BLEEDING PER RECTUM IN CHILDREN SURGICAL CAUSES AND MANAGEMENT

1. BLEEDING PER RECTUM IN CHILDREN SURGICAL CAUSES AND MANAGEMENT DR NANDLAL KELLA ASSOCIATE PROFESSOR AND CHAIRMAN DEPT; OF PEDIATRIC SURGERY LUMHS JAMSHORO

2. Mommy, the toilet’s red!! DR NANDLAL KELLA ASSOCIATE PROFESSOR AND CHAIRMAN DEPT; OF PEDIATRIC SURGERY LUMHS JAMSHORO

3. Objectives Definitions Common causes of GI bleeding in different age group Differential Diagnoses Diagnostic and therapeutic approach diagnostic and therapeutic approach to the pediatric patient with GI bleeding Review the most common etiologies for GI bleeding in pediatric patients in various age groups

4. Important Definitions Hematochezia – passage of bright or dark red blood per rectum in general, the redder the blood, the more distal the site of bleeding Melena – the passage of black, tarry stools indicates likely UGI bleed (proximal to the ileocaecal valve) Hemetemesis – vomitus containing frank blood or brown-black “coffee grounds”(proximal to ligament of Treitz)

5. Further assessment • Is it really blood? • Hemoccult stool, gastroccult emesis • Apt-Downey test in neonates • Nasogastric aspiration and lavage • Clear lavage makes bleeding proximal to ligament of Treitz unlikely • Coffee grounds that clear suggest bleeding stopped • Coffee grounds and fresh blood mean an active upper GI tract source

6. Substances that deceive • Red discoloration • candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin • Black discoloration • bismuth, activated charcoal, iron, spinach, blueberries, licorice

7. History • Present illness • duration of bleeding , Quality of bleeding ))fresh, clotted or mixed) or quantity of bleeding • associated GI symptoms (vomiting, diarrhea, pain) • Review of systems • GI disorders, liver disease, bleeding diatheses • medications (NSAID’s, warfarin) • Family history :hemophilia or other bleeding disorder

8. History • In newborn • We have to focus mode of delivery • Laboured delivered • Meconeum aspiration • Severe respiratory distress • Trauma • Sepsis/shock

9. Physical examination • Vital signs, including orthostatics • Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill • ENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding • Abdomen: organomegaly, tenderness, ascites, caput medusa • Perineum: fissure, fistula, induration • Rectum: gross blood, melena, tenderness

10. Gastrointestinal Bleeding • Blood streaks on the stool indicates anal outlet bleeding • Blood mixed with stool indicates bleeding source higher than the rectum • Blood with mucus indicates an infectious or inflammatory disease • Currant jelly-like material indicates vascular congestion and hyperemia (intussusception or midgut volvulus)

11. DDx: neonates • Upper GI bleeding • swallowed maternal blood • stress ulcers, gastritis • duplication cyst • vascular malformations • vitamin K deficiency • hemophilia • maternal ITP • maternal NSAID use • Lower GI bleeding • swallowed maternal blood • dietary protein intolerance • infectious colitis • necrotizing enterocolitis • Hirschsprung’s enterocolitis • duplication cyst • coagulopathy • vascular malformations

12. Presentation and Management in newborn in bleeding • presentation • S/s of sepsis • Respiratory distress • Distension of abdomen • Shock • Hypothermia • Hypoglycemia • Diagnosis • Clinical Examination • Investigations; • CBC, PT APTT Calcium • Level ,Glucose level, • Urea Creatinine and blood • C/S • Ultrasound and X-Rays

13. Management • Temp Maintenance • NPO and NG Tube • I/V Fluid • Blood Transfusion • Vit K • Fresh frozen plasma • I/V antibiotics • Oxygen inhalation • If surgical issue ; intestinal perforation After resuscitation intervention may be done or patient is very sick then only peritoneal cannulation or catheterization is help full.

14. Neonatal stress ulcers or gastritis • Causes • Shock • Sepsis • Dehydration • Traumatic delivery • Severe respiratory distress • Hypoglycemia • Cardiac condition

15. Clinical Findings in PUDNeonatal Period • Gastric ulcers are more common than duodenal ulcers in neonates • Spontaneous Perforation is a more common presentation than bleeding • Frequently associated with: • Hypoxia, Sepsis, RDS, CNS disorder

16. DDx: infants • Hematemesis, melena • Esophagitis • Gastritis • Duodenitis • Hematochezia • Anal fissures • Intussusception • Infectious colitis • Dietary protein intol. • Meckel’s diverticulum • Duplication cyst • Vascular malformation

17. DDx: children • Upper GI bleeding • Esophagitis • Gastritis • Peptic ulcer disease • Mallory-Weiss tears • Esophageal varices • Pill ulcers • Lower GI bleeding • Anal fissures • Infectious colitis • Polyps and prolapse • Lymphoid nodular hyperplasia • IBD • HSP • Intussusception • Meckel’s diverticulum • HUS

20. Clinical Findings in PUDInfants and Toddlers • Presenting symptoms: • Vomiting • Poor feeding • Irritability during and after eating • Abdominal distention • Hematemesis, melena • Commonly associated with underlying disease in this age group

21. Clinical Findings in PUDPre-Schoolers • Periumbilical or generalized abdominal pain • Vomiting after eating • Nocturnal or early morning pain • Gastric ulcers are as common as duodenal ulcers • Primary ulcers are as common as secondary ulcers

22. Clinical Findings in PUDSchool Age • Male: Female ratio is 3:1 • Burning epigastric pain • Nocturnal pain • Melena, hematemesis, fecal occult blood • Primary ulcers are more common than secondary ulcers

23. Anal Causes • Hemorrhoids • Fissure • Perianal abscess/ fissure • Anal carcinoma

24. Hemorrhoids • Usually uncommon in children • Usually benign • When seen, must suspect portal hypertension • Avoidance of chronic constipation, fecal impaction or other irritating local factors

25. Anal Fissure • Small laceration of the mucocutaneous junction of the anus. • Acquired lesion secondary to the forceful passage of a hard stool, mainly seen in infancy. • Fissures appear to be the consequence and not the cause of constipation.

26. Anal Fissure Acute posterior anal fissure producing pain on digital exam. Sphincter tone increased. Exam limited by pain that may respond to NTG and Lidocaine.

27. Anal Fissure • Usually a history of constipation is elicited. • painful bowel movement • Patient retains the stool voluntarily to avoid a painful bowel movement • Bright red blood on the surface of the stool

28. Anal Fissure • Inspection of the Anal area • Infant’s hips are put in acute flexion • Buttocks are separated to expand the folds of the perianal skin • Fissure becomes evident as a minor laceration

29. Anal Fissure • The most important element in the treatment is for the parents to understand the origin of the laceration and the mechanism of the cycle of constipation. • Goal of the treatment : REVERSE the CYCLE • soft stools to avoid overstretching

30. Anal Fissure • Stool softener • Avoid hard stools and diarrhea • Treat the primary cause of constipation • Local application of pain killer

31. Anal Fissures in older children • A linear tear in the skin of the anal canal caused by passage of a hard stool, diarrhea, straining, sitting too long. May be seen in IBD or after rectal surgery. Increased sphincter tone. • Deep fissures expose underlying internal sphincter, white color. • Spasm, irritation, itching, pain after BM, and bleeding. • Acute fissures may heal with sitz baths, fiber, brief Rx steroid cream, leading to thin skin and sentinel pile. Pile may shrink after Rx. If persists may be excised after Rx of fissure completed. • Associated hemorrhoids are common. • NTG, Lidocaine ointment, fiber, fluids, no straining, banding. • Infected fissures Rx Flagyl.

32. Anal Fissure Rx • 6 weeks of twice a day intra-rectal NTG ointment, .12%, then 6 weeks of once a day NTG. Watch for headaches, tachycardia, or light headiness. needed. • 2 % Diltiazem, calcium channel blocker. ointment is an alternative in those with headaches and is used three time per day and may take longer. • Botox effectively paralyzes internal sphincter but costs $600 per vial and may cause incontinence. May be used in combination with NTG. • Surgery is effective but has a 10% incontinence rate.

33. Skin tags • Skin tags are extra folds of skin around the anal verge. Caused by stretching of skin from dilated external hemorrhoids. May interfere with cleaning and add to pruritus ani. Cosmetic issue to some. • Skin tag and can be removed or left alone depending on preference. • Removal requires local anesthesia and office excision. Takes 15 minutes and leads to 2-3 days of discomfort.

34. Associated skin tags

35. Colon Polyps • The term polyp of the colon refers to a protuberance into the lumen from the normally flat colonic mucosa. • Polyps are usually asymptomatic but may ulcerate and bleed, cause tenesmus if in the rectum,.

36. Colon Polyps • Neoplastic (adenomas and carcinomas), • Hamartomatous, • Non-neoplastic, and • Submucosal (neoplastic / non-neoplastic).

37. Non-neoplastic polyps • Hyperplastic • Mucosal • Inflammatory pseudopolyps • Submucosal

38. Juvenile Polyps • Juvenile polyps are hamartomatous lesions that consist of a lamina propria and dilated cystic glands rather than increased numbers of epithelial cells

39. Juvenile Polyp • May be single or a few, located throughout the colon; virtually always benign • Occasionally multiple (juvenile poyposis coli) • In JPC, may have potential for adenomatous change • Diagnosis: Colonoscopy • Treatment: Endoscopic Polypectomy

40. Juvenile colonic polyp

41. Familial Juvenile Polyposis • FJP is associated with an increased risk for the development of colorectal cancer, and in some families, gastric cancer, especially where there are both upper and lower gastrointestinal polyps.

42. Diagnosis and Treatment • Diagnosis almost always is made at digital rectal examination. • Double contrast barium enema is not suggested • Endoscopy for diagnostic as well for therapeutic • Polyps biopsy necessary to exclude malignancy

43. Rectal prolapse

44. Definition • Protrusion of few or all layers of rectal wall through anal sphincter

45. Etiology • Constipation • Diarrhoea • Parasites • Neuro muscular and pelvic disorders • Malnutrition • Surgical causes ARM Cloacal exstrophy

46. Presentation • Prolapse of rectum • Incontinence of stool • Bleeding from prolapse

47. management • Treat the cause • Pushing back of prolapsed rectum • Decrease straining • Laxatives and stool softener • High protein diet • Rarely surgery or sclerotherpy

48. What is Meckel’s • A Meckel's diverticulum is a small bulge in the small intestine present at birth • It is a vestigial remnant of the omphalomesenteric duct, and is the most frequent malformation of the gastrointestinal tract • It is present in approximately 2% of the population, found twice as frequently in males as females, although males more frequently experience symptoms • It is named after Johann Friedrich Meckel, who first described this type of diverticulum in 1809

49. What is Meckel’s It can usually be found within about 60-100 cm of the ileocecal valve. It is typically 3-5 cm long, runs antimesenterically and has its own blood supply

50. Symptoms of Meckel’s • Approximately 98% of people afflicted with Meckel's diverticulum are asymptomatic. If symptoms do occur, they typically appear before the age of two. • The most common presenting symptom is painless rectal bleeding, followed by intestinal obstruction, volvulus and intussusception. • Occasionally, Meckel's diverticulitis may present with all the features of acute appendicitis. Also, severe pain in the upper abdomen is experienced by the patient along with bloating of the stomach region. • At times, the symptoms are so painful such that they may cause sleepless nights with extreme pain in the abdominal area.