Per Rectal Bleeding in Children

Per Rectal Bleeding in Children. Causes, Diagnosis, and Management.

Introduction. Definition: Passage of blood through the anus May be mixed with stool, separate, or only on wiping Haematemesis:Emesis of blood Melena:Black tarry foul smelling stool Hematochezia:Blood mixed with stool Rectorrhagia:Fresh bleeding per retum.

Types of Blood in Stool Color of Blood Bright Red Dark Red Dark & Tarr Like Likely Origin of Bleeding Lower colon or rectum High in the colon or in the small intestine Stomach.

AGE GROUP UPPER GI BLEEDING LOWER GI BLEEDING NEONATE swallowed maternal blood, Coagulopathies Gastric stress ulcer Hemorrhagic disease of newborn Withdrawl bleeding of neonate Anal fissure, NEC, Hirschsprung enterocolitis 1MONTH-1 YEAR Gastritis Anal fissure Intussusception Midgut volvulus Strangulated hernia >1YEAR/CHILDREN Gastritis Oesophageal varices PUD Meckel’s diverticulitis Juvenile polyp Anal fissure Haemorrhoid Amoebic colitis (HIT JAMA) IBD Trauma.

PER RECTAL BLEEDING. PAINFUL BLEEDING PAINLESS BLEEDING Necrotising enterocolitis Anal fissure Intussusception IBD External haemorroid Infectious colitis Henoch scholein purpura Swallowed maternal blood Vitamin K deficiency Gastritis Juvenile polyp Meckel’s diverticulitis Variceal bleeding Vascular malformation Internal haemorroid.

Common Causes. Anal fissure – most common; due to hard stool Infective colitis – bacterial/viral/parasitic Juvenile polyps – painless rectal bleeding Meckel's diverticulum – painless, intermittent Intussusception – red currant jelly stools.

INTESTINAL POLYP. NON-NEOPLASTIC NEOPLASTIC 1.Inflammatory polyp 2.Hyperplastic polyp 3.Hamartomatous polyp Juvenile polyp Peutz jeghers polyp FAP syndrome Adenomatous-1.Tubular 2.Villous 3.Tubulo-villous.

JUVENILE POLYP. Non-neoplastic polyp Age:<5 year Site:Rectum Number:single-Retention polyp multiple-juvenile polyposis syndrome(>5) Type- pedunculated sessile.

Flat (sessile) Polyp Polyp with Stalk (pedunculated).

NECROTISING ENTEROCOLITIS. Occur in premature,low birth wt baby Defined as an acute inflammation ofthe intestine with necrosis,which may occur in the absence of intestinal obstruction. Etiology:Unknown. Meternal factor-Eclampsia,PROM,Fetal distress post-natal factor-prematurity,perinatal asphyxia,Exchange transfusion.

Pathogenesis. Due to any stress(free radicle,infection,formula feed,etc) ↓ Ischemic injury to intestinal mucosa ↓ bacterial colonisation of mucosa ↓ blebs of gas are visible in the wall of the intestine ↓ extensive area of necrosis are seen in advanced case cause bowel perforation,local peritonitis..

C/F: abdominal distension bloody stool with mucous Billious vomiting Feature of peritonitis in severe cases. Investigation: plain x-ray abdomen-Pneumatosis intestinalis.In severe case ,free gas under dome of diaphragm..

Bell's Staging Criteria Stage l. Suspected NEC II. Confirmed NEC Ill. Advanced NEC Clinical • Mild abd. distension Poor feeding tolerance Temp instability • Lethargy • Apnea • Bradycardia Emesis • Significant abdominal distention • GI bleed Septic shock • • Metabolic acidosis May progress to bowel perforation • • x-Ray Mild abdominal distension with mild ileus Significant abdominal distention with ileus Small bowel separation with edema in bowel wall or peritoneal fluid Persistent rigid bowel loops Pneumatosis intenstinalis Portal vein gas Pneumoperitoneum secondary to perforation Treatment Evaluation of electrolyte • status & coagulation studies Rule out: Sepsis, gastroenteritis, hypoglycemia... D/C enteral feeds • IV antibiotics Decompression of the • bowel Initiation of systemic • systemic broad spectrum antibiotic therapy Surgical intervention •.

HAEMORRHOID. Rectum Internal HeØorrhoids Anus External Hemorrhoids dreamfbtme.com ID 193070018 @ Chernetskaya.

ANAL FISSURES TYPES O TYPICAL / PRIMARY FISSURES local trauma OATYPICAL / SECONDARY FISSURES assc. u/ corÅtiion LONGITUDINAL TEARS ANAL MUCOSA DENTATE LINC INNERVATED SOMATIC NERVES pANFlJL.

TRAIT HAEMORROID ANAL FISSURE ANATOMY Swollen blood vessels skin creak around anus CAUSE Obesity,Pregnency, Low fibre diet,Genetics, Aging,Chronic constipation Surgery,laxitive abuse,IBD, Sexually abused SYMPTOM Painless rectal bleeding Constipation Red and sore anus Hard and blood stool Severe pain during and after defecation PRECAUTION Do not stop or force stool Eat fibre and drink more water Exercise Avoid long hours of sitting Avoid straining the bowel Go to toilet when urge Maintain free bowel movement TREATMENT Laxative Increase fluid and fibre exercise daily Sitz bath with Epsom salt Daitery fibre Use of local anesthetics Sclerotherapy Haemorroidoplasty Rubber band ligation Laser surgery Lateral internal sphincterotomy.

Pneumonic for prevention of anal fissure. F-Fibre in diet I-Increase fluid intake B-Bulk purgatives(ispagol husk) R-Reading in toilet discourged E-Encourged to loose weight S-sitz bath.

INFLAMMATORY BOWEL DISEASE Portion of GI tract Route of Spread Malignant Potential Macroscopic Features Microscopic Features Extraintestinal Manifestations Treatment CROHN DISEASE Diffuse; often rectal sparing Skip lesions Low Transmural inflammation, cobblestoning, creeping fat, aphthoid ulcers, "string sign," perianal fissures, fistulas Noncaseating granulomas Uveitis, erythema nodosum, ankylosing spondylitis, migratory polyarthritis Corticosteroids, 5-ASA (more effective in ulcerative colitis), immunomodulating agents ULCERATIVE COLITIS Rectum and colon Continuous High Mucosal and submucosal inflammation, friability, pseudopolyps No granulomas Primary sclerosing cholangitis, pyoderma gangrenosum 5-ASA, corticosteroids, immunomodulating agents; total colectomy is curative.

Clinical Evaluation. History: Age:NEC(neonate),Intussusception(Infant),Juvenile polyp(children) Bleeding:Onset(acute/chronic), Colour(red/black) frequency, stool pattern(blood mixed with stool/streak of blood over hard stool), Abdominal pain present or not Amount Duration Drug history-aspirin/NSAIDS/Steroid Any history of brusing or abnormal bleeding from cut site Associated symptom:Fever,Diarrhoea,Vomiting.

Physical exam: General:Anaemia,dehydration,Bleeding menifestation(patechial Hg/gum bleeding),Vitals(BP,HR,U/O,temp) abdominal exam:Any distention of abdomen(any tenderness,Ascitis,Hepatomegaly,spleenomegaly) Perianal inspection:Fissure,Fisula,Trauma Digital rectal exam (if indicated):Polyp,IBD,Any lesion.

Investigations. LABORATORY: CBC:HB%, Platelet,Blood grouping, Coagulation profile(BT,CT,PT) Stool test – occult blood, infection.

IMAGING. Abdominal USG – Intussusception Plain X-ray abdomen-Pneumatosis intestinalis(NEC) Meckel's scan – Suspected Meckel’s diverticulum Colonoscopy – Polyps, IBD Upper GI endoscopy-Gastritis ,Oesophageal varices.

Management:. conservative;ABC I/v fluid antibiotic monitoring vital sign clinical observation for development of gangrene or perforation of bowel, serial x-ray to monitor progress or to detect complication requiring surgical intervention..

Definative Management. Anal fissure – stool softeners, local anesthetics Infective colitis – hydration, antibiotics if needed Polyps – endoscopic removal Meckel’s – surgical excision IBD – pediatric GI referral NEC:nectrotic bowel resected and promal viable bowel exteriorised. Intussusception:Manual removal or resection.