Rosen & Barkin's 5-Minute Emergency Medicine Consult (434 page)

Gastrointestinal Bleeding

CODES

530.7 Gastroesophageal laceration-hemorrhage syndrome

BASICS

• Incomplete rotation and fixation of intestine during embryogenesis during transition from extracolonic position during week 10 of gestation
  
• Risk factor:
  
  • Heterotaxia syndromes
    
• Associated conditions:
  
  • Gastrointestinal anomalies:
    
    • Duodenal stenosis, atresia, web
      
    • Meckel diverticulum
      
    • Intussusception
      
    • Gastroesophageal reflux
      
    • Omphalocele or gastroschisis
      
    • Congenital diaphragmatic hernia
      
    • Abdominal wall defect
      
    • Hirschsprung disease
      
  • Metabolic acidosis
    
  • Congenital cardiac anomalies; present in 27% of patients with malrotation; increases morbidity to 61%
    

• Duodenojejunal junction remains right of midline
  
• Cecum remains in the upper left abdomen with abnormal mesenteric attachments
  
• Volvulus is complication of malrotation when small bowel rotates around superior mesenteric artery and vein resulting in vascular compromise to midgut
  
• Abnormal anatomy predisposes to obstruction and other conditions
  
• Usually found in combination with other congenital anomalies (70%): Cardiac, esophageal, urinary, anal
  
• Epidemiology:
  
  • 1 in 500 live births
    
  • High mortality in infants: Up to 24%
    
  • Necrotic bowel at surgery increases mortality by 25×.
    
  • Incidence:
    
    • In neonates, male-to-female ratio 2:1
      
    • 75% diagnosed newborn period
      
    • 90% diagnosed by age 1 yr of life
      
    • Can present during adulthood
      

DIAGNOSIS

• Neonates:
  
  • Bilious emesis
    
  • Abdominal distention
    
  • Bloody stools
    
  • Constipation/obstipation
    
  • Difficulty feeding
    
  • Poor weight gain
    
• >1 yr: Abdominal pain followed by bilious emesis
  
• Older children and adolescents:
  
  • Chronic vomiting
    
  • Intermittent colicky abdominal pain
    
  • Diarrhea
    
  • Hematemesis
    
  • Constipation
    
  • May not exhibit abnormal physical findings at time of presentation (50–75%)
    
• Adults: Symptoms vague and nonspecific
  
• General:
  
  • Dehydration, acidosis
    
  • Peritonitis
    
  • Ischemic bowel
    
  • Sepsis, shock
    

• Vomiting in infant is the most common sign, but may or may not be bilious
  
• Signs of small bowel obstruction in early infancy
  
• Bilious vomiting associated with abdominal pain
  
• In older children and adults, the most common symptom is abdominal pain
  
• Other pertinent history—acute or chronic abdominal pain, poor feeding, lethargy, malabsorption, chronic diarrhea
  

• Abdominal exam may show distension from obstruction
  
• Blood in the stool indicates bowel ischemia
  
• Evaluate for congenital anomalies
  

Diagnosis is suggested by history and physical exam findings and is delineated by contrast radiography.

• CBC
  
• Venous blood gas
  
• Electrolytes, BUN, creatinine, glucose
  
• Urinalysis/urine culture
  
• Type and screen
  
• Prothrombin time, partial thromboplastin time, international normalized ratio
  
• Lactate
  

• Plain abdominal radiographs:
  
  • Diagnostic in <30%
    
  • Volvulus likely if accompanied by:
    
    • Duodenal obstruction
      
    • Gastric distention with paucity of intraluminal gas distal to volvulus in complete volvulus
      
    • Generalized distention of small-bowel loops
      
    • “Double-bubble sign” can be seen on upright film from partial duodenal obstruction causing distension of stomach and duodenum
      
• Upper GI contrast studies:
  
  • 95% sensitive and 86% accurate
    
  • Findings:
    
    • Absence of ligament of Treitz or on the right side of the abdomen with misplaced duodenum
      
    • Dilation of proximal duodenum with termination in conical or beak shape
      
    • Spiral or corkscrew appearance of duodenum with volvulus
      
    • Proximal jejunum on right side of abdomen (although readily displaced in neonates)
      
    • Thickening of small-bowel folds
      
• Contrast enema:
  
  • Can be useful to determine position of cecum in equivocal cases
    
  • Evaluates position of cecum in midline of upper abdomen or to left of midline
    
  • >20% false-negative results
    
• Ultrasound:
  
  • US can be very sensitive in experienced hands
    
  • US shows abnormal relationship between superior mesenteric artery and vein in malrotation
    
  • “Whirlpool” sign on Doppler US of superior mesenteric artery and vein twisting around the base of mesenteric pedicle seen in volvulus
    
  • Normal ultrasound does not exclude malrotation
    
• CT:
  
  • Little benefit in infants and children
    
  • More likely to be used for diagnosis in adults
    

• Early life:
  
  • Hirschsprung disease
    
  • Necrotizing enterocolitis
    
  • Intussusception
    
• Children with acute abdominal pain and peritoneal signs:
  
  • Appendicitis
    
  • Intussusception
    
  • Overwhelming sepsis
    
• Older children and adults with vague abdominal pain:
  
  • Irritable bowel syndrome
    
  • Peptic ulcer disease
    
  • Biliary and pancreatic disease
    
  • Psychiatric disorders
    

TREATMENT

Rapid transport to ED

• ABCs
  
• NS (0.9%) IV fluid bolus (20 mL/kg) for shock, sepsis, or dehydration
  
• Consider nasogastric tube
  
• 2 IVs and/or CV catheter
  
• Initiate broad-spectrum antibiotics for signs of sepsis or peritonitis
  

• Emergent surgical correction
  
• May require transfer to facility with pediatric surgical expertise when associated with midgut volvulus for:
  
  • Detorsion of volvulus
    
  • Restoration of intestinal perfusion
    
  • Resection of obviously necrotic areas
    
  • Replacement of long segments with questionable vascular integrity back into abdominal cavity for return evaluation and possible celiotomy in 36 hr
    
• Diet:
  
  • NPO
    

• Broad-spectrum antibiotics prior to surgery
  
• Correct fluid and electrolyte abnormalities
  
• Vasopressors
  

FOLLOW-UP

• Acute abdomen
  
• Surgical intervention
  
• Significant dehydration
  
• Acidosis
  
• Sepsis
  
• Shock
  

Stable, asymptomatic, incidental finding without associated condition, although patients are usually admitted

• Pediatric surgical evaluation prior to discharge