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James Markowitz, MD
Division of Pediatric Gastroenterology
Cohen Children’s Medical Center of NY
New Hyde Park, NY
Objectives
• Definitions
• Quick Cases
o Differential Diagnoses
o Evaluation
• Treatment
Important Definitions
Hematochezia – passage of bright or dark red
blood per rectum
• in general, the redder the blood, the more distal the site
of bleeding
Impression:
1.Red blood pr = likely hematochezia
2.Orthostatic, anemic = significant bleeding
3.Painless
Case 1 – Differential Dx
Hematochezia in a Child
• Anal fissure
• Juvenile polyp
• Nodular lymphoid hyperplasia
• Infectious colitis
• Hemolytic uremic syndrome
• Inflammatory bowel disease
• Intussusception
• Henoch-Schonlein purpura
• Meckel’s diverticulum
• Intestinal duplication
• Vascular malformations
• Neutropenic colitis
Meckel Scan
• Technetium-99-
pertechnetate
• Concentrates in gastric
mucosa
• Premedicate with H2
blocker to enhance uptake
and minimize risk of
stomach or bleeding
obscuring the diverticulum
• Can also identify
duplications
• Diagnosis: Colonoscopy
• Treatment: Endoscopic Polypectomy
Case 1c – Painful hematochezia in the Child
• Labs:
o Guaiac positive
Milk Protein Allergy
• Presentations
o Hematochezia – usually in first 3 months of life
Diarrhea, irritability, ± poor weight gain
o Hypoalbuminemia, anasarca
o “GE reflux”
• Labs
o Variable eosinophilia in blood and biopsy
o Skin prick, RAST testing negative
• Treatment
o Casein hydrolysate or amino acid based formula
Case 3b
• 6 week old girl with streaks of bright red
blood per rectum
o Full term, no neonatal problems
o Breast fed x 2 weeks but changed to intact
milk protein formula due to “constipation”
o At 4 weeks, developed streaks of blood in
mucusy stool, that persisted with change to
casein hydrolysate formula
o Poor intake on all feeds except breast milk
(“She didn’t like the taste”), and gained weight
poorly
Case 3b: Evaluation
Tachycardic
• PE: Irritable but consolable Hypotensive
o Temp 38o; other VS normal for age
o Weight 50% at birth → 10% now
o Benign abdomen, normal perineal anatomy
www.bio.ri.ccf.org
Portal Hypertension
• Intrahepatic (e.g. cirrhosis)
• Post-sinusoidal
o Budd Chiari syndrome (hepatic vein thrombosis)
• Presinusoidal
o Splenic vein thrombosis
o Cavernous transformation of the portal vein
Endoscopic Therapy for Varices
Sclerotherapy Band Ligation
Case 6 -
• One day old full term male with bloody emesis
o Unremarkable pregnancy
o Complicated delivery: Apgars 4 and 8
o Breast feeding, but taking poorly
• PE:
o WD WN, weight appropriate for gestational age
o Anicteric, normal abdominal exam
Case 6 – Differential Diagnosis
Hemetemesis/Melena in the Infant
• Swallowed maternal blood
• Stress gastritis
• Intestinal duplication
• Vascular malformation
• Vitamin K deficiency
• Hemophilia
• Maternal ITP
• Maternal NSAID use
Case 6 - Evaluation
• Apt test
• Esophagogastroduodenoscopy
• Treatment:
o Supportive care
o H2 blocker
• Surgery