Giuliano Lombardi - Gastroenterologiaroma.it present as an .. ACUTE and life-threatening event CHRONIC BLEEDING which might manifest as iron-deficiency anemia, fecal occult blood or

UPPER AND LOWER

GASTROINTESTINAL BLEEDING:

clinical and endoscopic approach

Giuliano Lombardi

ENDOSCOPIA GASTROINTESTINALE IN PEDIATRIA E NON SOLO...

PEDIATRIC GASTROINTESTINAL ENDOSCOPY AND BEYOND Roma,12-13 Aprile 2013 PRESIDENTE: PROF. SALVATORE CUCCHIARA

Ospedale Reg. di Pescara U.O.C. di Pediatria Medica, Direttore dott. Giuliano Lombardi

Unità di Gastroenterologia Ped /Servizio Speciale di Endoscopia Digestiva Ped

ANY BLEED THAT OCCURS DISTAL TO THE LIGAMENT OF TREITZ

AND SUPERIOR TO THE ANUS

INCLUDING THE LAST ¼ OF THE DUODENUM, AND THE ENTIRE AREA OF THE JEJUNUM, ILEUM,

COLON, RECTUM

LOWER GASTRO-INTESTINAL BLEEDING (LGIB)

Can present as an ..

ACUTE and life-threatening event

CHRONIC BLEEDING

which might manifest as

iron-deficiency anemia, fecal

occult blood or intermittent scant

hematochetia

Acute bleeding from the colon is usually less dramatic than upper gastrointestinal hemorrhage and is self-limiting in most cases.

Barnert J and Messmann H “Diagnosis and management of lower gastrointestinal bleeding” – Gastroenterol Hepatol 6, 637-646 (2009)



Results from capsule and double-balloon endoscopy have revolutionized tha management algorithm of small bowel bleeding. Bleeding from the small bowel represents a distinct entity.



GASTROINTESTINAL BLEEDING

UPPER MIDDLE LOWER

Consensus statement

sul sanguinamento gastrointestinale in età pediatrica (giugno 2005)

Panel

A. Barabino - [SIGENP] Genova

P. Betalli - [SICP] Padova

F. Cosentino - [SIED] Milano

L. Dall’Oglio - [SICP] [SIED] Roma

G. L.’de Angelis - [SIGENP] Parma

C. De Giacomo - [SIGENP] Milano

D. Falchetti - [SICP] Brescia

P. Gandullia - [SIGENP] Genova

G. Guariso - [SIGENP] Padova

G. Lombardi - [SIGENP] Pescara

A. Rossi - [SIED] Milano

V. Tomaselli - [SICP] Milano

Coord: C. Romano (SIGENP) Messina

Società Italiana di Gastroenterologia

Epatologia e Nutrizione Pediatrica

Società Italiana di Endoscopia Digestiva

Società Italiana di Chirurgia Pediatrica

Italian Panel Pediatric Endoscopy

Bleeding definition

The stool of a person with a lower gastrointestinal bleed is a good (but not infallible) indication of where the bleeding is occurring.

Black tarry appearing stools medically referred to as MELENA usually indicates blood that

has been in the GI tract for at least 8 hours.

Melena is four-times more likely to come from an upper g-I bleed than from the lower GI tract; however, it can also occur in either the duodenum and

jejunum, and occasionally the portions of the small intestine and proximal colon

Bright red stool, called HEMATOCHEZIA is the sign of a fast moving active GI bleed.

The bright red or maroon color is due to the short time taken from the site of the bleed and the exiting at the anus. The presence of hematochezia is six-times

greater in a LGIB than with a UGIB.

CLINICAL DIAGNOSIS

AGE

LOCATION OF THE HEMORRHAGIC SITE

COLOUR AND SEVERITY OF THE BLEEDING

PRESENCE OR ABSENCE OF PAIN AND DIARRHEA

GOOD HISTORY is crucial to determinate the source of bleeding

Acuteness or chronicity of bleeding, color and quantity of the blood in stool or emesis, antecedent symptoms, history of straining, abdominal pain, or trauma.

Anorectal disorders, fissures, and distal polyps produce red blood

Melena rather than bright red blood per rectum is usually a sign of bleeding that comes from a source proximal to the ligament of Treitz

Massive upper GI bleeding can produce bright red blood per rectum if GI transit time is rapid

Blood mixed in stool or dark red blood implies a proximal source with some degree of digestion of the blood

Age- and etiology-specific symptoms to be aware of:

O Hsia, R Halpern and J Mola “Gastrointestinal bleeding” Pediatrics 2008


A history of vomiting, diarrhea, fever, ill contacts, or travel suggests an infectious etiology

Bloody diarrhea and signs of obstruction suggest volvulus, intussusception, or necrotizing enterocolitis, particularly in the ex-premature infant

Recurrent or forceful vomiting is associated with Mallory-Weiss tears

Familial history of NSAID use may suggest ulcer disease

Age- and etiology-specific symptoms to be aware of:



Recent jaundice, easy bruising, and changes in stool color may signal liver disease

Other evidence of coagulation abnormalities elicited from the history may also point to disorders of the kidney or reticuloendothelial system

For complaints of bloody stool, make sure to elicit on history foods or drugs that may give a stool bloody appearance (certain antibiotics, iron supplements, red licorice, chocolate, kool-Aid, flavored gelatin, or bismuth-containing products

Undiagnosed organ dysfunction possibilities to be aware of:


“ FALSE” GI BLEEDING

DEGLUTITION OF BREAST MILK

EPIXTASIS

HEMOPTYSIS

DRUGS AND FOODS

DIFFERENTIAL DIAGNOSIS

Neonates 1 month – 3 years > 3 years

Swallowed maternal blood Necrotizing enterocolitis Malrotation with midgut volvulus Allergic colitis (cow’s milk protein) Hirschsprung’s disease Anorectal fissures Coagulopathy Drugs

Allergic colitis (cow’s milk protein) Anorectal fissures Intussusception Meckel’s diverticulum Gastrointestinal duplication Polyps Ischemic bowel secondary to volvulus Rectal prolapse Infectious colitis Vascular malformation Drugs

Juvenile polyps IBD Vascular malformation Hemolytic uremic syndrome (HUS) Henoch Schonlein Purpura Iatrogenic Trauma - abuse

MUCOSAL LESION

VASCULAR LESION

DEFECTS IN HEMOSTASIS

OBSCURE GASTROINTESTINAL BLEEDING

unknown origin that persists or recurs after initial negative endoscopy

< 3 yrs > 3 yrs

GASTRIC- DUODENUM

ULCERS POLYPS

INTESTINE MECKEL MECKEL VASCULAR ANOMALIES

COLON ALLERGIC OR ACUTE COLITIS

IBD

5% between Treitz’s ligament and ileo-cecal valve

SIGNS OF IMPAIRED CIRCULATION

INSPECTION OF MOUTH

PURPURIC LESIONS (Shonlein-Henoch)

ORAL or LABIAL SIGNS of Peutz-Jaeghers

HEPATOSPLENOMEGALY

INSPECTION of the ANUS–RECTAL EXAMINATION

ASSESSMENT OF CARDIO-PULMONARY

SKIN COLOR

SENSORY EVALUATION

MUSCLE TONE

PUPIL REACTIVITY

FISICAL EXAM

LABORATORY

Complete blood count

PCR

Hepatic function

Renal function

Stool examination

OBSCURE-OCCULT BLEEDING

UPPER and LOWER ENDOSCOPY -if necessary repeat the exam

PUSH ENTEROSCOPY

-expert hands -also with therapeutic purposes MASSIVE BLEEDING

SCINTIGRAPHY

ANGIOGRAPHY

ENDOSCOPY

SURGERY

BLEEDING RELATIVELY MINOR

ENDOSCOPY

de Franchis R, 1996 - Baveno II

CLINICALLY SIGNIFICANT BLEEDING

TRANSFUSION REQUIREMENT of > 2 Units of blood within 24 h of time zero

PLUS A SYSTOLIC BLOOD PRESSURE OF < 100 MMHG

POSTURALE CHANGE OF > 20 mmHg

PULSE RATE OF > 100 /min AT TIME ZERO

PRIMARY CARE AND “ URGENT MANAGEMENT”

Angiography (positive on 27-77% acute LIB) Endoscopy Enteroscopy (single/double balloon; intraoperative)

Capsule endoscopy Scintigraphy (positive on 45% of LIB)

Surgery

DIAGNOSTIC EVALUATION

Enteroscope, single/double balloon

Antegrade (oral) DBE Retrograde (anal) DBE

Obscure GI bleeding Second-look endoscopy

overt occult

Capsule endoscopy

Angiography

Massive bleeding

positive

Specific management Medical treatment

PE or DBE cauterization Angiography + embolization

Laparoscopy IOE

negative

Further work-up needed?

Observation Medical treatment

Repeat routine endoscopy /CE Meckel’s scan

Laparoscopy/IOE

recurrence

positive negative

Follow up Specific management

No further Work up

NO

NO

YES

YES

Wireless Capsule Endoscopy

• Time efficient, patient friendly, sensitive method to visualize the small bowel

• Disadvantages

– No therapeutics

– Unable to control movement

– Unable to clear bubbles and debris

PillCamTM SB Vascular Lesions

Shonlein Henoch

3-7 aa GI localization 45-75%

~15%: GI bleeding and other GI symptoms preceding skin lesions

DD other vasculitis

Ulcers - Crohn’s disease

- Ulcer isolated (idiopathic, NSAIDs, 6 mercapt, ischemic) - Meckel’s diverticulum, Zollinger Ellison’s syndrome,

Vasculitis - Infections (Clostridium difficile, Salmonella,Tbc, Tifo, Campylobacter

jejuni, Yersinia, Rotavirus)

Small bowel

Crohn's disease

•panenteric inflammation

•characteristically segmental

Lenaerts C and others Pediatrics 83:777-781,1989

Crohn's disease

Example of Crohn's disease involving the small intestine. Here, the mucosal surface demonstrates an irregular nodular appearance with hyperemia and focal superficial ulceration.

MECKEL’S DIVERTICULUM

Treatment only of vascular lesions bleeding Always exclude coagulation disorders Individual therapy; there is no uniformity of treatment

Realistic treatment goals Carefully evaluate the entire small intestine before any surgery Other diseases often coexist

THERAPHY

“expertise”

THERAPHY

VASOACTIVE DRUGS SPLANCHNIC VASOCONSTRICTION,

REDUCING FLOW AND PORTAL PRESSURE

OCTEOTRIDE

4-8 g/kg/die

bolus ev 1-2 µg/Kg (5 min) 1-2 g/kg/h

time: RANGE 28.5-168 h

SOMATOSTATIN 50-100 mcg seguiti da

250 mcg/h ev for 24-120 h

GLYPRESSIN 1-2 mcg IV every

4-6h for 24h

R. De Franchis “ SMT and analogues and other vasoactive drugs in the treatment of bleeding oesophageal varices “

Digestive and Liver Disease 36 ( Suppl.1), 2004, S 93-100

….safe and effective in controlling nonarterial severe GI bleeding in children …..

…an important adjunct in the initial treatment of patients with severe GI bleeding and requiring stabilization before endoscopic or other investigative procedures…

ENDOSCOPIC TREATMENT OF BLEEDING

Therapeutic modalities

Contact thermal devices (eg, heater probe [HP], multipolar electrocautery[MPEC] probes, and hemostatic graspers) Noncontact thermal devices (eg, argon plasma coagulator [APC]) Injection needles Mechanical devices (eg, band ligators, clips, and loops)

CONCLUSIONS

ACCURATE DIAGNOSTIC ITER IS ESSENTIAL

IN MANAGEMENT OF DIGESTIVE BLEEDING

PHISICAL AND PSYCHOLOGICAL DIFFICULTIES

AND THE COSTS OF INAPPROPRIATE INVESTIGATIONS

ARE NOT REFUNDABLE………….!!!!!!!

Documents

Giuliano Lombardi - Gastroenterologiaroma.it present as an .. ACUTE and life-threatening event CHRONIC BLEEDING which might manifest as iron-deficiency anemia, fecal occult blood or