NEONATAL GASTROINTESTINAL BLEEDING

A. Upper GI bleeding (Neonate) : Initially do an Apt test to determine if blood comes from fetal origin or maternal origin (blood swallowed by the fetus). If its of fetal origin then consider a coagulation profile (PT, PTT). If this coagulation profile is normal the possibilities are either stress gastritis or ulcer disease. If the coagulation profile is abnormal then consider hematologic disease of the newborn and manage with vitamin K. The apt test is performed by mixing 1 part of vomitus with 5 part H2O, centrifuge the mixture and remove 5 ml (pink). Then add 1 ml 1% NaOH, wait 2 minutes and if it remains pinks is fetal blood, if it turns brown-yellow its maternal blood.

B. Lower GI bleeding (Neonate) : Again start with an Apt test, if its positive its maternal swallow blood, if its negative do a PT, PTT. If the coagulation profile is abnormal give Vit K for hematologic disorder of newborn. If it's normal do a rectal exam.

A fissure could be the cause, if negative then consider either malrotation or Necrotizing enterocolitis.
1- Necrotizing Enterocolitis (NEC) : Although the exact pathogenesis of NEC is not known, the most widely held theory is that of perinatal stress leading to selective circulatory ischemia. The stress includes prematurity, sepsis, hypoxia, hypothermia, and jaundice. These babies frequently have umbilical artery, vein catheters, have received exchange transfusions or early feeds with hyperosmolar formulas. The intestinal mucosal cells are highly sensitive to ischemia and mucosal damage leads to bacterial invasion of the intestinal wall. Gas-forming organisms produce pneumatosis intestinalis (air in the bowel wall readily seen on abdominal films). Full-thickness necrosis leads to perforation, free air and abscess formation. These usually premature infants develop increased gastric residuals, abdominal distension, bloody stools, acidosis and dropping platelet count. The abdominal wall becomes reddened and edematous. There may be persistent masses and signs of peritonitis. Perforation leads to further hypoxia, acidosis and temperature instability. The acid-base status is monitored for worsening acidosis
and hypoxia. Serial platelet counts are obtained and, with increasing sepsis, the platelet count drops <50,000, indicating intravascular coagulation and decreased bone marrow production. The white blood cell count may be high, low or normal and is not generally of help. Serial abdominal films are obtained to look for evidence of free abdominal air, a worsening picture of pneumatosis intestinalis, or free portal air. Therapy consist initially of stopping feeds, instituting nasogastric suctioning and beginning broad-spectrum antibiotics (ampicillin and gentamycin). Persistent or worsening clinical condition and sepsis or free air on abdominal films require urgent surgical intervention. Attempts to preserve as much viable bowel as possible are mandatory to prevent resultant short gut syndrome.

Complicated NEC is the most common neonatal surgical emergency of modern times, has diverse
etiologies, significant mortality and affects mostly premature babies. The use of primary peritoneal drain (PPD) in the management of NEC dates from 1977. The technique is used in the very low birth weight premature infant (<1500 gm) with pneumoperitoneum, metabolic and hemodynamic instability. Consist of a right lower quadrant incision and placement of a drainage (Penrose or catheter) under local anesthesia with subsequent irrigation performed bedside at the NICU. Initially used as a temporizing measure before formal laparotomy, some patient went to improvement without the need for further surgery (almost one-third). They either had an immature (fetal type) healing process or a focal perforation (not associated to NEC?) which healed spontaneously. Those babies not improved by PPD either die (20%), go on to laparotomy and half die (20%) or develop complications (24%). Some suggestion made are: PPD should be an adjunct to preop stabilization, before placing drain be sure pt has NEC by X-rays, persistent metabolic acidosis means uncontrolled peritoneal sepsis, do not place drain in pts with inflammatory mass or rapid development of intraperitoneal fluid, the longer the drainage the higher the need for laparotomy.