Common Sources of GI Bleeding: Anal Fissures in First Two Years of Life (3)
a. Superficial tear of squamous lining
b. Large constipation stool
c. Child learns to hold back
Common Sources of GI Bleeding: Cow’s Milk Protein Intolerance (6)
a. Cow’s milk and soy are most often responsible
b. Appear health and normal weight gain
c. Allergic eosinophilic gastroenteritis RARE
d. Infiltration of GI tract with eosinophils May have iron deficiency anemia, FTT
e. Watery diarrhea
f. Postprandial vomiting
Common Sources of GI Bleeding: Polyps (3)
a. Beyond two years of age, polyps are most common cause of painless lower GT Bleeding
b. Poly will outgrow its blood supply and slough off of its stalk
c. Usually left sided and solitary; Usually painless
Common Sources of GI Bleeding: Genetic Syndromes Associated with Multiple Polpys (3)
- Familial polyposis
- Peutz Jegher syndrome
* Will have freckles all over their face and body
* Freckles around the lips
* HALLMARK: Freckles
* Look for family history of colon cancer - Gardner’s syndrome
Lower GI bleed: Neonatal Period (11)
- Cow’s milk protein allergy
- Midgut volvulus
- Hirschsprungs
- DIC
- Intussusception
- Vascular malformation
- Anal fissures
- Swallowed maternal blood
- Infectious diarrhea
- Duplication
- Hemorrhagic disease of newborn
Lower GI bleed: 30 days to 2 years old (10)
a. Anorectal lesion
b. Infectious diarrhea
c. Intussusception
d. Meckel’s
e. Midgut volvulus
f. Vascular malformation
g. Duplication
h. Hemolytic uremic syndrome
i. IBD
j. Acquired thrombocytopenia
Lower GI bleed: 2-5 years old (11)
- Anal Fissure
- Infectious diarrhea
- Juvenile Polyp
- Intussusception
- Henoch-Schonlein purpura
- Meckels
- HUS
- IBD
- Ulcer
- Vasculitis
- Nodular lymphoid Hyperplasia
Lower GI bleed: 5-15 years old (12)
- Infectious diarrhea
- HUS
- Polyp
- IBD
- Hemorrhoids
- Anal fissure
- Meckel’s
- Intussusception
- HSP
- Vasculitis
- IBD-Ulcer Colitis
- Nodular lymphoid Hyperplasia
Lower GI bleed: History (6)
- Weight loss, anorexia, arthralgia, red eyes
- Dietary history: Milk
- Exposure to infection
- Family history bleeding polyps
- Drug history: NSAID, salicylates, iron
- Constipation
Lower GI bleed: Physical Exam (2)
a. Abdominal tension Mass
b. Anus, rectal; skin tags, polyps, fissure
Lower GI bleed: Labs to obtain (4)
a. CBC
b. Stool C and S
c. Stool O and P
d. Stool for WBC
Lower GI bleed: Diagnostics (5)
a. Gastric aspirate
b. Acute abdominal series
c. Ultrasound
d. CT of abdomen
e. Air contract enema
Lower GI bleed PE: Possible Dx for fever
Points to infection
Lower GI bleed PE: Possible Dx for petechiae, ecchymosis
Coagulopathy, thrombocytopenia –> Henoch Schonlen purpura
Lower GI bleed PE: Possible Dx for cutaneous perioral and oral pigmentation
Peutz Jegher syndrome
Lower GI bleed PE: Possible Dx for digital clubbing, palmar erythema, gynecomastia and hepatosplenomegaly
cirrhosis of the liver
Pancreatitis overview (3)
a. Inflammation within the parenchyma of the pancreas
b. Reversible
c. Acute inflammation
Pancreatitis causes (8)
- Blunt Trauma: accounts for 10% to 40% of the cases
i. Amylase may be elevated due to intestinal perforation - Systemic disease
i. Sepsis, hemolytic uremic syndrome, SLE - Structure/biliary disease
i. Pancreas divisum with presence of a dorsal and ventral pancreas Gallbladder sludge - Medications
- Infections—mumps, hepatitis A, rotavirus, hepatitis E, varicella and host of virus
- Metabolic
- Hereditary: CF, Abnormalities of the cationic trypsinogen gene(PRSS1)
- Idiopathic
Pancreatitis symptoms (6)
- Abdominal pain
- Epigastric region in 62% to 89% of cases
- Can also be diffuse and in lower abdominal area
- Younger children fever and irritability
- Nausea or vomiting
- Fever and jaundice
Pancreatitis physical exam (7)
- Uncomfortable with movement*****
- Quiet bowel sounds
- Abdominal tenderness
- Dyspnea
- Epigastric mass (pseudo cyst formation)
- Hemorrhagic pancreatitis with bluish flanks (Grey Turner sign)*****
- Bluish area surround the umbilicus (Cullen Sign)
Pancreatitis diagnostics (10)
- Ultrasound initial test
i. Pancreas is difficult to visualize but this is first test - CT with contrast can help evaluate severity
- MRI limited data in children
- Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasound
- Elevation of serum amylase and lipase
- Sensitivity in amylase is 50 to 90%
- Lipase remains elevated longer and correlates with severity
- Elevation of both sensitivity of 94% CBC
- Elevation of WBC and Hematocrit due to hemoconcentration and volume depletion
- Hypocalcemia and hyperglycemia in acute pancreatitis
Pancreatitis treatment (3)
a. Pain control
b. Fluid restriction
c. Nutrition; Jejunal feedings
