BLEEDING PER RECTUM IN CHILDREN

Prof. Sushmita N. BhatnagarMBBS, M.S., M.Ch,M.PHIL(Hospital Management)

HEAD, PEDIATRIC SURGERYB.J WADIA CHILDREN’S HOSPITAL, MUMBAI

CONSULTANT PEDIATRIC SURGEONBOMBAY HOSPITAL

JOINT SECRETARY ASSOCIATION OF MEDICAL CONSULTANTS

INTRODUCTION

UPPER GIT LOWER GIT

HematocheziaMalena Occult

COMMON CAUSES OF BPR

NEWBORNS

RED BLACK

UPPER GIT(Esophagus, stomach, small bowel)

.Volvulus of midgut

.Bacterial enteritis

.Drug induced

.Congenital or acquired coagulopathies. Hemorrhagic disease of newborn.Intussusception

.Erosions in stomach, esophagus, duodenum.Peptic ulcer disease

LOWER GIT( Colon, rectum, anus)

.Anal fissure

.Arterio-venous malformations

INFANTS/TODDLERS

RED BLACK

UPPER GIT

. Volvulus of midgut

. Bacterial enteritis

. Drug induced

. Congenital/acquired coagulopathies

. Gangrenous bowel-other causes

. Band obstruction

. Intussuception

. Meckel’s diverticulum

. Benign hamartomas

. Tumors - Lymphoma/Carcinoid

. GER

. Gastritis/H.Pylori/Sress/Drugs/Systemic illness/ . Peptic ulcer disease

LOWER GIT

. Rectal polyp

. Anal fissure

. Arterio-venous malformations

. Colonic polyps

OLDER CHILDREN

RED BLACK

UPPER GIT(Esophagus, stomach, small bowel)

. Esophageal varices – Portal HTN

. Gastric varices

. Volvulus of midgut

. Bacterial enteritis

. Drug induced

. Congenital/acquired coagulopathies

. Hemorrhagic disease of newborn

. Intussusception

. Esophageal varices – Portal hypertension. Peptic ulcer disease

LOWER GIT( Colon, rectum, anus)

. Anal fissure

. Inflammatory bowel disease

. Infectious diarrhoea

.Arterio-venous malformations

Quantification

MASSIVE – Evaluation & Rx of shock, control of bleed + evaluation of cause of bleed

MODERATE – hospitalisation, rapid evaluation of source of bleed, control of bleed

MILD – evaluation of cause on outpatient basis, Rx as per the source of bleed

Clinical scenarios

Clinical picture Diagnosis

Blood mixed with stools Infective – enteritis/colitis, Hemolytic Uremic syndrome, NEC, Eosinophilic enterocolitis, IBD

Blood streaks on stool Anal fissure/rectal mucosal ulcerationConstipationRectal prolapse

Blood after defecation in drops with normal stools

Rectal polypVascular anomalies of lower GIT

Blood with mucus in stools Infective Intussusception

Frank blood Volvulus of midgutArteriovenous malformationsNEC

Occult bleeding PR Worm infestationAcid peptic disease of upper GITCeliac diseaseIBDPolyposis

How could the clinician determine the severity of GI bleed?

• Physical appearance• Pallor• Hemodynamic status• Estimated volume of blood lost• Color of lost blood

Worrisome S/SPallor

DiaphoresisRestlessness

LethargyAbdominal pain

DANGER SIGNALSOrthostatic changes in HR

& BP

Clinical approach

• Look at the child – well or ill

• Look at vital parameters – hemodynamically stable or not

• Look at the abdomen – distended or normal, lump

palpable, tenderness anywhere,

• Look at the rectum – do a per rectal examination – anal

fissure, polyps

• Look at the type of blood in the stools

Can the child suspected with bleeding PR be normal?

Substances that deceive• Red discoloration• candy, fruit punch, Jell-o, beets, watermelon, laxatives,

phenytoin, rifampin

• Black discoloration• bismuth, activated charcoal, iron, spinach, blueberries,

licorice

Surgeon’s role