GASTROINTESTINAL BLEEDING ATAN BAAS SINUHAJI Sub Division of Pediatrics Gastroentero-Hepatology Department of Child Health, School of Medicine University of Sumatera Utara/ Adam Malik Hospital MEDAN 1
GASTROINTESTINAL
BLEEDING
ATAN BAAS SINUHAJI
Sub Division of Pediatrics Gastroentero-Hepatology
Department of Child Health, School of Medicine
University of Sumatera Utara/ Adam Malik Hospital
MEDAN
1
GI Bleeding
Acute
2
Stable
4 important points
GI bleeding
Blood ?
Gut
1
3
Gut
Out In
Upper or lower
Spesific site
2
3
4
Materials
Heme protein
4
Hydrogen peroxidase
Colorless guaiac Blue quinone
Tabel 1. Substances that interfere with Guaiac test
for fecal occult blood
False - Positive results
- Meat (rare or well-done)
- Horseradish
False -Negative results
-Vitamin C
- Storage of specimen > d
5
- Horseradish
- Turnips
- Ferrous sulfate (stool pH <6,0)- Tomatoes
- Fresh red cherries
- Storage of specimen > 4 d- Outdated reagent or card
GI BleedingGI Bleeding
Gut
6
Out In
Ingestion Non ingestion Upper Lower
Non ingestion
- Blood disorders : leukemia,ITP, etc
7
- Blood disorders : leukemia,ITP, etc
- Systemic : sepsis
- Rupture aortic aneurysma with enteric fistula
- Hemorrhagic Disease of the Newborn
Ingestion
Newborn
Swallowed maternal blood
Infants & young children
- Nipples
8
Swallowed maternal blood
APT Downey Test
- Nipples
- Epistaxis
- Oropharyngeal bleeding
- Blood tinged sputum
Newborn
Hb F Hb A Hb A2
9
50-90%
Alkali resistent
Manifestation of GI Bleeding
Blood per os Blood per anum
10
Hematemesis
Upper GIT
Occult Overt
Melena Hematochezia
Upper GIT
Hematochesia
With diarrhoea Without diarrhoea Without stools
11
Dysentry
syndrome
Blood strike
Anorectal area
•Anal fissure
•Polyps
Currant jelly
stools
Intussusception
GI Bleeding
Causes
12
Non lesion GIT Lesion GIT
Lesion GIT
Upper Lower
13
Mucosal
lesionVariceal
bleedingSurgical
Non
surgical
•Emergency
•ElectiveInflammation
Clinical presentationClinical presentation
•Hematemesis
•Melena
•Hematochezia
•Hystory & physical examination
•Laboratory evaluation
14
Stable
Nasogastric tube
Blood (+) Blood (-)
Upper GIT bleeding Lower GIT bleeding
•Contrast radiography
•Endoscopy
Gastric aspiration
The site of bleeding •The amount of bleeding
•The bleeding stop ?
15
Not totally exclude
upper GIT bleeding
•Competent pyloric
•No reflux
•Bleeding stopped
Clinical presentation
•Hystory and physical examination
•Laboratory evaluation
Stable
Nasogastric tube
Blood (+) Blood (-)
16
Upper GIT bleeding Lower GIT bleeding
Plain abdominal X-ray
(erect & supine)
Obstruction No obstruction
Barium enema
Surgery
•Stool examination / culture
•Meckel’s scan
•Double contrast barium enema
•Colonoscopy
Figure 2. A diagnostic approach
of lower bleeding GIT
Treatment
A General measures
BControl of upper
17
Treatment BControl of upper
GIT bleeding
CControl of lower
GIT bleeding
A General measures
1. To restore iv volume
& O2 carrying
capacity
2. To increased
hematocrit
•NaCl 0,9%
•Lactate Ringer
Blood/product
18
A General measureshematocrit
3. Underlying
coagulopathies
•Vit K 1 mg/year
(max 10 mg)
•Fresh Frozen Plasma
•Platelets
BControl of upper
Gastric lavage with ice saline
19
BControl of upper
GIT bleeding
Specific
Specific treatment of upper GIT bleeding
Mucosal lesion Variceal bleeding
20
Acid neutralizing /
supressor agent
•Vasoactive agent
•Balloon tamponade
•Sclerosing
•Surgery
Gastric lavage with ice saline
•Standart treatment
•Clearing of fresh blood and clots
21
•Clearing of fresh blood and clots
Adverse effect:
Hypothermia and electrolytes
abnormalities in infant
Gastric lavage with ice saline
� The recommended volume:
� 50 mL (infants)
� 100-200 mL (older children)
� Rapidly infused to stomach� Rapidly infused to stomach
� Allow to stay for 2-3 minutes and gently aspirated out
� The tube left in place to monitoring any
subsequent hemorrhage
22
Mucosal lesion
- Self limiting (spontaneously / ice saline)
- Acid neutralizing / supressor agent
23
Do not stop active bleeding
Antacid 1 mL/kg/dose (max 30 mL/dose)•Every 1-2 hours � gastric pH ≥5
•Thereafter: 1-3 hours after meal & at bed time
6 weeks
Variceal bleeding
Stop spontaneously
Vasoactive agent
(vasopressin & octreotide)
24
(vasopressin & octreotide)
Splanchnic arterial
blood flow ↓↓
Portal pressure ↓↓
Variceal bleeding
Radical/surgical consultation
ICU
Resuscitation
25
Endoscopy to visualize varices
Vasoactive agent
Sengstaken – Blackmore tube
Sclerosing therapy Emergency therapy
Figure 3. An approach to the management of variceal bleeding
VASOPRESSIN
� Bolus dose: 0,3 U/kg (max 20 U/kg) dilluted in
2 mL/kg 5% Dextrose � 20 minutes
� Continous infusion: 0,2-0,4 U/1,73m2/min,if necessarynecessary
� The bleeding cases: the infant is maintained
at the initial dose for 12 hours and then
gradually tapered � 24-36 hours
� Side effect: hypertension, myocardial
ischemic, arrhythmias, water retention and
venous thrombosis26
OCTREOTIDE
� Bolus dose: 1 μg/kg
� Continued infusion: 1 μg/kg/h with titration
of both bolus and constant infusion up to 5μg/kg/h μg/kg/h
� The bleeding cases: doses should be tapered
by 50% for 12 hours, can be discontinued
when dose is 25% initial dose
27
Balloon tamponade
Sengstaken-Blackmore tube
Indication:
•Massive life threatening bleeding
•Continued bleeding despite 4-6 hours
28
•Continued bleeding despite 4-6 hoursof i.v. vasopressin
Complication:
•Ulceration
•Airway obstruction
•Aspiration
•Esophageal rupture
C Control of lower GIT bleeding
29
•Severe lower GIT bleeding is uncommon
•Definitive treatment: depend on the cause
B � Ongoing bleeding
L � Low systolic blood pressure
E � Elevated prothrombine time
30
E � Elevated prothrombine time
E � Erratic in mental status
D � Comorbid disease (other thanbleeding) requiring admission
to ICU
Figure 4, Predictors of outcome
CONCLUSION
GI Bleeding
Not unusual
Life threatening problem
31
Life threatening problem
Stable
Bleeding source
Thank Thank Thank Thank
YouYouYouYou
32