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Kocic M, Rasic P, Marusic V, Prokic D, Savic D, Milickovic M, Kitic I, Mijovic T, Sarajlija A. Age-specific causes of upper gastrointestinal bleeding in children. World J Gastroenterol 2023; 29:6095-6110. [PMID: 38186684 PMCID: PMC10768410 DOI: 10.3748/wjg.v29.i47.6095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/05/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.
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Affiliation(s)
- Marija Kocic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Petar Rasic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Vuk Marusic
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Dragan Prokic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Djordje Savic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Maja Milickovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Ivana Kitic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Tanja Mijovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Adrijan Sarajlija
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
- Pediatric Day Care Hospital Department, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Eastern Sarajevo, Foča 73300, Bosnia and Herzegovina
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Metezai H, Wahid A, Jones C, Evans J. Fifteen-minute consultation: Rectal bleeding in children. Arch Dis Child Educ Pract Ed 2023; 108:320-325. [PMID: 36564158 DOI: 10.1136/archdischild-2022-324626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022]
Abstract
Bleeding per rectum in children is an infrequent presentation associated with a wide range of differential diagnoses, from benign to life-threatening. Irrespective of the underlying aetiology, it is typically a worrisome symptom for caregivers. Published data are limited, particularly for the UK population, from which to provide clear evidence-based guidance for assessment and management of infants, children and young people presenting with bleeding per rectum. In this Fifteen-Minute Consultation, we therefore explore the common aetiologies and combine opinions from acute paediatrics, paediatric gastroenterology and paediatric surgery to offer a structure for a diagnostic approach and initial management of lower gastrointestinal bleeding in infants, children and young people.
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Affiliation(s)
- Huria Metezai
- Paediatric Emergency Department, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Amar Wahid
- Department of Paediatric Gastroenterology, Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Ceri Jones
- Department of Paediatric Surgery, Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jordan Evans
- Paediatric Emergency Department, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
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Shah P, Rubia A, Iqbal N, Gonzalez L, Basak RB. Blood Clots Per Rectum in a Pediatric Patient With Salmonella Enteritis: A Case Report. Cureus 2022; 14:e27618. [PMID: 36059330 PMCID: PMC9436443 DOI: 10.7759/cureus.27618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/11/2022] Open
Abstract
Infection is a common cause of hematochezia in children. While infectious diarrhea can present with bloody stools, it is rare to have the passage of frank blood clots per rectum in the pediatric population. This is a case of a seven-year-old male who presented with vomiting, diarrhea, severe abdominal pain, and passage of blood clots per rectum. As symptoms progressed, consideration of non-infectious causes was investigated and subsequently ruled out. The stool polymerase chain reaction (PCR) was positive for Salmonella species, while stool culture was negative for any enteropathogen. This report highlights the unusual occurrence of the passage of blood clots per rectum in a child with salmonella enterocolitis.
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Affiliation(s)
- Puja Shah
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Arnikka Rubia
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Nimrah Iqbal
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | | | - Ratna B Basak
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
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Kang A, Kim SH, Cho YH, Kim HY. Surgical perspectives of symptomatic omphalomesenteric duct remnants: Differences between infancy and beyond. World J Clin Cases 2021; 9:11228-11236. [PMID: 35071553 PMCID: PMC8717527 DOI: 10.12998/wjcc.v9.i36.11228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/29/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The clinical manifestations of omphalomesenteric duct remnant (OMDR) can vary with the age at diagnosis, from asymptomatic incidental findings to symptoms related to gastrointestinal complications. The lifelong complication rates are reported as 4%-34%, and complications are more common in patients younger than 2 years of age. The authors attempted to identify different clinical features and management for the various pediatric age groups.
AIM To find surgical perspectives for the pediatric age-related variants of OMDR and make recommendations for optimal management.
METHODS The medical records of pediatric patients diagnosed with OMDR were reviewed retrospectively. Fifteen patients diagnosed based on incidental findings during other surgeries were excluded. The patients were divided into two groups based on age: < 12 mo (infants) and > 12 mo (beyond infancy). We analyzed the demographic characteristics, clinical manifestations, diagnostic tools, surgical procedures, and clinical outcomes of the patients and compared them for the age groups. Chi-squared and Fisher's exact tests were used for nominal scales and a Mann-Whitney test was used for ratio scales.
RESULTS A total of 35 patients (7 infants, 28 children beyond infancy) were finally included. In both groups, Meckel's diverticulum (MD) was the most common type of OMDR, while umbilical lesions were more common in the infant group (P = 0.006). Hematochezia and abdominal pain were common in the beyond infancy group, while umbilical lesions were the most frequent symptoms in the infant group. Several diagnostic tools were used, but Meckel's scan was most useful in diagnosing OMDR in patients with painless rectal bleeding. Minimally invasive surgery was more commonly performed for children than for infants (P = 0.016). Single-incision laparoscopic surgery (SILS) was performed for fifteen patients who underwent laparoscopic surgery. There were only three cases of postoperative complications, and all patients survived in good condition.
CONCLUSION The clinical type of OMDR varies with age, umbilical lesions in infants, and MD beyond infancy. SILS is effective for managing children with MD regardless of age.
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Affiliation(s)
- Ayoung Kang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Soo-Hong Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Yong-Hoon Cho
- Department of Surgery, Pusan National University School of Medicine, Yangsan 50612, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Hae-Young Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
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Henkel S, Vetterly C, Squires R, McKiernan P, Squires J. Pharmacological management of portal hypertension and its complications in children: lessons from adults and opportunities for the future. Expert Opin Pharmacother 2020; 22:291-304. [PMID: 33074032 DOI: 10.1080/14656566.2020.1825685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. AREAS COVERED The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. EXPERT OPINION Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
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Affiliation(s)
- Sarah Henkel
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Carol Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy , Pittsburgh, PA
| | - Robert Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - James Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
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Pokhrel B, Daha SK, Shrestha N, Sah PK, Khanal N. Massive Gastrointestinal Bleeding Masquerading Coagulopathy in Acute Viral Hepatitis: A Case Report. JNMA J Nepal Med Assoc 2020; 58:419-422. [PMID: 32788760 PMCID: PMC7580357 DOI: 10.31729/jnma.5007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hepatitis A virus infection is typically an acute self-limiting illness associated with general nonspecific symptoms such as fever, malaise, anorexia, nausea, vomiting, abdominal pain or discomfort, and diarrhea. This may have atypical manifestation like prolonged cholestasis. Despite having varying typical and atypical manifestations such a case may present with life-threatening bleeding from a co-existing surgical cause such as perforation of Meckel's diverticulum.
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Affiliation(s)
| | | | - Nikhil Shrestha
- Oxford University Clinical Research Unit-Nepal, Lalitpur, Nepal
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Abstract
Gastrointestinal endoscopy permits direct observation of the alimentary tract, acquisition of mucosal tissue for histopathologic examination, and other diagnostic and therapeutic maneuvers. Endoscopes of appropriate size for many neonates and an expanding array of compatible tools and accessories have broadened what is possible, although few neonatal data exist to guide use. Evaluation and treatment of gastrointestinal bleeding, evaluation and dilation of fibromuscular congenital esophageal stenosis, and the bedside placement of gastrostomy tube have been described. Careful consideration of risks, benefits, and discussions between involved specialties permit patient-specific application of these tools and techniques to augment care of this vulnerable population.
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Affiliation(s)
- Ethan A Mezoff
- Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA; Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Kent C Williams
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Steven H Erdman
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
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Presentation and Management of Food Allergy in Breastfed Infants and Risks of Maternal Elimination Diets. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:52-67. [DOI: 10.1016/j.jaip.2019.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
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Green DS, Abdel‐Latif ME, Jones LJ, Lui K, Osborn DA. Pharmacological interventions for prevention and treatment of upper gastrointestinal bleeding in newborn infants. Cochrane Database Syst Rev 2019; 7:CD011785. [PMID: 31265739 PMCID: PMC6605977 DOI: 10.1002/14651858.cd011785.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding is typically a mild, self-limiting condition that can affect both preterm and term neonates, although it can be severe particularly when associated with co-morbidities. Pharmacological interventions with a proton pump inhibitor (PPI), H2 receptor antagonist (H2RA), antacid, bismuth and sucralfate may have effects on both the prevention and treatment of upper gastrointestinal bleeding in infants. OBJECTIVES To assess how different pharmacological interventions (PPIs, H2RAs, antacids, sucralfate or bismuth salts) administered to preterm and term neonates for the prevention or treatment of upper gastrointestinal bleeding to reduce morbidity and mortality compare with placebo or no treatment, supportive care, or each other. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 6), MEDLINE via PubMed (1966 to 12 July 2018), Embase (1980 to 12 July 2018), and CINAHL (1982 to 12 July 2018). We also searched clinical trial databases, conference proceedings, the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials, and online for Chinese literature articles. SELECTION CRITERIA We selected randomised, quasi-randomised and cluster-randomised trials involving preterm and term neonates. Trials were included if they used a proton pump inhibitor, H2 receptor antagonist, antacid, sucralfate or bismuth either for the prevention or treatment of upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. We conducted meta-analysis using a fixed-effect model. We used the GRADE approach to assess quality of evidence. MAIN RESULTS Eleven studies with 818 infants met the criteria for inclusion in this review.Four trials with 329 infants assessed the use of an H2 receptor antagonist for prevention of upper gastrointestinal bleeding in high-risk newborn infants. Meta-analysis of these four trials identified a reduction in any upper gastrointestinal bleeding when using an H2 receptor antagonist (typical risk ratio (RR) 0.36, 95% confidence interval (CI) 0.22 to 0.58; typical risk difference (RD) -0.20, 95% CI -0.28 to -0.11; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 9). The quality of evidence was moderate. A single trial with 53 infants assessing prevention of upper gastrointestinal bleeding reported no difference in mortality in infants assigned H2 receptor antagonist versus no treatment; however the quality of evidence was very low.Seven trials with 489 infants assessed an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) for treatment of gastrointestinal bleeding in newborn infants. Meta-analysis of two trials (131 infants) showed no difference in mortality from use of a H2 receptor antagonist compared to no treatment. The quality of evidence was low. Meta-analysis of two trials (104 infants) showed a reduction in duration of upper gastrointestinal bleeding from use of an inhibitor of gastric acid compared to no treatment (mean difference -1.06 days, 95% CI -1.28 to -0.84). The quality of evidence was very low. Meta-analysis of six trials (451 infants) showed a reduction in continued upper gastrointestinal bleeding from use of any inhibitor of gastric acid compared to no treatment (typical RR 0.36, 95% CI 0.26 to 0.49; typical RD -0.26, 95% CI -0.33, -0.19; NNTB 4, 95% CI 3 to 5). The quality of evidence was low. There were no significant subgroup differences in duration of upper gastrointestinal bleeding or of continued upper gastrointestinal bleeding according to type of inhibitor of gastric acid. A single trial (38 infants) reported no difference in anaemia requiring blood transfusion from use of a H2 receptor antagonist compared to no treatment.Although no serious adverse events were reported from the use of a H2 receptor antagonist or proton pump inhibitor, some neonatal morbidities - including necrotising enterocolitis, ventilator-associated pneumonia, duration of ventilation and respiratory support, and duration of hospital stay - were not reported. Long-term outcome was not reported. AUTHORS' CONCLUSIONS There is moderate-quality evidence that use of an H2 receptor antagonist reduces the risk of gastrointestinal bleeding in newborn infants at high risk of gastrointestinal bleeding. There is low-quality evidence that use of an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) reduces the duration of upper gastrointestinal bleeding and the incidence of continued gastric bleeding in newborn infants with gastrointestinal bleeding. However, there is no evidence that use of an inhibitor of gastric acid in newborn infants affects mortality or the need for blood transfusion. As no study reported the incidence of necrotising enterocolitis, ventilator- or hospital-associated pneumonia, sepsis, or long-term outcome, the safety of inhibitors of gastric acid secretion is unclear.
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Affiliation(s)
- Daniel Stephen Green
- Australian National UniversityThe Medical School, College of Health and MedicineActon, CanberraACTAustralia2601
- Concord Repatriation General HospitalHospital RoadConcord, SydneyNSWAustralia2139
| | - Mohamed E Abdel‐Latif
- Australian National UniversityDiscipline of Neonatology, The Medical School, College of Medicine and Health54 Mills RoadActon, CanberraACTAustralia2601
- Centenary Hospital for Women and Children, Canberra HospitalDepartment of NeonatologyBuilding 11, Level 2, 77 Yamba DriveGarranACTAustralia2605
| | - Lisa J Jones
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownNSWAustralia
| | - Kei Lui
- Royal Hospital for WomenDepartment of Newborn CareBarker StreetRandwickNew South WalesAustralia2031
- Lei LuiSchool of Women's and Children's HealthSydneyNSWAustralia2052
| | - David A Osborn
- Central Clinical School, School of Medicine, The University of SydneySydneyAustralia2006
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McClelland K, Ibrahim J. Case 3: Abdominal Distention and Bloody Stools in a 2-week-old Term Neonate. Neoreviews 2019; 20:e415-e418. [PMID: 31261109 DOI: 10.1542/neo.20-7-e415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Katybeth McClelland
- Division of Newborn Medicine, Children's Hospital of Pittsburgh/UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - John Ibrahim
- Division of Newborn Medicine, Children's Hospital of Pittsburgh/UPMC Magee-Womens Hospital, Pittsburgh, PA
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Zheng W, Jiang L, Jia X, Long G, Shu X, Jiang M. Analysis of risk factors and development of scoring system to predict severity of upper gastrointestinal bleeding in children. J Gastroenterol Hepatol 2019; 34:1035-1041. [PMID: 30462839 DOI: 10.1111/jgh.14548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/29/2018] [Accepted: 11/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Upper gastrointestinal bleeding is a rare and potentially life-threatening condition in children. Herein, clinical features and risk factors in children with upper gastrointestinal bleeding were analyzed, and a clinical scoring system was constructed to assess severity. METHODS This retrospective cohort study involved 224 children hospitalized with upper gastrointestinal bleeding between January 2012 and April 2018. Demographic data, clinical information, and laboratory test results on admission were statistically examined. RESULTS Out of 224 upper gastrointestinal bleeding cases, 76 were diagnosed as severe and 148 as mild cases according to the rate of blood loss and severity. Severe group was significantly different from mild group in 23 items including age, number of patients aged more than 7 years, and so forth (P < 0.01 or P < 0.05). Positive detection rate of bleeding etiology was gradually decreased (P < 0.01) in relation to delay in timing of endoscopy. Analysis of logistic regression evinced five independent risk factors for severe cases to be associated with poor consciousness, hemoglobin < 80 g/L, hemoglobin drop of > 20 g/L, hematochezia, and anemic appearance (P < 0.01 or P < 0.05). Using these five parameters, a number of scoring models were tested. The most predictive resulted in a scoring system constructed with a total of 16 and a cutoff for intervention of 8. CONCLUSIONS Amalgamation of risk factors with the scoring system plays an important role in assessing upper gastrointestinal bleeding severity in children.
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Affiliation(s)
- Wei Zheng
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Linmei Jiang
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xinyi Jia
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Gao Long
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoli Shu
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mizu Jiang
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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The utility of guaiac stool testing in the detection of gastrointestinal complications in infants with critical congenital heart disease. Cardiol Young 2019; 29:655-659. [PMID: 31155016 DOI: 10.1017/s1047951119000659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Guaiac stool testing has been routinely used as a method to detect gastrointestinal complications in infants with critical congenital heart disease (CHD); however, the sensitivity and specificity have not been established. METHODS A retrospective chart review was performed investigating the presence of heme-positive stools and subsequent gastrointestinal complications as well as time to goal caloric intake and radiograph exposure. RESULTS The presence of heme-positive stools was not a statistically significant factor in patients with critical CHD that experienced gastrointestinal complications. Additionally, patients with heme-positive stools did undergo more abdominal X-rays than those with heme-negative stools. CONCLUSIONS The routine use of guaiac stool testing in infants with critical CHD is not a predictor of possible gastrointestinal complications and leads to more radiograph exposure for the patient. Close clinical monitoring can be used to evaluate feeding tolerance in infants with critical CHD.
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Drapkin Z, Franchek-Roa K, Srinivas GL, Buchi KF, Miescier MJ. Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors. Am J Emerg Med 2019; 37:1153-1159. [PMID: 30952605 DOI: 10.1016/j.ajem.2019.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022] Open
Abstract
Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.
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Affiliation(s)
- Zachary Drapkin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA; Department of Surgery, Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | | | - Ganga L Srinivas
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Karen F Buchi
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michael J Miescier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
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14
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Mehr S, Brown-Whitehorn T. What do allergists in practice need to know about non-IgE-mediated food allergies. Ann Allergy Asthma Immunol 2019; 122:589-597. [PMID: 30935977 DOI: 10.1016/j.anai.2019.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Sam Mehr
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Allergy and Immunology, Children's Hospital at Westmead, Sydney, New South Wales, Australia.
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology, Department of Pediatric, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
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Heinz P, Wintermeyer P, Hosie S. Überraschung in der Windel. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0556-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Jafari SA, Kiani MA, Kianifar HR, Mansooripour M, Heidari E, Khalesi M. Etiology of gastrointestinal bleeding in children referred to pediatric wards of Mashhad hospitals, Iran. Electron Physician 2018; 10:6341-6345. [PMID: 29629057 PMCID: PMC5878028 DOI: 10.19082/6341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022] Open
Abstract
Background Gastrointestinal (GI) bleeding, which has several clinical manifestation and origins, is known as one of the most life-threatening events in children. Several etiologies have been suggested for GI bleeding. Objective To determine the most important causes of GI bleeding in children referred to Ghaem Hospital and Dr. Sheikh Hospital, Mashhad, Iran. Methods In this cross-sectional study, after obtaining written informed consent of their parents, 113 patients aging from newborn infants to 18-year-old children with GI bleeding admitted to Ghaem Hospital and Dr. Sheikh hospital were enrolled in this study from June 2012 to June 2014. After performing routine diagnostic and therapeutic procedures, a checklist containing all necessary information including demographic data, clinical history of patients, endoscopy and pathology findings, clinical and preclinical information were collected. The data were then analyzed using Statistical Package for the Social Sciences (SPSS) version 16. Results Of a total 113 study children, 61 (54%) were male and 52 (46%) were female. The results of this study showed that the most important causes of bleeding in upper GI among all admitted patients were prolapse gastropathy (18.6%), esophagitis (15.9%) and esophageal varices, gastritis, and coagulopathy (7.1% for each). The main causes of lower GI bleeding were polyp (32.5%), chronic nonspecific colitis (20.7%), and proctitis (18.2%). Conclusion Findings of this study indicated that prolapse gastropathy and esophagitis are more prevalent causes of upper GI bleeding. Furthermore, esophageal varices were more common in children older than 13 years. Polyp, chronic nonspecific colitis and proctitis are the most prevalent causes of lower GI bleeding.
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Affiliation(s)
- Seyed Ali Jafari
- MD, Associate Professor, Department of Pediatric Gastroenterology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Ali Kiani
- MD, Associate Professor, Department of Pediatric Gastroenterology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Reza Kianifar
- MD, Professor, Allergy research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Elahe Heidari
- MD, Assistant Professor, Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Khalesi
- MD, Assistant Professor, Department of Pediatric Gastroenterology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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17
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Kuiper GA, van Prehn J, Ang W, Kneepkens F, van der Schoor S, de Meij T. Clostridium difficile infections in young infants: Case presentations and literature review. IDCases 2017; 10:7-11. [PMID: 28791215 PMCID: PMC5536825 DOI: 10.1016/j.idcr.2017.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 12/17/2022] Open
Abstract
It has been assumed that symptomatic Clostridium difficile infections do not occur in young infants, as this specific group would lack specific C. difficile toxin receptors. As a consequence, it is often current practice not to test for C. difficile in neonates and young infants up to 2 years of age presenting with (bloody) diarrhea. The evidence to support this is, however, weak and largely based on small, poorly designed animal studies. We present two young infants with recurrent bloody diarrhea following antimicrobial therapy, positive testing for toxigenic C. difficile and successfully treated with metronidazole and vancomycin, and provide an overview of the literature on C. difficile infections in children under two years of age. Both our case histories and the literature search provide evidence for C. difficile infection as a potential cause of bloody diarrhea in neonates and young infants, in particular after previous treatment with antimicrobials.
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Affiliation(s)
- Gé-Ann Kuiper
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis locatie Oost, Amsterdam, The Netherlands
| | - Joffrey van Prehn
- Department of Medical Microbiology and Infection Control, VU Medical Center, Amsterdam, The Netherlands
| | - Wim Ang
- Department of Medical Microbiology and Infection Control, VU Medical Center, Amsterdam, The Netherlands
| | - Frank Kneepkens
- Department of Pediatric Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
| | - Sophie van der Schoor
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis locatie Oost, Amsterdam, The Netherlands
| | - Tim de Meij
- Department of Pediatric Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
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18
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Abstract
There is a broad clinical spectrum of gastrointestinal bleeding in children, ranging from subtle laboratory findings to dramatic clinical presentations. This review provides a framework for the evaluation and management of gastrointestinal hemorrhage for pediatricians. It outlines strategies for obtaining a tailored patient history and conducting a thorough physical examination that can shed light on the location, severity, and likely etiology of bleeding. It appraises blood tests, radiologic tools, and endoscopic modalities frequently used to identify and control a source of bleeding.
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Affiliation(s)
- Anita K Pai
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Victor L Fox
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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19
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Romano C, Oliva S, Martellossi S, Miele E, Arrigo S, Graziani MG, Cardile S, Gaiani F, de’Angelis GL, Torroni F. Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology. World J Gastroenterol 2017; 23:1328-1337. [PMID: 28293079 PMCID: PMC5330817 DOI: 10.3748/wjg.v23.i8.1328] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 01/01/2017] [Accepted: 01/17/2017] [Indexed: 02/06/2023] Open
Abstract
There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the "Gastro-Ped Bleed Team" of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE via PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: "upper GIB" and "pediatric" [all fields]; "lower GIB" and "pediatric" [all fields]; "obscure GIB" and "pediatric" [all fields]; "GIB" and "endoscopy" [all fields]; "GIB" and "therapy" [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.
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20
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Gastrointestinal endoscopic practice in infants: Indications and outcome. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2016. [DOI: 10.1016/j.epag.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Franke M, Geiß A, Greiner P, Wellner U, Richter-Schrag HJ, Bausch D, Fischer A. The role of endoscopy in pediatric gastrointestinal bleeding. Endosc Int Open 2016; 4:E1011-6. [PMID: 27652293 PMCID: PMC5025350 DOI: 10.1055/s-0042-109264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 05/23/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Gastrointestinal bleeding in children and adolescents accounts for up to 20 % of referrals to gastroenterologists. Detailed management guidelines exist for gastrointestinal bleeding in adults, but they do not encompass children and adolescents. The aim of this study was to assess gastrointestinal bleeding in pediatric patients and to determine an investigative management algorithm accounting for the specifics of children and adolescents. PATIENTS AND METHODS Pediatric patients with gastrointestinal bleeding admitted to our endoscopy unit from 2001 to 2009 (n = 154) were identified. Retrospective statistical and neural network analysis was used to assess outcome and to determine an investigative management algorithm. RESULTS The source of bleeding could be identified in 81 % (n = 124/154). Gastrointestinal bleeding was predominantly lower gastrointestinal bleeding (66 %, n = 101); upper gastrointestinal bleeding was much less common (14 %, n = 21). Hematochezia was observed in 94 % of the patients with lower gastrointestinal bleeding (n = 95 of 101). Hematemesis (67 %, n = 14 of 21) and melena (48 %, n = 10 of 21) were associated with upper gastrointestinal bleeding. The sensitivity and specificity of a neural network to predict lower gastrointestinal bleeding were 98 % and 63.6 %, respectively and to predict upper gastrointestinal bleeding were 75 % and 96 % respectively. The sensitivity and specifity of hematochezia alone to predict lower gastrointestinal bleeding were 94.2 % and 85.7 %, respectively. The sensitivity and specificity for hematemesis and melena to predict upper gastrointestinal bleeding were 82.6 % and 94 %, respectively. We then developed an investigative management algorithm based on the presence of hematochezia and hematemesis or melena. CONCLUSIONS Hematochezia should prompt colonoscopy and hematemesis or melena should prompt esophagogastroduodenoscopy. If no source of bleeding is found, additional procedures are often non-diagnostic.
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Affiliation(s)
- Markus Franke
- University Hospital Freiburg, Department of General and Digestive Surgery – University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Andrea Geiß
- University Hospital Freiburg, Department of General and Digestive Surgery – University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Peter Greiner
- University Hospital Freiburg, Department of Pediatric and Adolescent Medicine – University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Ulrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Hans-Jürgen Richter-Schrag
- University Hospital Freiburg, Department of Medicine II – University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Dirk Bausch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Germany
| | - Andreas Fischer
- University Hospital Freiburg, Department of Medicine II – University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Corresponding author Andreas Fischer, MD University Hospital FreiburgInterdisciplinary Gastrointestinal EndoscopyDepartment of Medicine IIHugstetter Str. 55Freiburg 79106Germany+4976127025411
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22
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Gonzalez de Alba CE, Estrada Fajardo L, Molina Berganza F, Fergie J. A 19-Year-Old Girl With Rectal Bleeding: Broadening Pediatricians' Differential Diagnoses. Clin Pediatr (Phila) 2016; 55:890-1. [PMID: 26416984 DOI: 10.1177/0009922815608280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | - Jaime Fergie
- Driscoll Children's Hospital, Corpus Christi, TX, USA
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23
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Abstract
BACKGROUND Gastrointestinal bleeding refers to loss of blood from any site of the digestive tract. In paediatric clinical practice, it is usually a complaint of children attending the emergency department as a symptom of diseases such as ulcers, gastric or oesophageal varices, gastritis, Mallory-Weiss tears, anorectal fissures, allergic colitis, infectious colitis, intussusception, Henoch-Schonlein purpura, and Meckel's diverticulum; it also occurs with high incidence in critically ill children hospitalised in intensive care units and is caused by stress-induced gastropathy. No matter what the cause of gastrointestinal bleeding, fasting is believed to be necessary due to the fear that eating may affect haemostasis or aggravate bleeding. OBJECTIVES To assess the effects and safety of fasting for haemostasis in gastrointestinal bleeding in children. SEARCH METHODS We searched EBM Reviews - the Cochrane Central Register of Controlled Trials (CENTRAL) (May 2016), Ovid MEDLINE(R) (1946 to 3 May 2016), EMBASE (1980 to 2016 Week 18), Chinese Biomedical Database (CBM) (1978 to 3 May 2016), China National Knowledge Infrastructure (CNKI) (1979 to 3 May 2016), VIP Database (1989 to 4 May 2016) and Wanfang Data (1990 to 4 May 2016). We used no restrictions on language or study setting and limited searches in CNKI and Wanfang Data to the medical field. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs in children with gastrointestinal bleeding that compared fasting with feeding. DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature search results, and there were no disagreements. MAIN RESULTS We identified no RCTs or quasi-RCTs that compared the effects and safety of fasting with feeding for haemostasis in children with gastrointestinal bleeding. No study fulfilled the criteria for considering studies for our review. AUTHORS' CONCLUSIONS There is currently no information available from RCTs or quasi-RCTs to support or refute the use of fasting for haemostasis in children with gastrointestinal bleeding.
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Affiliation(s)
- Shuang-Hong Luo
- Department of Pediatrics, West China Second University Hospital, West China Women's and Children's Hospital, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, Sichuan, China, 610041
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24
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Green DS, Abdel-Latif ME, Jones LJ, Osborn DA. Pharmacological interventions for prevention and treatment of upper gastrointestinal bleeding in newborn infants. Hippokratia 2015. [DOI: 10.1002/14651858.cd011785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Daniel S Green
- Australian National University; Medical School, College of Medicine, Biology & Environment; 54 Mills Road Acton, Canberra ACT Australia 2601
| | - Mohamed E Abdel-Latif
- Australian National University; Discipline of Neonatology, Medical School and Canberra Hospital, College of Medicine, Biology & Environment; 54 Mills Road Acton, Canberra ACT Australia 2601
| | - Lisa J Jones
- University of Sydney; Central Clinical School, Discipline of Obstetrics, Gynaecology and Neonatology; Camperdown NSW Australia
| | - David A Osborn
- University of Sydney; Central Clinical School, Discipline of Obstetrics, Gynaecology and Neonatology; Sydney NSW Australia 2050
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25
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An unusual case of hematemesis in a 12-month-old. Pediatr Emerg Care 2015; 31:433-4. [PMID: 25285388 DOI: 10.1097/pec.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 12-month-old male with a history of failure to thrive and hypothyroidism presented to a pediatric emergency department twice in a 24-hour period with complaint of hematemesis. The patient had a recent upper endoscopy and biopsy as part of a work-up for failure to thrive, but had no other pertinent positives in clinical history. Ultrasound demonstrated findings concerning for an intramural duodenal hematoma. The patient was admitted to the gastroenterology service for intravenous hydration and nasogastric decompression. He did not require any invasive management or blood products. Duodenal hematoma is a known, but very uncommon complication of upper endoscopy.
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26
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Chegondi M, Loux T, Totapally BR, Burnweit CA. Unusual etiology for upper gastrointestinal bleeding in a previously healthy child. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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27
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Kim KS, Kang CH, Kim JY. Availability of blood urea nitrogen/creatinine ratio in gastrointestinal bleeding with melena in children. Pediatr Gastroenterol Hepatol Nutr 2015; 18:30-8. [PMID: 25866731 PMCID: PMC4391998 DOI: 10.5223/pghn.2015.18.1.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/23/2014] [Accepted: 01/13/2015] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The aims of our study were to evaluate the blood urea nitrogen to creatinine ratio (BUN/Cr ratio) for distinguishing between an upper and lower gastrointestinal bleeding (GIB), and differentiating between the two most common causes of upper gastrointestinal bleeding (UGIB) presenting with melena in children. METHODS Retrospective data of patients with GIB presenting with melena were analyzed. The data from 60 cases were reviewed including demographics, laboratory findings, diagnostic modalities and results, treatments, and transfusions. RESULTS Among the 60 cases, UGIB and lower gastrointestinal bleeding (LGIB) were found in 35 cases (58.3%) and 14 cases (23.3%), respectively. The two common causes of UGIB were varices (37.1%), and peptic ulcer diseases (PUD) (31.4%). The BUN/Cr ratio of 30 or greater was higher in UGIB than LGIB (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 1.3-37.2). In UGIB, the BUN/Cr ratio of the varices group was higher than that of the PUD group (p=0.015). The OR for the BUN/Cr ratio appeared as 1.2 per unit increase in the varices group than the PUD group (95% CI, 1.03-1.3). There was no difference between the PUD group and Meckel's diverticulum group. CONCLUSION The BUN/Cr ratio was not uneven in differentiating UGIB from LGIB of children with melena in our study. This suggests that BUN/Cr ratio should be interpreted carefully.
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Affiliation(s)
- Kyu Seon Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Ho Kang
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Young Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
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28
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Abstract
• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.
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Affiliation(s)
- Gary A Neidich
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
| | - Sarah R Cole
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
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29
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Abstract
• On the basis of strong research evidence, children with severe upper gastrointestinal tract bleeding should be treated with intravenous proton pump inhibitors. • On the basis of some research evidence and consensus, children with severe gastrointestinal bleeding should be evaluated by endoscopy. • On the basis of some research evidence and consensus, children in whom endoscopy has not been able to confirm a bleeding source should be considered for capsule endoscopy.
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Affiliation(s)
- Gary A Neidich
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
| | - Sarah R Cole
- Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, and Sanford Children's Specialty Clinic, Sioux Falls, SD
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30
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Abstract
Guaiac testing the stool of very low birth weight (VLBW; <1,500 g) preterm infants has been a standard of care for many neonatal intensive care units (NICUs) and considered a diagnostic tool that could potentially provide early warning of gastrointestinal disturbances, feeding intolerance (FI), or necrotizing enterocolitis (NEC). Evidence to either support or eliminate testing stool for occult blood from standard care practices is lacking. Support to eliminate testing is often based on the knowledge that neonatal treatment interventions-such as gastric tube placement, intubation, and/or suctioning- may often result in occult blood in stools. However, there is also reasonable concern that occult blood may indicate a cascade of pathophysiological events, which may lead to FI and NEC, is in progress.Feeding intolerance remains one of the most consistent reasons VLBW preterm infants experience poor weight gain and extended hospital stays. Every nursing assessment is strategic to the early identification of contributing factors to either the development of FI or NEC. Including low-cost, noninvasive diagnostic tools to augment the findings of the nursing assessment can only help guide health care providers in appropriate decision making related to the feeding plan.
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31
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Neonatal isolated rectal bleeding and the risk of hypersensitivity syndromes. J Perinatol 2014; 34:39-42. [PMID: 24113397 DOI: 10.1038/jp.2013.129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE When rectal bleeding occurs in an otherwise asymptomatic child, it can be classified as isolated rectal bleeding (IRB). Among the different etiologies suggested for IRB, one of the most common is a hypersensitivity reaction of the bowel mucosa to digested antigens. The objective of this study was to assess the long-term outcomes and the risk of developing hypersensitivity syndromes among infants following an IRB event. STUDY DESIGN A historical prospective comparative study was carried out. The study compared 77 infants who were born at the Sheba Medical Center in Israel during the period 2002 to 2009 and who experienced a neonatal IRB event to 77 infants with the same gestational age, but without IRB. Data were obtained from hospital records and from phone interviews with the parents regarding hypersensitivity syndrome between the ages of 3 and 10 years. RESULT The IRB group was not at an increased risk of developing a hypersensitivity syndrome or gastrointestinal symptoms compared to the control group. Longer duration of breast-feeding was found to be related to a lower incidence of hypersensitivity symptoms. CONCLUSION An IRB event in the neonatal period does not increase the risk of developing hypersensitivity syndromes or food allergies during childhood.
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32
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Parra DA, Chavhan GB, Shammas A, John PR. Computed Tomography Angiography in Acute Gastrointestinal and Intra-abdominal Bleeding in Children: Preliminary Experience. Can Assoc Radiol J 2013; 64:345-50. [DOI: 10.1016/j.carj.2012.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 11/13/2012] [Accepted: 12/05/2012] [Indexed: 01/08/2023] Open
Affiliation(s)
- Dimitri A. Parra
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Image Guided Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Govind B. Chavhan
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amer Shammas
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Philip R. John
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Image Guided Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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El-Mazary AAM, Elfoly MA, Ahmed MF, Abdel-Hamed WM, Hassan ZM. Helicobacter Pylori Infection in a Group of Egyptian Children With Upper Gastro-Intestinal Bleeding. Gastroenterology Res 2013; 6:95-102. [PMID: 27785236 PMCID: PMC5051152 DOI: 10.4021/gr533e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 01/21/2023] Open
Abstract
Background Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage. Helicobacter pylori (H. pylori) is a Gram negative spiral-shaped bacterium that is found in the gastric mucous layer or adherent to the epithelial lining of the stomach. It causes more than 90% of duodenal ulcers and up to 70-80% of gastric ulcers. The relationship between H. pylori infection and upper GIT bleeding in children is still un-clear. This study aimed to estimate the incidence of H. pylori infection in children presented with upper GIT bleeding and correlation between H. pylori infection and endoscopic findings of the cause of bleeding. Methods The study included 70 children presented with upper GIT bleeding indicated for upper gastrointestinal endoscopy admitted in pediatric department, Minia University Hospital, Egypt during the period from February 2010 to December 2012. Thirty healthy children were included as a control group with age and sex matched. After medical history taking and physical examination all children were exposed for laboratory investigations (CBC, prothrombin time and concentration, liver function tests, hepatitis viral markers, blood urea and serum creatinine and Helicobacter pylori stool antigen test). Upper endoscopy was done for patients only. Patients were classified into variceal and non variceal groups according to upper endoscopy. Results Helico-pylori infection was significantly higher in children with non-variceal bleeding than controls (P = 0.02) and children with variceal bleeding (P = 0.03) with no significant difference between children with variceal bleeding and controls (P = 0.9). Both weights and BMIs centile were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 and 0.01 & 0.001 respectively). AST, ALT and direct bilirubin levels were significantly higher in variceal group than controls (P = 0.001, 0.004 & 0.001 respectively). Prothrombin concentration and albumin levels were significantly lower in variceal group than controls (P = 0.001 & 0.01 respectively). Hemoglobin levels were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 respectively). No significant differences were present as regards age, sex, height or platelets count between cases (variceal and non-variceal) and controls. Conclusions H. pylori infection is significantly higher in children with non-variceal bleeding than controls. No significant difference between children with variceal bleeding and controls. Triad of increased ALT, decreased albumin levels and negative H. pylori infection could be a significant triad in predicting variceal bleeding as a cause of upper GIT bleeding in children.
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Affiliation(s)
| | - Mostafa A Elfoly
- Pediatric Department, Minia University, Minia city, Minia, Egypt
| | - Magdy F Ahmed
- Tropical-Medicine Department, Minia University, Minia city, Minia, Egypt
| | | | - Zmzm M Hassan
- Pediatric Department, Minia University, Minia city, Minia, Egypt
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35
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Approach to a child with upper gastrointestinal bleeding. Indian J Pediatr 2013; 80:326-33. [PMID: 23504479 DOI: 10.1007/s12098-013-0987-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 02/04/2013] [Indexed: 12/17/2022]
Abstract
Upper gastrointestinal bleeding (UGIB) is a potentially life threatening medical emergency requiring an appropriate diagnostic and therapeutic approach. Therefore, the primary focus in a child with UGIB is resuscitation and stabilization followed by a diagnostic evaluation. The differential diagnosis of UGIB in children is determined by age and severity of bleed. In infants and toddlers mucosal bleed (gastritis and stress ulcers) is a common cause. In children above 2 y variceal bleeding due to Extra-Hepatic Portal Venous Obstruction (EHPVO) is the commonest cause of significant UGIB in developing countries as against peptic ulcer in the developed countries. Upper gastrointestinal endoscopy is the most accurate and useful diagnostic tool to evaluate UGIB in children. Parenteral vitamin K (infants, 1-2 mg/dose; children, 5-10 mg) and parenteral Proton Pump Inhibitors (PPI's), should be administered empirically in case of a major UGIB. Octreotide infusion is useful in control of significant UGIB due to variceal hemorrhage. A temporarily placed, Sengstaken-Blakemore tube can be life saving if pharmacologic/ endoscopic methods fail to control variceal bleeding. Therapy in patients having mucosal bleed is directed at neutralization and/or prevention of gastric acid release; High dose Proton Pump Inhibitors (PPIs, Pantoprazole) are more efficacious than H2 receptor antagonists for this purpose.
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Emergency management of lower gastrointestinal bleed in children. Indian J Pediatr 2013; 80:219-25. [PMID: 23355012 DOI: 10.1007/s12098-012-0955-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 12/21/2012] [Indexed: 12/11/2022]
Abstract
Lower gastro intestinal bleed (LGIB) is defined as any bleeding that occurs distal to the ligament of Treitz (situated at the duodeno jejunal junction). It constitutes the chief complaint of about 0.3 % of children presenting to the pediatric emergency department(ED). Among Indian children the most common causes are colitis and polyps. In most of the cases of LGIB the bleeding is small and self limiting, but conditions like Meckel's diverticulum often presents with life threatening bleeds. The approach in ED should include in order of priority-assessment and maintenance of hemodynamic stability, confirmation of LGIB and then to attempt for specific diagnoses and their management. This is achieved with help of rapid cardiopulmonary assessment, focused history and examination. The management of all serious hemodynamically significant bleeds includes, rapid IV access, volume replacement with normal saline 20 ml/kg, blood sampling (for cross matching, hematocrit, platelet, coagulogram and liver function tests), Inj. Vit K 5-10 mg IV, acid suppression with H2 antagonists/PPI and nasogastric lavage to rule out upper gastrointestinal bleed. Continuous ongoing monitoring of vital signs is important after stabilization. In ill looking infant, infectious colitis, Necrotizing enterocolitis (NEC), Hirschsprung enterocolitis and volvulus and in older infants and children, intussusceptions, typhoid fever, volvulus should be looked for. Proctosigmoidoscopy remains the first investigation to be done and reveals majority of etiology. Multidetector CT scan, Tc 99 m RBC scan, angiography and Push enteroscopy are the further investigation choices according to the clinical condition of the child. Intra operative enteroscopy is reserved for refractory cases with an obscure etiology.
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Carter BM. Feeding Intolerance in Preterm Infants and Standard of Care Guidelines for Nursing Assessments. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.nainr.2012.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
OBJECTIVES The aim of the present study was to determine the incidence of peptic ulcer bleeding (PUB) in pediatric patients. METHODS A hospital inpatient database, Premier Perspective, and an insurance claims database, MarketScan, were analyzed to estimate upper and lower limits for the annual incidence of PUB in the US pediatric population. RESULTS Using data from the Premier Perspective database and database-specific projection methodology, the total number of cases of hospitalization of pediatric patients for PUB in the United States in 2008 was estimated to be between 378 and 652. This translated to an incidence of 0.5 to 0.9/100,000 individuals in the pediatric population. Using data from the MarketScan database, the incidence of PUB in the insured pediatric population was estimated to be 4.4/100,000 individuals. Overall, 17.4% of insured pediatric patients diagnosed as having any upper gastrointestinal ulcer in 2008 were reported to have developed PUB. CONCLUSIONS The estimated incidence of PUB in the US pediatric population in 2008 ranged from 0.5 to 4.4/100,000 individuals. The total number of cases of PUB in pediatric patients in the United States each year was thus estimated to be between 378 and 3250. Such estimates provide a likely lower and upper limit for the total number of cases of the condition annually.
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Abstract
Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include variceal hemorrhage (most commonly extra-hepatic portal venous obstruction in our settings) and mucosal lesions (gastric erosions and ulcers secondary to drug intake). While most gastrointestinal bleeding may not be life threatening, it is necessary to determine the source, degree and possible cause of the bleeding. A complete and thorough history and physical examination is therefore vital. Esophagogastroduodenoscopy and colonoscopy are currently considered the first-line diagnostic procedures of choice for upper and lower GI bleeding, respectively. The goals of therapy in a child with GI bleeding should involve hemodynamic resuscitation, cessation of bleeding from source and prevention of future episodes of GI bleeding. Antacids supplemented by H2- receptor antagonists and proton pump inhibitors are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, therapeutic emergency endoscopy is the treatment of choice after initial hemodynamic stabilization of the patient. Independent prognostic factors are presence of shock and co-morbidities. Underlying diagnosis, coagulation disorder, failure to identify the bleeding site, anemia and excessive blood loss are other factors associated with poor prognosis.
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Affiliation(s)
- Vidyut Bhatia
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Intensive care management of children with acute liver failure. Indian J Pediatr 2010; 77:1288-95. [PMID: 20799075 DOI: 10.1007/s12098-010-0167-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 07/30/2010] [Indexed: 12/20/2022]
Abstract
Acute liver failure is an uncommon condition associated with multi organ involvement, high morbidity and mortality. Etiology of acute liver failure varies with age and geographical location. Most cases of acute liver failure in India are due to infectious causes predominantly viral hepatitis. A significant group with indeterminate causation remains, despite careful investigation. The etiology of acute liver failure in infants is largely metabolic. The mainstay of management is supportive care in an intensive care unit. Monitoring of clinical and biochemical parameters is done frequently until the patient becomes stable. Mortality is predominantly due to raised intracranial pressure, infections and multi-organ failure. Liver transplant is an important life saving procedure for children with acute liver failure.
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Lowers J, Jaffe A, Zenel JA, Cabana MD, Donahue C, Uba A. Visual diagnosis: four infants who have red, "bloody" stools. Pediatr Rev 2009; 30:146-9. [PMID: 19339389 DOI: 10.1542/pir.30-4-146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jill Lowers
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
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