Pediatric Lower GI Bleeds – Dr. Lyvers

Usually occur inferior to the ligament of Trietz

80-90/100,000 complaints of peds ED visits

• Most are self-limited, however can be more complicated if there is severe bleeding, lethargy, fever, pallor, etc.

Some cases of suspected GI bleeding are not blood

Red Brick Diaper Syndrome

• Caused by increased concentration of uric acid crystals in a newborn. Common and benign finding.

Cefdinir – Often a cause of red-purple stools

Some cases are blood but patients are not sick

Melena Neonatorum – Swallowed maternal blood during delivery or breast feeding, is the most common reasonof melena in a neonate. Can use the Apt test looking for HbF.

Anal Fissures

Some cases are a result of very concerning pathology

Midgut Volvulus – Occurs within the first month with bilious emesis and abdominal distention. Hematochezia is a late finding. Diagnosed by abdominal x-ray or upper GI series.

Nectrotizing Enterocolitis – Most commonly presents in pre-term infants in the NICU, however 13% occur in term neonates. Usually occur with underlying predisposition with sepsis or CHD. X-ray will show pneumatosis intestinalis or ileus in the early stages.

Hirschsprung’s Disease – Failure of neural crest cells to migrate during intestinal development resulting in aganglionic segments of bowel. Typically diagnosed as a failure to pass meconium in first 48 hours.

Hirschsprung’s Associated Enterocolitis – Can be seen 3 weeks to years after surgical repair. Abdominal distension, fever, vomiting, lethargy, foul smelling and bloody stools which can lead to shock. Provide with broad spectrum abx + metronidazole, as well as good resuscitation.

Meckel’s Diverticulum – Painless rectal bleeding caused by incomplete obliteration of the omphalomesenteric duct. Occurs from bleeding mucosal ulceration. Diagnosed by technetium-99 scan which collects dye in the gastric mucosa. 2x more common in males. 2 feet proximal to the ICV. 2 inches long. Symptoms occur before 2. 2% of patients develop complications.

Intussusception – Occur with currant jelly stool in later stages. Most common cause of obstruction 6 to 36 months. Diagnosed via ultrasound. Management initially with air enema and surgery if not successful.

Milk Allergy – Painless blood in stool in an exclusively breast fed infant occurring from 2 weeks to 1 year which resolves by 18 months. Can have a cross reactivity to soy protein. Can continue breast feeding if child is growing appropriately.

Infectious Colitis – Most common cause of hematochezia across all ages. Most common pathogen causing complications is HUS O157:H7 and other shiga toxin producing E Coli. Triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. 5-10 days of diarrhea in children < 5 years old. Early antibiotic administration may increase risk. 50% of kids who develop HUS require a period of dialysis.

Inflammatory Bowel Disease – Collection of diseases which include crohns disease, ulcerative colitis

Solitary rectal ulcer syndrome

GI Duplication Cysts

IgA Vasculitis (HSP)

Abdominal Pain – Dr. Thomas

Leading cause of ED visits 8.9% of cases

Up to 40% of patients may be discharged with a diagnosis of nonspecific abdominal pain

7% of all abdominal pain patients with life-threatening processes will present with NORMAL vital signs.

Risk is higher in elderly patients, especially with vascular causes.

History:

Abrupt onset is typically worse. Nausea / vomiting is more likely a surgical process.

Information on location and migration are useful.

Severity and description can vary greatly and has a low sensitivity and specificity.

Physical Exam:

Start in areas AWAY from where they localize the pain. Be complete.

Do not forget pelvic exam, rectal exam, or testicular exam, if required.

Imaging:

Abdominal x-rays are useful for obstruction, free air, or foreign body.

CT is often the most useful test, however is typically overused and comes with risk such as contrast reaction, cost, radiation, and difficulty managing care on a sick patient in the CT scanner.

High Risk Abdominal Pain

• Elderly
• Immunosuppressed
• Hepatology patients with ascites
• Post-op patients
• Traumatic patients

Visceral pain – occurs with stretching of the organs. Colicky and difficulty to localize. Ex: umbilical pain in early appendicitis

Somatic pain – Peripheral nerve pain from irritation, such as peritonitis. Better location with intense / constant pain. This is when pain associated with peritonitis or rebound pain can occur.

Referred pain – Any pain felt at a distance from the source

Elderly patients with presentation to the ED with abdominal pain have an approximately 10% mortality rate. 42% of these patients required surgery.

• Immune function decreases with age.
• Underlying conditions decrease immune function and reserve
  • Such as vascular, pulmonary disease, as well as DM.

Hysterectomy does not require pregnancy test, however a tubal ligation always does.

UTI / Pyelonephritis increases the risk of miscarriage, however PID is rare once pregnancy is established.

Pregnant patients may have the same etiology of pain as non-pregnant patients

• Biliary / appendix / gerd

Always have concern for SBP in a cirrhotic patient

• E Coli is present in 43% of isolates
• SBP usually is treat with a 3^rd generation cephalosporin, however always add vancomycin if they have a history of a staphylococcus aureus positive blood culture.

Paraplegic Patients

• Present a large risk when they are unable to feel a large majority of pain. May be only able to feel visceral pain or cramping.

Post-operative patients with shoulder pain may be peritonitic.

CT Abdomen / Pelvis -Dr. Elsaidy

Aorta

• Dissection / aneurysm

Thrombosis

• PE (right heart strain)

Air

• Emphysematous infection
• Free air
• Obstruction

Search Pattern

1. Air  in the lower chest (lung / heart / PE) then bowel
2. Bone (ribs, VBs, pelvis)
3. Circulatory (PE / dissection / aneurysm / active bleeding)
4. Solid organs
5. Feather (soft tissues)
6. Genitals