight loss, anorexia, arthralgia or erythema nodusum	School age	Colonoscopy

Дата добавления: 2014-10-15