Gastro-intestinal Bleeding

Question 1

What is important when caring for children with gastrointestinal bleeding?

Answer 1

It requires knowledge of the many aetiologies and differentiating symptoms and signs. A detailed history and examination are necessary.

Question 2

What are the two important differentiating factors in assessing gastrointestinal bleeding?

Answer 2

The patient’s age and the nature of the bleed.

Question 3

How is gastrointestinal bleeding classified?

Answer 3

Bleeding from sites proximal to the DJ flexure is upper GI bleeding, while bleeding from below the DJ flexure is lower GI bleeding.

Question 4

What are the typical signs of upper GI bleeding?

Answer 4

Upper GI bleeding typically presents with haematemesis (vomiting blood) or melena (black, tarry stools).

Question 5

How does lower GI bleeding typically present?

Answer 5

Lower GI bleeding may present with bloody diarrhoea, haematochezia (bright red blood in stool), blood streaks, or clots mixed with stool.

Question 6

What symptoms may indicate occult gastrointestinal bleeding?

Answer 6

Occult bleeding may present with fatigue, pallor, or anaemia.

Question 7

What should be assessed in a child with gastrointestinal bleeding?

Answer 7

Efforts should be made to determine if the child is actively bleeding, considering factors like swallowed maternal blood, coloured foods, or medications that can be misleading.

Question 8

How can swallowed maternal blood be differentiated in a child?

Answer 8

Swallowed maternal blood can be differentiated using the APT test.

Question 9

What should be examined if blood from the nasal mucosa is suspected?

Answer 9

The oropharynx, nasopharynx, and nares should be examined as blood from the nasal mucosa can be swallowed.

Question 10

What is the first step in managing unstable patients with gastrointestinal bleeding?

Answer 10

Unstable patients require urgent resuscitation according to APLS (Advanced Pediatric Life Support) guidelines.

Question 11

How should diagnostic tests and therapeutic interventions be guided?

Answer 11

The urgency of diagnostic tests and interventions will be guided by the child’s condition and their response to resuscitation.

Question 12

How should small bleeds without haemodynamic instability or abdominal signs be managed?

Answer 12

Small bleeds without haemodynamic instability or abdominal signs are usually not life-threatening, and investigations can be planned and executed systematically.

Question 13

What should be inquired about during the history of a child with gastrointestinal bleeding?

Answer 13

Enquire about:
• Previous nosebleeds
• Blood in vomitus or stool
• Colour of the bleed/stool
• Location of blood in stool
• Time, duration, and previous history
• Amount of blood
• Bleeding disorders
• Liver disease, varices, medication
• Dysphagia, dyspeptic symptoms, abdominal pain
• Fever, weight loss, irritability

Question 14

What should be examined in a child with gastrointestinal bleeding?

Answer 14

Examinations should assess:
• Vital signs, mental status
• Skin colour, capillary refill
• Bruising or jaundice
• Abdominal distension, tenderness, veins, or masses
• Rectal/perianal examination

Question 15

What are the common causes of upper gastrointestinal bleeding in newborns (<1 month)?

Answer 15

Common causes in newborns include swallowed blood.

Question 16

What are the common causes of upper gastrointestinal bleeding in infants (1 month – 2 years)?

Answer 16

Common causes in infants include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, and varices.

Question 17

What are the common causes of upper gastrointestinal bleeding in preschool-aged children (2 – 5 years)?

Answer 17

Common causes in preschool-aged children include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, and Dieulofoy’s lesion.

Question 18

What are the common causes of upper gastrointestinal bleeding in school-aged children (>5 years)?

Answer 18

Common causes in school-aged children include allergic enteritis, oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, and Dieulofoy’s lesion.

Question 19

What are some causes of upper gastrointestinal bleeding specific to certain age groups?

Answer 19

• Newborns (<1 month): Swallowed blood
• Infants (1 month – 2 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices
• Preschool (2 – 5 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, Dieulofoy’s lesion
• School age (>5 years): Oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, varices, Dieulofoy’s lesion

Question 20

What are some causes of upper gastrointestinal bleeding that may occur across multiple age groups?

Answer 20

Causes that may occur across multiple age groups include oesophagitis, gastritis, gastroduodenal ulcers, Mallory Weiss, and varices.

Question 21

What are some causes of upper gastrointestinal bleeding specific to older children or adults?

Answer 21

Causes like congenital malformations, intestinal duplication, coagulopathy, liver disease, haemangiomas, and Dieulofoy’s lesion may occur in specific age groups but are less common in younger children.

Question 23

What are the common causes of lower gastrointestinal bleeding in newborns (<1 month)?

Answer 23

Common causes in newborns include swallowed blood and necrotizing enterocolitis.

Question 24

What are the common causes of lower gastrointestinal bleeding in infants (1 month – 2 years)?

Answer 24

Common causes in infants include allergic enteritis, necrotizing enterocolitis, malrotation with volvulus, intussusception, Meckel’s diverticulum, AVM’s, and infectious colitis.

Question 25

What are the common causes of lower gastrointestinal bleeding in preschool-aged children (2 – 5 years)?

Answer 25

Common causes in preschool-aged children include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, and inflammatory bowel disease.

Question 26

What are the common causes of lower gastrointestinal bleeding in school-aged children (>5 years)?

Answer 26

Common causes in school-aged children include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, and inflammatory bowel disease.

Question 27

What are some causes of lower gastrointestinal bleeding specific to certain age groups?

Answer 27

• Newborns (<1 month): Swallowed blood, necrotizing enterocolitis • Infants (1 month – 2 years): Necrotizing enterocolitis, malrotation with volvulus, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis • Preschool (2 – 5 years): Intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, inflammatory bowel disease • School age (>5 years): Intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, juvenile polyps, inflammatory bowel disease

Question 28

What are some causes of lower gastrointestinal bleeding that may occur across multiple age groups?

Answer 28

Causes that may occur across multiple age groups include allergic enteritis, intussusception, Meckel’s diverticulum, AVM’s, infectious colitis, and juvenile polyps.

Question 29

What are some causes of lower gastrointestinal bleeding specific to older children or adults?

Answer 29

Causes like Hirschsprung’s enteritis, coagulopathy, liver disease, anal fissure, intestinal duplication, and inflammatory bowel disease may be more common in older children or adults.

Question 30

How are investigations for gastrointestinal bleeding directed?

Answer 30

Investigations are guided by the patient’s state, demographics, nature of the bleed, and examination findings.

Question 31

What investigations should be done for patients with signs of liver disease?

Answer 31

A full blood profile, including a full blood count, clotting investigations, liver function tests, electrolytes, and renal function should be conducted.

Question 32

What is the investigation of choice for upper gastrointestinal bleeding?

Answer 32

Oesophagogastroduodenoscopy is the investigation of choice for upper GI bleeding as it allows for both diagnosis and treatment of some conditions.

Question 33

When should upper gastrointestinal endoscopy be performed?

Answer 33

Upper GI endoscopy is required in cases of liver disease, and in patients with epigastric pain, coffee ground vomiting, or melena stools.

Question 34

What is the first step in diagnosing a neonatal patient with abdominal distension and blood per rectum?

Answer 34

Neonates with these symptoms may require an x-ray to diagnose necrotizing enterocolitis (NEC).

Question 35

When is colonoscopy useful in cases of lower gastrointestinal bleeding?

Answer 35

Colonoscopy is useful in patients with frank fresh red blood or ongoing bloody diarrhoea to assess for polyps, inflammatory bowel disease, or infective or allergic colitis.

Question 36

What is the appropriate investigation for a child with painful constipated stools and red blood on the outside of the stool?

Answer 36

An examination under anaesthetic is more appropriate to confirm an anal fissure in such a case.

Question 37

How should a child in the 6 to 18-month group, with a history of viral infection or gastroenteritis, and a sausage-shaped abdominal mass be investigated?

Answer 37

An ultrasound should be performed to rule out intussusception.

Question 38

What investigation may be indicated for a patient with maroon-coloured PR bleeding and a normal colonoscopy?

Answer 38

A Meckel’s scan may be indicated for such patients.

Question 39

What investigations may be required for patients with occult blood in the stool?

Answer 39

Both upper and lower GI endoscopy may be required to find the cause of occult blood in the stool.

Question 40

What is the general management approach for patients presenting with gastrointestinal bleeding?

Answer 40

The management focuses on restoring haemodynamic status, raising haemoglobin with haematinics or transfusion if needed, and managing the underlying condition.

Question 41

How is gastritis or oesophagitis treated in patients with gastrointestinal bleeding?

Answer 41

Gastritis or oesophagitis is treated with a proton pump inhibitor (PPI), and investigations and management of underlying gastro-oesophageal reflux disease (GORD) and Helicobacter pylori are also required.

Question 42

How are bleeding gastric or duodenal ulcers managed?

Answer 42

Bleeding gastric or duodenal ulcers are managed with IV proton pump inhibitors and may require injection of the bleeder with vasoconstrictors.

Question 43

How is portal hypertension managed in patients with gastrointestinal bleeding?

Answer 43

Management of portal hypertension may include banding or injection sclerotherapy, progressing to a Sengstaken-Blakemore tube for life-threatening bleeds, along with beta blockers and Octreotide to reduce portal pressure. In severe cases, porto-systemic shunting or liver transplantation may be required.

Question 44

How is intussusception managed in patients with gastrointestinal bleeding?

Answer 44

Patients with intussusception undergo air reduction or surgical correction as discussed in the relevant section.

Question 45

What is the management for isolated colonic polyps in children?

Answer 45

Isolated colonic polyps, usually hamartomas, are not premalignant and can be snared endoscopically.

Question 46

How are polyps related to familial polyposis syndromes managed?

Answer 46

Polyps related to familial polyposis syndromes have their own management algorithms and should be referred to specialist centres for lifelong follow-up.

Question 47

What is the most common cause of lower GI bleeding in all ages, and how is it managed?

Answer 47

Fissure in ano is the most common cause of lower GI bleeding. Management includes breaking the vicious cycle of stool withholding by using stool softeners, anti-constipation diets, a stooling routine, and topical local anaesthetic mixed with topical isosorbide mononitrate or calcium channel blockers to relieve anal spasm and improve blood flow for healing.

Question 48

What is the common cause of painless bleeding with stools in children, and how is it managed?

Answer 48

Painless bleeding with stools is often caused by a juvenile “mucous retention” polyp. Treatment involves addressing associated constipation with stool softeners and diet modification. Polyps may be snared on sigmoidoscopy or colonoscopy, and biopsies should be taken if there are more than five polyps or a family history of polyposis.

Question 49

How is a prolapsed rectal polyp managed?

Answer 49

A prolapsed rectal polyp, which looks like a “red cherry,” is often mistaken for haemorrhoids (rare in children). Management involves reducing the polyp and buttock strapping along with stool softeners. Sclerotherapy is used if it recurs or persists for more than three months despite treatment, and rectopexy may be necessary for severe, refractory cases.

Question 50

How is rectal prolapse treated in children?

Answer 50

Rectal prolapse, which may be mucosal or full-thickness, is managed conservatively with reduction, buttock strapping, and stool softeners, or resolution of diarrhoea. If recurrent and lasting more than three months, sclerotherapy is used, and rectopexy is considered for severe cases.

Question 51

How do you distinguish between rectal prolapse and rectal prolapse due to intussusception?

Answer 51

Rectal prolapse due to intussusception can be distinguished by a side-wards curl (can form a “pigtail” twist), the ability to pass an examining finger between the mass and rectal wall, and associated vomiting (usually bilious) and palpable abdominal mass. Management involves addressing bowel obstruction.