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LOWER GASTROINTESTINAL BLEEDING IN CHILDREN
Category: Pediatric Surgery
Abstract :
Lower gastrointestinal bleeding in children 1- Anal Fissure : Anal fissure is the most common cause of rectal bleeding in the first two years of life. Outstretching of the anal mucocutaneous junction caused by passage of large hard stools during defecation produces a superficial tear of the mucosa in the posterior midline. Pain with the next bowel movement leads to constipation, hardened stools
Lower gastrointestinal bleeding in children
1- Anal Fissure : Anal fissure is the most common cause of rectal bleeding in the first two years of life. Outstretching of the anal mucocutaneous junction caused by passage of large hard stools during defecation produces a superficial tear of the mucosa in the posterior midline. Pain with the next bowel movement leads to constipation, hardened stools that continue to produce cyclic problems.
Large fissures with surrounding bruising should warn against child abuse. Crohn's disease and leukemic infiltration are other conditions to rule-out. The diagnosis is made after inspection of the anal canal. Chronic fissures are associated with hypertrophy of the anal papilla or a distal skin tag. Management is directed toward the associated constipation with stool softeners and anal dilatations, warm perineal baths to relax the internal muscle spasm, and topical analgesics for pain control. If medical therapy fails excision of the fissure with lateral sphincterotomy is performed.
2- Meckel’s Diverticulum : Meckel's diverticulum denotes those anatomic structures resulting from the umbilical and intra-abdominal persistence of the embryonic vitelline duct (yolk stalk). Meckel's diverticulum is clinically significant, either when discovered incidentally at celiotomy or recognize as the cause of symptoms, which are intestinal bleeding, abdominal pain, or intestinal obstruction. Children with symptomatic Meckel's present with hemorrhage (40%), intestinal obstruction (30%), diverticulitis (20%), and umbilical discharge or disease (6%). Diagnosis is related to presentation. Intermittent rectal bleeding may be diagnosed on occasion by 99mTc sodium pertechtenate. Barium studies are unreliable. Persistent bleeding requires laparotomy even if the Meckel's scan is negative. Diverticulitis or perforation presents with finding similar to appendicitis. Obstruction secondary to intussusception is diagnosed by clinical findings and barium enema. Incidental Meckel's diverticulum is generally handled by simple wedge excision in children. Bleeding Meckel's is managed by resection of the bowel and end-to-end anastomosis. Diverticulitis is handled by either method. Asymptomatic Meckel’s diverticula identified incidentally should be removed if upon palpation there is questionable ectopic (gastric or pancreatic) mucosa.
3- Polyps : Juvenile Polyps comprise 80% of childhood polyps. This is a mucous retention polyp and histologically features a cluster of mucoid lobes surrounded by flattened mucus-secreting glandular cells. There is no malignant potential. These polyps are most commonly seen in children age 3-10 with a peak at age 5-6. 85% of children have a solitary polyp. The most common complaint is rectal bleeding and occasionally the polyps may prolapse out the rectum. Diagnosis is by barium enema, rectal exam and/or endoscopy. Removal by endoscopy is the treatment of choice. rarely, exploratory lap with colotomy and excision is required. Lymphoid polyps are not polyps at all, but rather localized elevations of colonic mucosa that on barium enema produce filling defects resembling polyps. They are produced by hyperplasia of submucosal lymphoid tissue. These make up about 15% of childhood polyps. They begin to appear during the first year of life, peak at about the third year of life, and diminish in number by 5 years of age. These are multiple and may present with mild chronic blood loss. Diagnosis is made by barium enema. endoscopy and biopsy. No treatment is necessary since they will regress spontaneously.
Peutz-Jeghers syndrome are polyps associated with melanin hyperpigmentation of the lips and oral
mucosa. The polyps are usually multiple and hamartomas. They will appear anywhere, but the majority are limited to the jejunum and ileum. Chronic blood loss anemia in a child with repeated bouts of colicky abdominal pain secondary to actual or incipient intussusception are typical. Diagnosis is by contrast studies. GI malignancy has been reported in 2-3% of patients. Females with Peutz-Jeghers syndrome seem predisposed to develop ovarian tumors, usually in adolescence. Treatment depends on the severity of symptoms and extend of involvement.
Familial Polyposis Coli has an autosomal dominant inheritance. Hundreds of adenomatous colonic polyps with virtually all developing adenocarcinoma of colon by the third decade of life. The most common and
best-recognized variant is patients with Gardner's syndrome, which combines the premalignant adenomatous colonic polyps with soft and hard tissue tumors. Diagnosis is by family history, and contrast studies followed by biopsy. Treatment is total colectomy with ileostomy or endorectal pull-through with ileo-anal anastomosis.
4- Familial Adenomatous Polyposis : Familial history of colon cancer is an important indicator of future risk for colorectal cancer. The more extensive and closer the affected relatives, the greater the risk. Highest risk is found in Familial Adenomatous Polyposis (FAP). Once the risk is appreciated screening for the disease must take place. This involves genetic analysis for members of syndrome families along with lower gastrointestinal endoscopy for the rest as polyps can occur throughout the gastrointestinal tract. FAP is a genetic (autosomal dominant) premalignant condition that will ultimately manifest with the development of colorectal carcinoma. FAP has been linked to germline mutations of the adenomatous polyposis coli (APC) gene. Initial presentation can be rectal bleeding. Besides multiple adenomatous polyps of the colon predisposing to malignancy at an early age, a variety of extra colonic manifestations are associated with this condition. Once the diagnosis of FAP is established endoscopic surveillance should be instituted. All polyps should be subjected to histopathological exam to determine presence of adenomatous epithelium. With the presence of dysplastic changes total colectomy with the creation
of an ileorectal or ileoanal (pouch) anastomosis is recommended. Almost one-third of cases develops
adenomas in the ileal pouch after proctocolectomy. Baseline small bowel enteroscopy should be done at the time of surgery and in the postop period in children with FAP and juvenile polyposis. With duodenal polyps enteroscopy should be done at the time of surgery. Biopsy and/or excision of larger polyps should be done as they may harbor a carcinoma.
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