Chapter 68 2-Year-Old Boy with Gastrointestinal Bleeding (Case 49)
Differential Diagnosis
| Polyps | Peptic ulcer disease | Anal fissure |
| Meckel’s diverticulum | GI duplication | Inflammatory bowel disease |
PATIENT CARE
Clinical Thinking
• Bleeding in any child can be a self-limiting condition, easily treated, or a serious life-threatening problem.
• Physical examination, simple laboratory tests, and x-rays will, in many cases, establish the dx and allow for expeditious tx.
• Consideration of the differential dx of GI hemorrhage begins with consideration of the child’s age. Common causes of bleeding in newborns include necrotizing enterocolitis, swallowed maternal blood, coagulopathy, and midgut volvulus. Common causes of GI bleeding in children ages 2 to 8 years include polyps, Meckel’s diverticulum, GI duplication, and peptic ulcer disease. Bleeding in older children is more commonly from esophageal varices, polyps, Meckel’s diverticulum, and inflammatory bowel disease.
History
• For newborns, the obstetrical hx should focus on the possibility that the infant may have had a stressful birth and potentially swallowed maternal blood. Duration and severity of the bleeding are important, as are the relationship of bleeding to other events (i.e., lack of stooling and vomiting suggests midgut volvulus or intussusception, while rapid and voluminous bleeding is more indicative of a peptic ulcer or a Meckel’s diverticulum).
• Always check family hx for disorders that may cause bleeding, such as hemophilia or other coagulation abnormalities.
• Melanotic stools are usually a sign of bleeding from the upper GI tract, while bright red bleeding is more indicative of lower GI tract hemorrhage.
Physical Examination
• First determine the presence or absence of shock. Appropriate resuscitation should take precedence over the investigation of the source of GI bleeding.
• A complete physical examination may reveal clues of an underlying condition causing the bleeding. For example, the presence of dark pigmented lesions in the oral mucosa may suggest Peutz-Jeghers polyposis.
• The abdomen should be inspected and carefully palpated. Some conditions that cause GI bleeding are associated abdominal distention and peritonitis late in their course. Examples are midgut volvulus and intussusception.
• Careful evaluation of the anus and rectum may provide substantial information as to the source of bleeding (e.g., fissure, polyps).
Tests for Consideration
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| Clinical Entities | Medical Knowledge |
|---|---|
| Gastrointestinal Polyps | |
| PΦ | Young children and toddlers can have juvenile or inflammatory polyps. These are thought to be caused by an inflammatory process that gradually increases over time as the peristalsis drags the inflammatory mass into the lumen of the colon. Other polyps are associated with chromosomal and genetic abnormalities, including Peutz-Jeghers disease, familial polyposis of the colon, juvenile polyposis of the colon, and Gardener’s syndrome. |
| TP | Colonic and intestinal polyps often present with intermittent episodes of hematochezia, which can be dark red or bright red. Occasionally there is severe bleeding, which can impact hemodynamic stability. |
| Dx | The dx of polyps is made on physical examination of the rectum and by sigmoidoscopy or colonoscopy. A contrast study may be helpful, particularly for small bowel polyps as seen in Peutz-Jeghers syndrome. Often, rectal polyps can be visualized on a simple rectal examination. |
| Tx | The most important consideration is to determine the pathology of the polyp. After the polyp is removed, a careful examination of the colon is always indicated. The histological nature of the polyp is determined after it is removed, checking for a genetic or precancerous dx. Multiple polyps raise the possibility of a genetic syndrome. In adenomatous polyposis of the colon and other polyposis syndromes the patient will require monitoring and possible removal of the premalignant colonic mucosa. Almost all polyps can be removed by sigmoidoscopy or colonoscopy. See Sabiston 50; Becker 21, 26. |
| PΦ | Meckel’s diverticulum is a remnant of the omphalomesenteric duct that originally connected to the embryonic yolk sac. It is present in approximately 2% of the population. It is usually located on the antimesenteric side of the intestine, approximately 2 feet from the ileocecal valve. Ectopic tissue, including pancreatic tissue, colonic tissue, and particularly gastric mucosa, may be present. Of most significance is the ectopic gastric mucosa, which secretes acid and may cause an ulcer in the adjacent small bowel mucosa, which predisposes to hemorrhage. |
| TP | The bleeding with Meckel’s diverticulum is usually severe and painless. The mean hemoglobin has been reported to average from 7 to 8 g. It tends to cease spontaneously, which allows for a careful evaluation of the source of bleeding. |
| Dx | The dx is made by a careful hx, noting a sudden onset of painless and massive bleeding. Insertion of an NG tube usually r/o the upper GI tract as the source. If the bleeding is coming from the lower GI tract, a lower endoscopy is indicated. If the bleeding source is not identified, the child is stabilized and a technetium scan searching for an area of ectopic gastric mucosa usually establishes the dx. |
| Tx | A bleeding Meckel’s diverticulum should be removed after the patient has been stabilized. It is unusual to have to operate emergently, although this may be necessary if the bleeding continues. The Meckel’s diverticulum is excised, ensuring that all of the ectopic gastric mucosa has been removed. Surgery is curative. See Sabiston 48, Becker 57. |
| PΦ | The etiology of both Crohn’s disease and ulcerative colitis is unknown. Evidence is accumulating that both diseases occur as a result of both genetic and environmental factors. Crohn’s disease can be present throughout the GI tract and results in transmural involvement of the affected area. Ulcerative colitis is typically confined to the colon, although it can have extraintestinal manifestations. |
| TP | Children with Crohn’s disease are often underweight for their age. Perianal ulcers are a strong clue that this disease is the source of the GI bleeding. Patients with ulcerative colitis may also show signs of chronic malnutrition (e.g., underweight, delayed sexual maturity). The GI bleeding with both of these conditions may be significant but is usually chronic in nature. |
| Dx | There are radiologic features associated with both of these conditions that provide additional evidence for the dx. Dx is usually confirmed through esophagogastroscopy or colonoscopy with biopsy. Endoscopy is also used to identify the location of bleeding prior to surgical intervention. |
| Tx | Medical therapy for inflammatory bowel disease involves a variety of anti-inflammatory and immunosuppressant medications. Surgery for Crohn’s disease is indicated in patients who do not respond to medical therapy. Surgical therapy for GI bleeding from ulcerative colitis usually involves a total colectomy and ileostomy with reconstructive surgery done when the patient is stable. See Sabiston 48, 50; Becker 22. |
| PΦ | Duplications of the GI tract are congenital abnormalities of the bowel that can be spherical or cylindrical. Most will have a communication with the GI tract and are located on the mesenteric side of the bowel. If they contain gastric mucosa, the secretions may cause mild to moderate bleeding from an ulcer in the adjacent mucosa of the small bowel, stomach, duodenum, or colon. Rarely, severe bleeding may occur. |
| TP | Abdominal pain and frequent stools containing dark red or tarry stools are characteristic findings. |
| Dx | A technetium scan is the most effective preoperative diagnostic test. Occasionally an upper GI series with small bowel follow-through may identify the duplication. |
| Tx | Removal of the duplication is the preferred tx. This requires a resection of the involved portion of bowel. |
| PΦ | The cause is often a change in diet from formula or breast milk to more solids, causing a thickening and sometimes hardening of the stool. Many times this is a direct result of introducing table food into the diet, although anal fissures do occur in newborns. Constipation and stool withholding are common contributing factors in toddlers and older children. Stooling is quite painful with a fissure, as the sensory nerves in the anus are quite sensitive to stretch during defecation. Child abuse may need to be considered. A dx of child abuse must be r/o by a careful hx and examination of the infant, looking for other signs of abuse. |
| TP | The typical presentation of anal fissure is of an infant who has straining at the stool, pain during defecation, and red streaking of small amounts of blood in the stool or on the diaper. |
| Dx | The dx of a fissure is made by inspection. A sentinel tag of skin may be present at the site of the internal fissure. Constant gentle anal pressure will in most cases evert the anal mucosa to visualize the fissure. Use of a glass test tube or nasal speculum inserted gently into the anus may be of help in identifying the fissure. |
| Tx | The tx consists of adding fiber to the diet and altering the diet so that the child doesn’t become chronically constipated. Adequate fluid intake should also be assured. Stool softening agents minimize pain and help promote more complete evacuation. See Sabiston 51, Becker 21. |
| PΦ | The etiology of peptic ulcer disease may be related to other conditions such as burns, trauma, malignancy, or sepsis. In addition, the child may have been taking salicylates or NSAIDs. Children infected with Helicobacter are more prone to develop peptic ulcer disease. |
| TP | Although patients with peptic ulcer disease may pass blood in their stool, these patients usually pass larger amounts of blood than children with intussusception or polyps. Many times the bleeding can be relatively severe and cause hemodynamic instability. |
| Dx | A patient with peptic ulcer disease can be relatively easily differentiated from a child with bleeding from the lower GI tract by placement of an oro- or nasogastric tube. In addition endoscopy is indicated in most cases to determine the exact nature and location of the bleeding as well as to potentially treat the bleeding ulcer or visualize the extent of the gastritis. |
| Tx | Most patients with peptic disease can be treated by medical means. Acute bleeding usually does not continue, and tx with acid-suppressive medications usually suffices to treat the upper GI tract hemorrhage. Rare patients who continue to bleed may require endoscopic coagulation of the bleeding areas. In unusual cases an operation to ligate the bleeding vessel in the duodenum or stomach may be a life-saving measure. See Sabiston 46, Becker 26. |
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