Etiology. Rectal Bleeding in Infancy

Rectal Bleeding in Infancy

Outcomes

Treatment

Treatment of symptomatic Meckel's diverticula is surgical. After appropriate resuscitation, exploration through a right-lower quadrant incision or laparoscopically is performed. Options for resection depend on the anatomy of the individual diverticulum: the presence of perforation, the amount of inflammation, or the extent of ischemic bowel in cases of herniation, intussusception or volvulus. Interventions range from simple diverticulectomy to wedge resection, or ileal resection with primary anastomosis. In cases that present as intussusception, it is acceptable to reduce the intussusception hydrostatically with a therapeutic barium enema prior to elective surgical intervention.

When a Meckel's diverticulum is an incidental finding during laparotomy or laparoscope the indications for surgical intervention are more controversial. In general, resection is reserved for cases discovered in patients that have unexplained abdominal pain and for diverticula containing ectopic mucosa (generally palpable if present) or attachments to the abdominal wall.

Surgical cure of gastrointestinal bleeding and inflammation associated with Meckel's diverticula is complete. Complications are similar to those associated with appendectomy, with small bowel obstruction secondary to postoperative adhesions being the most common with a 5-10% lifetime risk.

Rectal bleeding, although not a frequently encountered presenting symptom in neonates or infants, causes significant parental anxiety and should be regarded seriously. Because rectal bleeding may result from several different diagnoses, its exact occurrence is difficult to quantitate. Blood loss is usually minor and self-limited; massive rectal hemorrhage is uncommon. Allergic colitis and anorectal fissure are increasingly common diagnoses in children younger than one year-old.

Age is an important consideration when evaluating a patient with rectal bleeding. A common cause of rectal bleeding in the newborn period is related to swallowing maternal blood at the time of birth. Rectal bleeding in newborns can also be caused by hemorrhagic diseases of the newborn, hypoprothombinemia and thrombocytopenia. Certain diagnoses such as necrotizing enterocolitis and allergic colitis are unique to neonates and younger infants. Juvenile polyps are occasionally the cause of rectal bleeding in older infants but are a more common cause in early childhood.

Rectal bleeding in infancy can occur as a result of hemorrhage at upper or lower gastrointestinal sites. Upper gastrointestinal bleeding is defined as hemorrhage that occurs from a source proximal to the ligament of Treitz; lower gastrointestinal bleeding occurs from a more distal source. Upper intestinal bleeding can present as rectal bleeding in young infants due to their faster intestinal transit time. Although many common etiologies of rectal bleeding in infancy have been described (Table 4.8), clinical diagnosis is illusive in nearly one-half of these children.

Table 4.8

Causes of rectal bleeding in infancy

(by Robert M. Arensman, 2009)

Location of Bleeding Source	Age
Neonate <1 month	1 month to 1 year	1 year to 2 year
Upper Gastrointestinal:
Hemorrhagic disease	+
Swallowed maternal blood	+
Esophagitis or gastritis	+	+ +
Peptic ulcer disease			+ +
Gastric teratoma
Esophageal or gastric varices			+
Lower Gastrointestinal:
Anal fissure	+ + +	+ +
Necrotizing enterocolitis	+ +
Gangrenous bowel		+ +
Malrotation with midgut volvulus	+ +
Hirschsprung's disease with enterocolitis
Allergic proctocolitis
Intussusception		+ +	+
Prolapse
Polyps		+ +	+
Meckel's diverticulum		+ +
Lymphonodular hyperplasia
Enteritis (i.e., Campylobacter, Yersinia, Salmonella)
Inflammatory bowel disease			+ +
Intestinal duplication
GI vascular malformation
+++ most common cause, ++ more common cause, + relatively more common.

Дата добавления: 2014-10-15