go and have a look at
www.cryingoverspiltmilk.co.nz/.
omeprazole should make a BIG difference, but be aware that the right dosage has to be found, so if after a week, he is still so sick, ask fo, insist, be a pain in the a... mother to be able to try for another week a different dosage.
Green poos or any odds poos, are typical of severe reflux, and usaully are a sign of allergies.
DS2 has had severe reflux , was on lanzoprazole for months. Have you already start with solids? anything? even just a spoon of fruit/bread/... ? Reflux gets worse with solids, and you have to find not only the right food, but the right texture as well.
Blood test showed allergy to cow milk, eggs, wheat, peach.
No experience with blood, sorry, but I found on the website above:
Starship Children?s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
GASTRO-INTESTINAL BLEEDING IN CHILDREN AND
ADOLESCENTS
Author: Dr Simon Chin Service Gastro-enterology
Editor: Dr Raewyn Gavin Date Issued: Reviewed November 2004
Gastro-Intestinal Bleeding In Children And Adolescents Page: 1 of 6
? Introduction
? Differential Diagnosis
? History
? Physical Examination
? Laboratory Tests
? Imaging Studies
? Endoscopy
? Treatment
? References
Introduction
There are many causes of gastro-intestinal bleeding in children. Some span the whole paediatric
age range, while others reflect congenital malformations and present with bleeding in early
childhood. Advances in paediatric endoscopy have allowed us to determine the cause in most
children who present with GI bleeding, provided the clinical evaluation and management are timely.
- Determine the severity of the bleeding
- Determine the site of bleeding
? Upper GI (proximal to the ligament of Treitz, the 2nd part of the duodenum) or
? Lower GI (distal to the ligament of Treitz).
? Exclude bleeding that is not gastro-intestinal e.g. epistaxis, maternal blood, dental work,
haemoptysis. Substances such as iron, bismuth, beets, spinach and blueberries can mimic
melaena.
? Colour of the bleeding.
? Haematemesis (vomited blood) can be either red or the colour of coffee grounds. It is most
commonly associated with an upper gastro-intestinal bleed. Bright red blood suggests
active bleeding which has not come into contact with the gastric acid secretions. Coffee
grounds result when the gastric secretions have the chance to interact with blood.
? Melaena (black tarry stools) generally indicates significant blood loss proximal to the
ileocaecal valve. The black colour results from bacterial break down of haemoglobin.
? Haematochezia (bright red blood per rectum) generally indicates a colonic site of bleeding.
Occasionally this type of bleeding may originate from the small intestine as a result of a fast
gut transit time.
- Consider other factors:
? Age is a major determinant for determining the likely cause (see Tables)
? The presence or absence of significant pain is important
? Signs of a surgical abnormality
? The presence or absence of diarrhoea.
Starship Children?s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
GASTRO-INTESTINAL BLEEDING IN CHILDREN AND
ADOLESCENTS
Author: Dr Simon Chin Service Gastro-enterology
Editor: Dr Raewyn Gavin Date Issued: Reviewed November 2004
Gastro-Intestinal Bleeding In Children And Adolescents Page: 2 of 6
Differential Diagnosis
Upper Gastro Gastro-Intestinal Bleeding.
Gastritis and duodenitis occurs in all age groups. Gastric ulcer is more common in early childhood
while duodenal ulcers are, in general, more common in the older age groups.
Oesophageal varices should be considered if there is any evidence of chronic liver disease and
this can occur from as early as a few months of life but usually from after 12 months of age.
Consider a Mallory-Weiss tear in any patient with protracted vomiting.
Rectal bleeding.
In infants, consider anal fissures, swallowed maternal blood, necrotising enterocolitis, mid gut
volvulus, intussusception, infectious diarrhoea and milk protein allergy (allergic colitis). Allergic
colitis is seen in infants up to four months of age exposed to cows? milk or Soya milk protein
formula. These infants are generally well and have normal slightly mucousy loose stool streaked
with blood. Bleeding from juvenile polyps may occur in the first year of life but usually presents
from 1 to 12 years. Nodular lymphoid hyperplasia may also cause lower GI bleeding in the first
years of life. Ulcerative colitis can present in the first year.
Bright red blood per rectum (with otherwise normal stool), or spots of red blood on the toilet paper
implies bleeding from anal or rectal lesions. Possibilities include anal fissures, juvenile polyp or
allergic proctitis.
Bright red blood mixed with mucus and associated with diarrhoea, abdominal cramps and
tenesmus suggests a colitis. The cause could be:
Infection: Salmonella, Campylobacter, Shigella, C-difficile as well as entero-invasive
E.coli and occasionally Yersinia. In patients who are immuno-compromised, consider CMV, HSV
and candida as well.
Pseudomembranous colitis
Ulcerative colitis.
Painless rectal bleeding suggests a Meckel?s diverticulum, duplication, polyp or angio dysplasia.
Rarely, painless rectal bleeding may be due to a deep ulcer in the right colon or terminal ileum
from Crohn?s disease. Copious amounts of red blood are seen with Meckel?s diverticulum or a
colonic arteriovenous malformation.
Massive G-I bleeding can be due to oesophageal varices, peptic ulcers, Meckel?s, AV
malformation.
Abdominal pain. If present, a surgical abnormality should be ruled out.
Peritonitis could indicate a perforated ulcer, necrotising enterocolitis in an infant or a perforated
viscus secondary to Crohn?s disease in an older patient.
Pain accompanies the vasculitis of Henoch-Schonlein purpura and sometimes gastro-intestinal
bleeding may precede the characteristic rash by several days.
If there are signs of bowel obstruction, exclude intussusception. While ?redcurrent jelly? stools are
a classic presentation, this sign is not always present.
Starship Children?s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
GASTRO-INTESTINAL BLEEDING IN CHILDREN AND
ADOLESCENTS
Author: Dr Simon Chin Service Gastro-enterology
Editor: Dr Raewyn Gavin Date Issued: Reviewed November 2004
Gastro-Intestinal Bleeding In Children And Adolescents Page: 3 of 6
History
Exclude chronic lung disease, renal disease, bleeding disorders or liver disease.
Cystic fibrosis patients are at risk of oesophageal varices due to biliary cirrhosis, and vitamin K
deficiency may be a factor secondary to fat soluble vitamin absorption.
Medications including NSAIDs and prior antibiotic exposure.
Overseas travel.
Family medical history: peptic ulcer disease, bleeding disorders, inflammatory bowel disease,
polyposis syndrome or early colon cancer. Other sick contacts may indicate an infectious cause
e.g. contaminated food.
Physical Examination
Look for:
Chronic constipation. Possible anal fissure. Rectal exam to exclude faecal retention.
If bleeding is severe, look for tachycardia and orthostatic hypertension (a rise in the pulse rate by
20 beats per minute or a fall in the systolic blood pressure of more than 10mmHg indicates
significant volume depletion, usually > 20%).
Cutaneous haemangiomas may indicate the presence of GI mucosal haemangiomas.
Pigmentation of the lips and buccal mucosa may suggest Peutz-Jeghers syndrome.
Purpura on the buttocks and lower extremities are characteristic of HSP.
Portal hypertension. Signs include hepatosplenomegaly, as well as other stigmata of chronic liver
disease (clubbing, spider naevi, jaundice and ascites).
Laboratory Tests
FBC. A recent bleed may not alter the haemoglobin or haematocrit but the MCV can be low in
chronic low grade bleeding. Raised eosinophils may signify an allergic colitis.
ESR. An elevated ESR may indicate inflammatory bowel disease.
Coagulation profile to rule out a bleeding disorder.
Liver function tests if there are signs of portal hypertension or chronic liver disease.
If there are loose stools, stool cultures and a C-difficile toxin assay.
Renal function tests. A high urea may be a clue for haemolytic uraemic syndrome or may indicate
the presence of dehydration.
Starship Children?s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
GASTRO-INTESTINAL BLEEDING IN CHILDREN AND
ADOLESCENTS
Author: Dr Simon Chin Service Gastro-enterology
Editor: Dr Raewyn Gavin Date Issued: Reviewed November 2004
Gastro-Intestinal Bleeding In Children And Adolescents Page: 4 of 6
Imaging Studies
Upper GI bleeding. Contrast studies should not be the initial study to rule out oesophagitis, gastritis
or peptic ulcers because of the lack of sensitivity. Endoscopy is far more sensitive. Contrast
studies may be indicated in patients with dysphagia or odynophagia. Ultrasound should be
requested if there is evidence of liver disease or splenomegoly.
Haemotochezia. Contrast studies should not be the initial evaluation. Flexible endoscopy is better.
The exception would be suspected intussusception, where ultrasound should be requested (and if
confirmed, an enema for reduction).
Massive painless bleeding. A Meckel scan is the procedure of choice. False negative results have
been reported because of insufficient gastric tissue mass, down stream washout of isotope,
impaired blood supply or suboptimal techniques. Repeat Meckel scans may therefore be
necessary to identify the type of gastric tissue.
Obscure bleeding in the upper or lower GI tract. Technetium labelled RBC scans may aid
localisation, but require active bleeding of > 0.5ml /min.
Strong gastritis may cause bleeding, and ime thing reflux babies have for sure is tons of acids.
Hope it helps
Endoscopy
Fibreoptic endoscopy and biopsy has increased the rate of positive diagnosis. The yield decreases
if endoscopy is delayed, so it is important that endoscopy occurs promptly. Preparation of the
patient is critically important. In emergency situations where bleeding is severe, resuscitation of the
patient is paramount. Endoscopy should not be performed hastily if the patient is unstable. For
colonoscopy, the patient requires adequate bowel preparation and this varies with the age and
compliance of the child. Urgent endoscopy does allow prompt diagnosis and the ability to perform
therapeutic interventions such as sclerotherapy.
For patients with melaena or haematemesis, upper endoscopy is usually done first. Patients with
haematochezia should at least receive a flexible sigmoidoscopy. Many would recommend
colonoscopy as the first examination, particularly if the procedure is being performed under general
anaesthetic. A significant number of polyps are found proximally, beyond the reach of rigid
sigmoidoscopes.
Treatment
If there is significant bleeding, re-establish blood volume and O2 carrying capacity (rapid infusion
of normal saline followed if appropriate by red cells)
Determine the site of blood loss
Known oesophageal varices and severe bleeding.
Octreotide infusion, starting with 1mcg/kg IV bolus followed by a continuous infusion of 1
mcg/kg/hour, increasing every eight hours if there is no reduction in the bleeding up to 4-5
mcg/kg/hour as a continuous infusion. When there is no active bleeding after 24 hours the dose
could be halved every 12 hours. Side effects of Octreotide include nausea, abdominal cramps,
diarrhoea, bradycardia and hyperglycemia which usually resolve spontaneously.
As a last resort, a Sengstaken tube. This has significant complications including aspiration and
oesophageal rupture.
Starship Children?s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.
GASTRO-INTESTINAL BLEEDING IN CHILDREN AND
ADOLESCENTS
Author: Dr Simon Chin Service Gastro-enterology
Editor: Dr Raewyn Gavin Date Issued: Reviewed November 2004
Gastro-Intestinal Bleeding In Children And Adolescents Page: 5 of 6
Sclerotherapy can be successful in obliterating oesophageal varices after multiple sessions in up
92% of paediatric patients. It is used in infants.
Oesophageal band ligation has also been successful, with fewer complications compared with
sclerotherapy.
Peptic disease such as gastritis or oesophagitis.
H2 antagonists such as Ranitidine (2-4mg/kg/dose, maximum 150 mg/dose, twice a day).
Proton pump inhibitors such as Omeprazole (0.7-1.4mg/kg/dose, max 40mg, once a day) are
indicated in selected cases. A liquid preparation is available where doses do not relate to capsule
sizes.
Sucralfate (250mg q.i.d. for children