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Saab MA, Jacobson E, Hanson K, Kruciak B, Miramontes D, Harper S. Prehospital Whole Blood Administration for Pediatric Gastrointestinal Hemorrhage: A Case Report. PREHOSP EMERG CARE 2024:1-4. [PMID: 38940756 DOI: 10.1080/10903127.2024.2372808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
The management of gastrointestinal (GI) hemorrhage in a prehospital setting presents significant challenges, particularly in arresting the hemorrhage and initiating resuscitation. This case report introduces a novel instance of prehospital whole blood transfusion to an 8-year-old male with severe lower GI hemorrhage, marking a shift in prehospital pediatric care. The patient, with no previous significant medical history, presented with acute rectal bleeding, severe hypotension (systolic/diastolic blood pressure [BP] 50/30 mmHg), and tachycardia (148 bpm). Early intervention by Emergency Medical Services (EMS), including the administration of 500 mL (16 mL/kg) of whole blood, led to marked improvement in vital signs (BP 97/64 mmHg and heart rate 93 bpm), physiology, and physical appearance, underscoring the potential effectiveness of prehospital whole blood transfusion in pediatric GI hemorrhage. Upon hospital admission, a Meckel's diverticulum was identified as the bleeding source, and it was successfully surgically resected. The patient's recovery was ultimately favorable, highlighting the importance of rapid, prehospital intervention and the potential role of whole blood transfusion in managing acute pediatric GI hemorrhage. This case supports the notion of advancing EMS protocols to include interventions historically reserved for the hospital setting that may significantly impact patient outcomes from the field.
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Affiliation(s)
- Mathew A Saab
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Eric Jacobson
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Kip Hanson
- San Antonio Fire Department, San Antonio, Texas
| | | | - David Miramontes
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Stephen Harper
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
- Department of Emergency Health Sciences, University of Texas Health Science Center San Antonio, San Antonio, Texas
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2
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Milosavljević MN, Gutić M, Janjić V, Veselinović S, Djordjić M, Ivanović R, Milosavljević J, Janković SM. Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2. Open Med (Wars) 2024; 19:20240970. [PMID: 38799251 PMCID: PMC11117451 DOI: 10.1515/med-2024-0970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/26/2024] [Accepted: 04/21/2024] [Indexed: 05/29/2024] Open
Abstract
Objective Our aim was to compare the costs and efficacy of ambroxol in combination with imiglucerase with the costs and efficacy of imiglucerase only in the treatment of Gaucher disease type 2 (GD2) in the socio-economic settings of the Republic of Serbia, an upper-middle-income European economy. Methods The perspective of the Serbian Republic Health Insurance Fund was chosen for this study, and the time horizon was 6 years. The main outcomes of the study were quality-adjusted life years gained with ambroxol + imiglucerase and comparator, and direct costs of treatment. The study was conducted through the generation and simulation of the Markov chain model. The model results were obtained after Monte Carlo microsimulation of a sample with 1,000 virtual patients. Results Treatment with ambroxol in combination with imiglucerase was cost-effective when compared with imiglucerase only and was associated with positive values of net monetary benefit regardless of the onset of the disease. Such beneficial result for ambroxol and imiglucerase combination is primarily driven by the low cost of ambroxol and its considerable clinical effectiveness in slowing the progression of neural complications of GD2. Conclusion If ambroxol and imiglucerase are used in combination for the treatment of GD2, it is more cost-effective than using imiglucerase alone.
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Affiliation(s)
- Miloš N. Milosavljević
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, 34000, Kragujevac, Serbia
| | - Medo Gutić
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, 34000, Kragujevac, Serbia
| | - Vladimir Janjić
- Department of Psychiatry, Faculty of Medical Sciences, University of Kragujevac, 34000, Kragujevac, Serbia
| | - Slađana Veselinović
- Department of Communication Skills, Ethics and Psychology, Faculty of Medical Sciences, University of Kragujevac, 3400, Kragujevac, Serbia
| | - Milan Djordjić
- Department of Communication Skills, Ethics and Psychology, Faculty of Medical Sciences, University of Kragujevac, 3400, Kragujevac, Serbia
| | - Radenko Ivanović
- University Hospital Foča, 73300, Foča, Republic of Srpska, Bosnia and Herzegovina
- Faculty of Medicine in Foča, University of East Sarajevo, 73300, Foča, Republic of Srpska, Bosnia and Herzegovina
| | - Jovana Milosavljević
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, 34000, Kragujevac, Serbia
| | - Slobodan M. Janković
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, 34000, Kragujevac, Serbia
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Vicente-Ferreira M, Lage J, Ribeiro J, Espinheira C, Pinto Pais I, Cardoso H, Teixeira I, Trindade E. Isolated small bowel ulcer as a cause of severe hemorrhage-Diagnostic challenge. J Pediatr Gastroenterol Nutr 2024; 78:1199-1201. [PMID: 38451054 DOI: 10.1002/jpn3.12173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/05/2024] [Accepted: 02/03/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Margarida Vicente-Ferreira
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Joana Lage
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Children and Youth, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Joana Ribeiro
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Hospital Sousa Martins, Unidade Local de Saúde da Guarda, Guarda, Portugal
| | - Céu Espinheira
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Isabel Pinto Pais
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Hélder Cardoso
- Department of Obstetrics, Gynecology and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Inês Teixeira
- Department of Pediatric Surgery, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Eunice Trindade
- Department of Pediatric Gastrenterology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Pediatrics, Centro Hospitalar Universitário São João, Porto, Portugal
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Taher KW, Yaseen R, Alnan M, Aburas W, Khalil H, Alabdulsalam M. Efficacy and safety of empiric treatment with omeprazole continuous infusion in critically ill children with gastrointestinal bleeding. Front Pediatr 2024; 12:1270911. [PMID: 38650990 PMCID: PMC11033492 DOI: 10.3389/fped.2024.1270911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction Gastrointestinal bleeding (GI) is a prevalent condition among pediatric patients, with a reported incidence of 6.4%, often severe enough to require admission to the pediatric intensive care unit (PICU). There are multiple therapies utilized in the management of GI bleeding in pediatrics, among which continuous intravenous (IV) infusion of omeprazole is used off-label without standard pediatric dosing recommendations. Reviewing the current literature reveals a lack of studies assessing the efficacy, safety, and appropriate dosing regimen of continuous omeprazole infusion in children with GI bleeding. This study aimed to evaluate the efficacy and safety of continuous IV omeprazole infusion in comparison to other therapeutic modalities in children. Methods This study is a single-center, retrospective chart review of children admitted to the PICU at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. The treatment group included pediatric patients with GI bleeding and receiving omeprazole IV continuous infusion over ≥24 h while the control group included pediatric patients with GI bleeding managed using other therapies. Primary outcomes were the efficacy of omeprazole continuous infusion in stopping GI bleeding, and PICU length of stay (LOS). Secondary outcomes included instances of rebleeding post- therapy discontinuation, transfusion requirements, and the safety of omeprazole continuous infusion. Results The study included 81 critically ill pediatric patients, 22 of whom received continuous infusion omeprazole while 59 received other therapies. The results indicated that patients in the control group had a significantly shorter PICU LOS (8 vs. 18.5 days, p < 0.001) and bleeding episode (4 vs. 10.5 days, p < 0.001) than those in the treatment group. However, no significant differences were observed between the two groups regarding secondary outcomes. The treatment group had a significantly lower all-cause mortality rate during hospitalization compared to the control group (16 patients [72.7%] vs. 56 patients [94.9%], respectively, p = 0.005). Conclusion Empirical use of omeprazole continuous intravenous infusion in children with GI bleeding was not favorable in terms of shortening PICU LOS and duration of GI bleeding. Our study results provide evidence supporting the safety and tolerability of omeprazole continuous infusion. Additional larger studies are necessary to determine the implication of such results.
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Affiliation(s)
- Khalid W. Taher
- Pharmaceutical Care Division, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Rahaf Yaseen
- College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Mayas Alnan
- College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia
| | - Wejdan Aburas
- PGY1 Pharmacy Residency Program, Pharmaceutical Care Division, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
| | - Hala Khalil
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Moath Alabdulsalam
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Piccirillo M, Pucinischi V, Mennini M, Strisciuglio C, Iannicelli E, Giallorenzi MA, Furio S, Ferretti A, Parisi P, Di Nardo G. Gastrointestinal bleeding in children: diagnostic approach. Ital J Pediatr 2024; 50:13. [PMID: 38263189 PMCID: PMC10807079 DOI: 10.1186/s13052-024-01592-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/07/2024] [Indexed: 01/25/2024] Open
Abstract
Different conditions may underlie gastrointestinal bleeding (GIB) in children. The estimated prevalence of GIB in children is 6.4%, with spontaneous resolution in approximately 80% of cases. Nonetheless, the initial approach plays a pivotal role in determining the prognosis. The priority is the stabilization of hemodynamic status, followed by a systematic diagnostic approach. GIB can originate from either upper or lower gastrointestinal tract, leading to a broad differential diagnosis in infants and children. This includes benign and self-limiting disorders, alongside serious conditions necessitating immediate treatment. We performed a nonsystematic review of the literature, in order to describe the variety of conditions responsible for GIB in pediatric patients and to outline diagnostic pathways according to patients' age, suspected site of bleeding and type of bleeding which can help pediatricians in clinical practice. Diagnostic modalities may include esophagogastroduodenoscopy and colonoscopy, abdominal ultrasonography or computed tomography and, when necessary, magnetic resonance imaging. In this review, we critically assess these procedures, emphasizing their respective advantages and limitations concerning specific clinical scenarios.
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Affiliation(s)
- Marisa Piccirillo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Valentina Pucinischi
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Maurizio Mennini
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Elsa Iannicelli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, Radiology Unit, Rome, Italy
| | - Maria Agostina Giallorenzi
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, Radiology Unit, Rome, Italy
| | - Silvia Furio
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Alessandro Ferretti
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Pasquale Parisi
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy
| | - Giovanni Di Nardo
- NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Pediatric Unit, Sant'Andrea University Hospital, Via Di Grottarossa1035-1039, 00189, Rome, Italy.
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Dave H, Bharwad A, Hattar L, Tofteland N. Unveiling the Mystery: Correlating Physical Findings with Endoscopy to Diagnose an Uncommon Lesion. Kans J Med 2023; 16:332-333. [PMID: 38298388 PMCID: PMC10829856 DOI: 10.17161/kjm.vol16.21074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 12/18/2023] [Indexed: 02/02/2024] Open
Affiliation(s)
- Hitanshu Dave
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Pediatrics Residency Program
| | - Aastha Bharwad
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Ascension Via Christi Hospitals
| | | | - Nathan Tofteland
- University of Kansas School of Medicine-Wichita, Wichita, KS
- Internal Medicine Residency Program
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7
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Kocic M, Rasic P, Marusic V, Prokic D, Savic D, Milickovic M, Kitic I, Mijovic T, Sarajlija A. Age-specific causes of upper gastrointestinal bleeding in children. World J Gastroenterol 2023; 29:6095-6110. [PMID: 38186684 PMCID: PMC10768410 DOI: 10.3748/wjg.v29.i47.6095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/05/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023] Open
Abstract
The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.
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Affiliation(s)
- Marija Kocic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Petar Rasic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Vuk Marusic
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Dragan Prokic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Djordje Savic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Maja Milickovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Ivana Kitic
- Department of Gastroenterology, Hepatology and Nutrition, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
| | - Tanja Mijovic
- Department of Abdominal Surgery, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
| | - Adrijan Sarajlija
- Faculty of Medicine, University of Belgrade, Belgrade 11000, Serbia
- Pediatric Day Care Hospital Department, Mother and Child Health Care Institute of Serbia “Dr. Vukan Cupic”, Belgrade 11000, Serbia
- Faculty of Medicine, University of Eastern Sarajevo, Foča 73300, Bosnia and Herzegovina
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Balfour-Lynn IM. Haemoptysis: is it really from the lungs? The well child who spits out blood. Arch Dis Child 2023; 108:879-883. [PMID: 36990647 DOI: 10.1136/archdischild-2022-324276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/12/2023] [Indexed: 03/31/2023]
Abstract
Blood appearing in a previously well child's mouth may have many sources, and it should not be assumed to be haemoptysis, that is, coming from the respiratory tract below the larynx. In addition to the lungs and lower airways, consider also the upper airways, the mouth, gastrointestinal tract and cardiovascular conditions. This article discusses the differential diagnosis and appropriate investigations.
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Affiliation(s)
- Ian M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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9
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Bloomfield V, Iseyemi A, Kives S. Clinical Review: Prepubertal Bleeding. J Pediatr Adolesc Gynecol 2023; 36:435-441. [PMID: 37301426 DOI: 10.1016/j.jpag.2023.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/15/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Prepubertal bleeding is a common presentation in the pediatric office and can be distressing for patients and families. A comprehensive approach to diagnosis and management allows clinicians to identify patients at risk for worrisome pathology and arrange timely care. OBJECTIVE We aimed to review the key features of clinical history, physical exam, and diagnostic workup of a child presenting with prepubertal bleeding. We reviewed potential pathologies requiring urgent investigations and management, such as precocious puberty and malignancy, as well as more common etiologies, including foreign bodies and vulvovaginitis. CONCLUSION Clinicians should approach each patient with the goal of excluding diagnoses that require urgent interventions. A thoughtful clinical history and physical exam can inform appropriate investigations to optimize patient care.
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Affiliation(s)
- Valerie Bloomfield
- Department of Pediatric and Adolescent Gynecology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abigail Iseyemi
- Department of Obstetrics and Gynecology, London Health Sciences Center - Victoria Hospital, London, Ontario, Canada
| | - Sari Kives
- Department of Pediatric and Adolescent Gynecology, Hospital for Sick Children, Toronto, Ontario, Canada.
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Metezai H, Wahid A, Jones C, Evans J. Fifteen-minute consultation: Rectal bleeding in children. Arch Dis Child Educ Pract Ed 2023; 108:320-325. [PMID: 36564158 DOI: 10.1136/archdischild-2022-324626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022]
Abstract
Bleeding per rectum in children is an infrequent presentation associated with a wide range of differential diagnoses, from benign to life-threatening. Irrespective of the underlying aetiology, it is typically a worrisome symptom for caregivers. Published data are limited, particularly for the UK population, from which to provide clear evidence-based guidance for assessment and management of infants, children and young people presenting with bleeding per rectum. In this Fifteen-Minute Consultation, we therefore explore the common aetiologies and combine opinions from acute paediatrics, paediatric gastroenterology and paediatric surgery to offer a structure for a diagnostic approach and initial management of lower gastrointestinal bleeding in infants, children and young people.
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Affiliation(s)
- Huria Metezai
- Paediatric Emergency Department, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Amar Wahid
- Department of Paediatric Gastroenterology, Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Ceri Jones
- Department of Paediatric Surgery, Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jordan Evans
- Paediatric Emergency Department, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
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11
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Isa HM, Alkharsi FA, Ebrahim HA, Walwil KJ, Diab JA, Alkowari NM. Causes of gastrointestinal bleeding in children based on endoscopic evaluation at a tertiary care center in Bahrain. World J Gastrointest Endosc 2023; 15:297-308. [PMID: 37138937 PMCID: PMC10150281 DOI: 10.4253/wjge.v15.i4.297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/23/2023] [Accepted: 03/17/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a serious health problem worldwide, particularly during childhood. This can be an alarming sign of an underlying disease. Gastrointestinal endoscopy (GIE) is a safe method for the diagnosis and treatment of GIB in most cases.
AIM To determine the incidence, clinical presentation, and outcomes of GIB in children in Bahrain over the last two decades.
METHODS This was a retrospective cohort review of the medical records of children with GIB who underwent endoscopic procedures in the Pediatric Department at Salmaniya Medical Complex, Bahrain, between 1995 and 2022. Demographic data, clinical presentation, endoscopic findings, and clinical outcomes were recorded. GIB was classified into upper (UGIB) and lower (LGIB) GIB according to the site of bleeding. These were compared with respect to patients’ sex, age, and nationality using the Fisher’s exact, Pearson’s χ2, or the Mann-Whitney U tests.
RESULTS A total of 250 patients were included in this study. The median incidence was 2.6/100000 per year (interquartile range, 1.4-3.7) with a significantly increasing trend over the last two decades (P < 0.0001). Most patients were males (n = 144, 57.6%). The median age at diagnosis was 9 years (5–11). Ninety-eight (39.2%) patients required upper GIE alone, 41 (16.4%) required colonoscopy alone, and 111 (44.4%) required both. LGIB was more frequent (n = 151, 60.4%) than UGIB (n = 119, 47.6%). There were no significant differences in sex (P = 0.710), age (P = 0.185), or nationality (P = 0.525) between the two groups. Abnormal endoscopic findings were detected in 226 (90.4%) patients. The common cause of LGIB was inflammatory bowel disease (IBD) (n = 77, 30.8%). The common cause of UGIB was gastritis (n = 70, 28%). IBD and undetermined cause for bleeding were higher in the 10–18 years group (P = 0.026 and P = 0.017, respectively). Intestinal nodular lymphoid hyperplasia, foreign body ingestion, and esophageal varices were more common in the 0–4 years group (P = 0.034, P < 0.0001, and P = 0.029, respectively). Ten (4%) patients underwent one or more therapeutic interventions. The median follow-up period was two years (0.5-3). No mortality was reported in this study.
CONCLUSION GIB in children is an alarming condition, whose significance is increasing. LGIB, commonly due to IBD, was more common than UGIB, commonly due to gastritis.
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Affiliation(s)
- Hasan M Isa
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
- Department of Pediatrics, Arabian Gulf University, Manama 26671, Bahrain
| | - Fatema A Alkharsi
- Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
| | - Hana A Ebrahim
- Department of Pediatrics, Royal College of Surgeons in Ireland-Medical University of Bahrain, Busaiteen 15503, Bahrain
| | - Kamel J Walwil
- Department of Pediatrics, Royal College of Surgeons in Ireland-Medical University of Bahrain, Busaiteen 15503, Bahrain
| | - Jumana A Diab
- Department of Pediatrics, Royal College of Surgeons in Ireland-Medical University of Bahrain, Busaiteen 15503, Bahrain
| | - Nafelah M Alkowari
- Department of Pediatrics, King Hamad University Hospital, Muharraq 24343, Bahrain
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Novak I, Bass LM. Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances. Gastrointest Endosc Clin N Am 2023; 33:401-421. [PMID: 36948753 DOI: 10.1016/j.giec.2022.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) in children has many causes, with its prevalence varying by age. Often presenting as hematemesis or melena, the initial treatment is stabilization of the patient, including protection of the airway, fluid resuscitation, and a transfusion hemoglobin threshold of 7 g/L. Endoscopy should be performed with the goal of using combinations of therapies to treat a bleeding lesion, generally involving epinephrine injection along with either cautery, hemoclips, or hemospray. This review discusses the diagnosis and treatment of variceal and non-variceal gastrointestinal bleeding in children with a focus on current advances in the treatment of severe UGIB.
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Affiliation(s)
- Inna Novak
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467, USA.
| | - Lee M Bass
- Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Chicago, IL 60611, USA
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13
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Krasaelap A, Lerner DG, Oliva S. The Role of Endoscopy in the Diagnosis and Management of Small Bowel Pathology in Children. Gastrointest Endosc Clin N Am 2023; 33:423-445. [PMID: 36948754 DOI: 10.1016/j.giec.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Small bowel evaluation has been transformed by capsule endoscopy and advances in small bowel imaging, which provide reliable and noninvasive means for assessing the mucosal surface. Device-assisted enteroscopy has been critical for histopathological confirmation and endoscopic therapy for a wide range of small bowel pathology that conventional endoscopy cannot reach. The purpose of this review is to provide a comprehensive overview of the indications, techniques, and clinical applications of capsule endoscopy; device-assisted enteroscopy; and imaging studies for small bowel evaluation in children.
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Affiliation(s)
- Amornluck Krasaelap
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Diana G Lerner
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Piazzale Aldo Moro, 5 00185, Roma, RM, Italy
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Endoscopy in Infants With Gastrointestinal Bleeding Has Limited Diagnostic or Therapeutic Benefit. J Pediatr Gastroenterol Nutr 2022; 75:514-520. [PMID: 35848737 DOI: 10.1097/mpg.0000000000003566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Pediatric gastroenterologists are often consulted to perform diagnostic and therapeutic endoscopy in infants with gastrointestinal bleeding (GIB). The value of endoscopy and risk of complications in this population are not well characterized. We aimed to describe findings and outcomes of infants with GIB who undergo endoscopy. METHODS Retrospective, single-center, cohort study of hospitalized infants ≤12 months who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy/flexible sigmoidoscopy (COL) for GIB. Current procedural technology codes, international classification of diseases codes, and quality control logs identified infants. RESULTS Fifty-six infants were identified from 2008 to 2019 (51.8% female; mean age 161.6 days). Seven endoscopies identified sources of GIB: gastric ulcers, a duodenal ulcer, gastric angiodysplasia, esophageal varices, and an anastomotic ulcer. Three infants underwent therapeutic interventions of banding/sclerotherapy of esophageal varices and triamcinolone injection of an anastomotic ulcer. Six infants underwent abdominal surgery for GIB or suspected intestinal perforation after endoscopy, where a gastric perforation, jejunal perforation at an anastomotic stricture, necrotizing enterocolitis totalis with perforation, Meckel's diverticulum, and a duodenal ulcer were identified. No source of bleeding was identified surgically in 1 infant with GIB. Respiratory failure, use of vasopressors or octreotide, administration of blood products, and high blood urea nitrogen were associated with increased likelihood of requiring surgery ( P < 0.05 for all). CONCLUSIONS There was limited utility to performing endoscopy in infants ≤12 months old with clinical GIB. Endoscopy in these sick infants carries risk, and 3 infants in this series presented with a gastrointestinal (GI) perforation shortly after the procedure. These limitations and risks should influence clinical decision-making regarding endoscopy in infants with GIB.
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15
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Flores-Calderón J, Cisneros-Garza LE, Chávez-Barrera JA, Vázquez-Frias R, Reynoso-Zarzosa FA, Martínez-Bejarano DL, Consuelo-Sánchez A, Reyes-Apodaca M, Zárate-Mondragón FE, Sánchez-Soto MP, Alcántara-García RI, González-Ortiz B, Ledesma-Ramírez S, Espinosa-Saavedra D, Cura-Esquivel IA, Macías-Flores J, Hinojosa-Lezama JM, Hernández-Chávez E, Zárate-Guerrero JR, Gómez-Navarro G, Bilbao-Chávez LP, Sosa-Arce M, Flores-Fong LE, Lona-Reyes JC, Estrada-Arce EV, Aguila-Cano R. Consensus on the management of complications of cirrhosis of the liver in pediatrics. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:462-485. [PMID: 35810090 DOI: 10.1016/j.rgmxen.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 12/07/2022]
Abstract
The Asociación Mexicana de Hepatología A.C. carried out the Consensus on the Management of Complications of Cirrhosis of the Liver in Pediatrics to provide physicians with useful information for treating said complications. A group of pediatric gastroenterologists and experts in nutrition, nephrology, and infectious diseases participated and reviewed the medical literature. The Delphi method was applied to obtain the level of agreement on the statements that were formulated. The statements were sent to the participants to be analyzed and voted upon, after which they were discussed in virtual sessions, and the final versions were produced. The aim of the consensus results was to issue indications for the management of pediatric patients with liver cirrhosis, to prevent or control complications.
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Affiliation(s)
- J Flores-Calderón
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico.
| | | | - J A Chávez-Barrera
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | | | | | | | | | | | | | - M P Sánchez-Soto
- Hospital de Especialidades del Niño y la mujer de Querétaro Dr. Felipe Núñez Lara, Querétaro, Mexico
| | | | - B González-Ortiz
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - S Ledesma-Ramírez
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | - D Espinosa-Saavedra
- UMAE Hospital de Pediatría, CMN XXI Dr. Silvestre Frenk Freund IMSS, Cd, México, Mexico
| | | | - J Macías-Flores
- Hospital Infantil de Especialidades de Chihuahua, Chihuahua, Mexico
| | | | - E Hernández-Chávez
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - J R Zárate-Guerrero
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - G Gómez-Navarro
- UMAE Hospital de Pediatría Centro Médico de Occidente, IMSS, Guadalajara, Mexico
| | - L P Bilbao-Chávez
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - M Sosa-Arce
- UMAE Hospital General CMN La Raza, Dr. Gaudencio González Garza IMSS, Cd, México, Mexico
| | - L E Flores-Fong
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - J C Lona-Reyes
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - E V Estrada-Arce
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
| | - R Aguila-Cano
- Nuevo Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Guadalajara, Mexico
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16
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Common Conditions II. Surg Clin North Am 2022; 102:797-808. [PMID: 36209746 DOI: 10.1016/j.suc.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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17
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Lin M, Zhu H, Zhang R, Wang H. Causes of bloody stools in neonates: a case series report. Transl Pediatr 2022; 11:1438-1444. [PMID: 36247883 PMCID: PMC9561507 DOI: 10.21037/tp-22-166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Bloody stools in a neonate may stand for a spectrum of conditions ranging from benign to life-threatening. It is critical to detect the cases that have significant underlying pathology, especially those which require urgent surgical intervention. Previous studies always focused on one particular disease related to bloody stools in neonates, or the study only involved a small number of cases. This study aimed to investigate the common causes of bloody stools in neonates. METHODS This retrospective cohort study included the neonates admitted to our institution due to "bloody stools" over a 5-year period. We compared the differences among patients' characteristics, feeding choice, underlying diseases, and operation rate between preterm and term neonates. RESULTS A total of 300 patients were included, accounting for 1.1% of the total neonatal admissions. The overall rate of exclusive breastfeeding was 28.0%. The most common underlying causes for bloody stools were: cow's milk protein allergy (CMPA, 53.3%), swallowed blood syndrome (10.0%), viral enteritis (9.7%), necrotizing enterocolitis (NEC) > stage II (8.3%), non-specific enteritis (7.3%), and anal fissure (5.0%). The median [interquartile range (IQR)] onset age for bloody stools for all infants was 12 [3-22] days after birth. Preterm neonates had a lower rate of exclusive breastfeeding (P=0.844), higher incidence of NEC > stage II (P=0.014), later bloody stools onset age (P<0.001), and longer length of hospital stay than term neonates (P<0.001). For neonates with NEC, those with bottle-fed had an earlier onset age for bloody stools than those with breast-fed (P=0.027). Only 1.7% (n=5) required surgery (2 stage III NEC, 1 post-NEC stricture, and 2 volvuli). Survival at hospital discharge was 100%. CONCLUSIONS Bloody stools in neonates is generally a benign, self-limiting disorder, not related to surgical conditions. The overall operation rate among neonates with bloody stools was only 1.7%. CMPA and NEC were the most common underlying non-surgical and surgical diseases, respectively, for neonates with bloody stools. Feeding choice is related to bloody stools in neonates, policies and strategies to support breastfeeding should be strengthened in the future.
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Affiliation(s)
- Mingchun Lin
- Department of Neonatology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Haitao Zhu
- Department of Pediatric Surgery, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Rong Zhang
- Department of Neonatology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Huanhuan Wang
- Department of Neonatology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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18
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Melchior R, Funke R, Wilken B, Jenke A. Trust Your Instinct-Lower Intestinal Bleeding Caused by Ehlers-Danlos-Syndrome. JPGN REPORTS 2022; 3:e233. [PMID: 37168646 PMCID: PMC10158485 DOI: 10.1097/pg9.0000000000000233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/28/2022] [Indexed: 05/13/2023]
Abstract
We report a 2.5-year-old boy who was presented with acute lower gastrointestinal bleeding. Emergency endoscopy showed two active mucosal bleeding sites that were successfully clipped. Initially, multiple intestinal angiodysplasias were considered, ruled out by a second control endoscopy. Here, multiple superficial lesions were observed that bled upon contact by the endoscope, suggestive of connective tissue disorder. However, the patient showed no clinical dysmorphias, only hypermobility of the toes but no other symptoms typical for such disorders. Gene testing for Ehlers-Danlos-syndrome (EDS) revealed a pathogenic mutation in the COL3A1 causing loss-of-function of type 3-collagen. Thus, diagnosis of EDS type IV was established. Overall, EDS is a rare cause for intestinal bleeding in children, even in children with no other clinical symptoms. This case is the earliest presentation of EDS type IV with intestinal complications.
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Affiliation(s)
- Ralph Melchior
- From the General Pediatrics and Neonatology, Childrens Hospital, Klinikum Kassel, Kassel, Germany
| | - Rudolf Funke
- Department of Pediatric Neurology, Childrens Hospital, Klinikum Kassel, Kassel, Germany
| | - Bernd Wilken
- Department of Pediatric Neurology, Childrens Hospital, Klinikum Kassel, Kassel, Germany
| | - Andreas Jenke
- From the General Pediatrics and Neonatology, Childrens Hospital, Klinikum Kassel, Kassel, Germany
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19
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Rabinovich E, Johnson-Arbor K, Serrano M, Chao C, Eblan MJ, Rao AD, Terao M, Toretsky J, Sarangi S, Varela C, Hong D. The Use of Hyperbaric Oxygen Therapy in the Management of Severe Radiation-Induced Hemorrhagic Gastritis in a Pediatric Patient. JPGN REPORTS 2022; 3:e144. [PMID: 37168767 PMCID: PMC10158405 DOI: 10.1097/pg9.0000000000000144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/08/2021] [Indexed: 05/13/2023]
Abstract
Radiation-induced hemorrhagic gastritis is a serious and rare complication of radiation therapy. Optimal therapies in the pediatric population are not well established. We report a 2-year-old female diagnosed with rhabdomyosarcoma who developed hemorrhagic gastritis following chemotherapy and radiation therapy. The patient presented with acute onset anemia, hematemesis, and melena. Endoscopies revealed circumferential ulceration at the pylorus with spontaneous oozing that failed to respond effectively with multimodal medical and endoscopic therapies. Following hemodynamic stabilization, the patient was treated with hyperbaric oxygen therapy with excellent clinical response of the bleeding. Further research on the benefit of hyperbaric oxygen therapy is warranted to determine if this treatment can reduce the incidence of gastrointestinal complications in patients who have received radiation therapy.
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Affiliation(s)
| | | | | | | | | | | | - Michael Terao
- From the MedStar Georgetown University Hospital, Washington, DC
| | | | - Susmita Sarangi
- From the MedStar Georgetown University Hospital, Washington, DC
| | - Carly Varela
- From the MedStar Georgetown University Hospital, Washington, DC
- INOVA Children’s Hospital, Falls Church, VA
| | - Dahye Hong
- From the MedStar Georgetown University Hospital, Washington, DC
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20
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Kang A, Kim SH, Cho YH, Kim HY. Surgical perspectives of symptomatic omphalomesenteric duct remnants: Differences between infancy and beyond. World J Clin Cases 2021; 9:11228-11236. [PMID: 35071553 PMCID: PMC8717527 DOI: 10.12998/wjcc.v9.i36.11228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/29/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The clinical manifestations of omphalomesenteric duct remnant (OMDR) can vary with the age at diagnosis, from asymptomatic incidental findings to symptoms related to gastrointestinal complications. The lifelong complication rates are reported as 4%-34%, and complications are more common in patients younger than 2 years of age. The authors attempted to identify different clinical features and management for the various pediatric age groups.
AIM To find surgical perspectives for the pediatric age-related variants of OMDR and make recommendations for optimal management.
METHODS The medical records of pediatric patients diagnosed with OMDR were reviewed retrospectively. Fifteen patients diagnosed based on incidental findings during other surgeries were excluded. The patients were divided into two groups based on age: < 12 mo (infants) and > 12 mo (beyond infancy). We analyzed the demographic characteristics, clinical manifestations, diagnostic tools, surgical procedures, and clinical outcomes of the patients and compared them for the age groups. Chi-squared and Fisher's exact tests were used for nominal scales and a Mann-Whitney test was used for ratio scales.
RESULTS A total of 35 patients (7 infants, 28 children beyond infancy) were finally included. In both groups, Meckel's diverticulum (MD) was the most common type of OMDR, while umbilical lesions were more common in the infant group (P = 0.006). Hematochezia and abdominal pain were common in the beyond infancy group, while umbilical lesions were the most frequent symptoms in the infant group. Several diagnostic tools were used, but Meckel's scan was most useful in diagnosing OMDR in patients with painless rectal bleeding. Minimally invasive surgery was more commonly performed for children than for infants (P = 0.016). Single-incision laparoscopic surgery (SILS) was performed for fifteen patients who underwent laparoscopic surgery. There were only three cases of postoperative complications, and all patients survived in good condition.
CONCLUSION The clinical type of OMDR varies with age, umbilical lesions in infants, and MD beyond infancy. SILS is effective for managing children with MD regardless of age.
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Affiliation(s)
- Ayoung Kang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Soo-Hong Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Yong-Hoon Cho
- Department of Surgery, Pusan National University School of Medicine, Yangsan 50612, South Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
| | - Hae-Young Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan 50612, South Korea
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21
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Heyne-Pietschmann M, Lehnick D, Spalinger J, Righini-Grunder F, Buettcher M, Lehner M, Stocker M. Newborns with Bloody Stools-At the Crossroad between Efficient Management of Necrotizing Enterocolitis and Antibiotic Stewardship. Antibiotics (Basel) 2021; 10:1467. [PMID: 34943679 PMCID: PMC8698526 DOI: 10.3390/antibiotics10121467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022] Open
Abstract
The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell's criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell's criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.
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Affiliation(s)
| | - Dirk Lehnick
- Biostatistics and Methodology, Clinical Trial Unit Central Switzerland, University of Lucerne, 6000 Lucerne, Switzerland;
- Department of Health Sciences and Medicine, University of Lucerne, 6000 Lucerne, Switzerland
| | - Johannes Spalinger
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland; (J.S.); (F.R.-G.)
| | - Franziska Righini-Grunder
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland; (J.S.); (F.R.-G.)
| | - Michael Buettcher
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland;
| | - Markus Lehner
- Department of Pediatric Surgery, Children’s Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Martin Stocker
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, Children’s Hospital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland;
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22
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Baker RD, Baker SS. Gastrointestinal Bleeds. Pediatr Rev 2021; 42:546-557. [PMID: 34599054 DOI: 10.1542/pir.2020-000554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Robert D Baker
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
| | - Susan S Baker
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY
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23
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Watanabe J, Kotani K. Polyethylene Glycol Versus Senna for Bowel Preparation for Colonoscopy in Children: Updated Evidence by a Systematic Review and Meta-Analysis. Cureus 2021; 13:e17813. [PMID: 34660023 PMCID: PMC8500257 DOI: 10.7759/cureus.17813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2021] [Indexed: 11/11/2022] Open
Abstract
For colonoscopy, bowel preparation, especially that using polyethylene glycol (PEG) or senna, is performed among children with gastrointestinal disorders; however, it is not fully grounded in evidence. This study reviewed via meta-analyses the approaches to bowel preparation for colonoscopy in children. Electronic databases and trial registries were searched until April 2021. Quality assessment was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation method. In total, three randomized controlled trials (318 patients) were identified. PEG was observed as a preferred protocol of bowel preparation compared with senna (risk ratio [RR] 1.35, 95% confidence interval [CI] 1.05-1.74; I2 = 15%). It was less painful than senna (RR 0.62, 95% CI 0.44-0.87; I2 = 0%). No serious adverse events were noted. Overall, the certainty of the evidence was low to moderate. PEG might be a preferred preparation agent for colonoscopy in children. Given the limited data, more studies are recommended.
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Affiliation(s)
- Jun Watanabe
- Community and Family Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Kazuhiko Kotani
- Community and Family Medicine, Jichi Medical University, Shimotsuke, JPN
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24
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Ruiz-Rodríguez AJ, García Robles A, Benavente Fernández A. Upper gastrointestinal bleeding in a patient with Marfan's disease. Med Clin (Barc) 2021; 158:237-238. [PMID: 34112511 DOI: 10.1016/j.medcli.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
| | - Adelina García Robles
- Servicio de Aparato Digestivo, Hospital Universitario Clínico San Cecilio, Granada, España
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25
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Talib MA, Aziz MT, Suleman H, Khosa GK, Joya SJ, Hussain I. Etiologies and outcome of lower gastrointestinal bleeding in patients presenting to a tertiary care Children's Hospital. Pak J Med Sci 2021; 37:556-560. [PMID: 33679949 PMCID: PMC7931281 DOI: 10.12669/pjms.37.2.2676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective: To determine etiology and outcome of children with lower gastrointestinal bleeding (LGIB). Methods: This was a prospective study conducted at the Department of Pediatric Gastroenterology and Hepatology, Children’s Hospital and The Institute of Child’s Heath, Multan, Pakistan, from July 2019 to March 2020. A total of 148 cases presented with bleeding per rectum and underwent colonoscopy, were included. Children of both genders and aged three month to 15 years were included. Detailed history, clinical examination, laboratory studies, colonoscopy and histopathology were done in all cases. Study information like demographics, complaints, general clinical examination, colonoscopy and histopathological findings were recorded. Results: Overall, mean age was noted to be 7.20±1.83 years. Abdominal pain was reported in 41 (27.7%), diarrhea 36 (24.3%), fever 12 (8.1%) and constipation in 4 (2.7%). Pallor was noted among 68 (45.9%), weight loss 39 (26.3%) and tachycardia 31 (20.9%). Colonoscopy revealed juvenile colonic / rectal polyps, infectious colitis and solitary rectal ulcer (SRU) as the most common etiologies found among 58 (39.2%), 20 (13.5%) and 19 (12.8%) cases respectively. Juvenile polyps and non-specific colitis were the commonest histopathological findings seen in 55 (37.2%) and 20 (13.5%) cases respectively. Colonoscopic polypectomy was used to remove all juvenile polyps. Conclusion: LGIB is presentation of various underlying causes. Children with LGIB commonly present with abdominal pain. Juvenile polyps were the most frequent cause of LGIB among children flowed by non-specific colitis. Most of the children having LGIB were diagnosed and treated successfully, few are in remission and very few were found resistant to treatment.
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Affiliation(s)
- Muhammad Abu Talib
- Muhammad Abu Talib, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
| | - Muhammad Tariq Aziz
- Muhammad Tariq Aziz, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
| | - Hassan Suleman
- Hassan Suleman, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
| | - Ghazi Khan Khosa
- Ghazi Khan Khosa, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
| | - Saima Jabeen Joya
- Saima Jabeen Joya, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
| | - Ibrar Hussain
- Ibrar Hussain, Department of Pediatric Gastroenterology and Hepatology, Children's Hospital and The Institute of Child's Heath, Multan, Pakistan
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Iwama I, Yoshida M, Hara T, Nambu R. Causes of Melena and Effective Examination Strategies in Children. Front Pediatr 2021; 9:780356. [PMID: 34956987 PMCID: PMC8692886 DOI: 10.3389/fped.2021.780356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background and Aim: Melena, or tarry black stool, is not a rare symptom encountered in pediatric clinical practice, and the bleeding source varies from the upper gastrointestinal tract to the small intestine. Endoscopy is effective in identifying bleeding, but it does not always identify the source of bleeding. Endoscopic examination in children is commonly challenging, and there are no detailed reports about the causes of melena in children. This observational study aimed to validate the cause of melena in children and to investigate more effective and less burdensome examination methods. Methods: We retrospectively reviewed the clinical records of 55 patients who underwent examination for melena. Results: In this research, 38 patients had underlying diseases such as malignancy and severe mental and physical disorders. The bleeding source was identified in 39 patients. The most common final diagnosis was duodenal ulcer (n = 22), and the other diagnoses were gastric ulcer, esophagitis, and esophageal varices. The upper gastrointestinal tract was the most common source of bleeding (n = 34). In five patients, the bleeding source was the small intestine. Vomiting, abnormal abdominal ultrasonography findings, and a hemoglobin level of ≤ 3 g/dL than the lower normal limit were significant factors indicating that the bleeding source can be found on esophagogastroduodenoscopy. Conclusions: The upper gastrointestinal tract was the most common bleeding source of melena in children. As in adults, esophagogastroduodenoscopy is the primary endoscopic method of choice. Furthermore, small bowel capsule endoscopy may be useful in identifying the bleeding source in children without upper gastrointestinal lesions.
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Affiliation(s)
- Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Masashi Yoshida
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Tomoko Hara
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
| | - Ryusuke Nambu
- Division of Gastroenterology and Hepatology, Saitama Children's Medical Center, Saitama, Japan
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Woodhull S, Goon H, Rajadurai P, Tan S, Tan Z. Adhesive subacute small bowel obstruction presenting with gross rectal bleeding. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Liu T, Mukosera GT, Blood AB. The role of gasotransmitters in neonatal physiology. Nitric Oxide 2019; 95:29-44. [PMID: 31870965 DOI: 10.1016/j.niox.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 11/07/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
The gasotransmitters, nitric oxide (NO), hydrogen sulfide (H2S), and carbon monoxide (CO), are endogenously-produced volatile molecules that perform signaling functions throughout the body. In biological tissues, these small, lipid-permeable molecules exist in free gaseous form for only seconds or less, and thus they are ideal for paracrine signaling that can be controlled rapidly by changes in their rates of production or consumption. In addition, tissue concentrations of the gasotransmitters are influenced by fluctuations in the level of O2 and reactive oxygen species (ROS). The normal transition from fetus to newborn involves a several-fold increase in tissue O2 tensions and ROS, and requires rapid morphological and functional adaptations to the extrauterine environment. This review summarizes the role of gasotransmitters as it pertains to newborn physiology. Particular focus is given to the vasculature, ventilatory, and gastrointestinal systems, each of which uniquely illustrate the function of gasotransmitters in the birth transition and newborn periods. Moreover, given the relative lack of studies on the role that gasotransmitters play in the newborn, particularly that of H2S and CO, important gaps in knowledge are highlighted throughout the review.
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Affiliation(s)
- Taiming Liu
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, 92354, USA
| | - George T Mukosera
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, 92354, USA
| | - Arlin B Blood
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, 92354, USA; Lawrence D. Longo Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, 92354, USA.
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Wen Q, Liu K, Yue W, Shao S, Zhang S, Li X, Hua Z. Clinical significance of positive fecal occult blood test in neonates. Sci Rep 2019; 9:17898. [PMID: 31784639 PMCID: PMC6884454 DOI: 10.1038/s41598-019-54511-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/12/2019] [Indexed: 11/14/2022] Open
Abstract
The fecal occult blood test (FOBT) is a screening tool for hematochezia. This study aims to summarize the clinical features associated with a positive FOBT in neonates and to explore some clues for the underlying causes. Combination with other clinical information, identifying the possible etiology is more likely and could be useful for choosing an effective therapeutic strategy. The medical records of 282 neonates with positive FOBTs from January 1 to July 31, 2016, were collected and retrospectively analyzed. The total incidence rate of FOBT positivity in neonates was 6.2%. Among these patients, 71 (25.2%) neonates had false-positive FOBTs, whereas 211 (74.8%) neonates had intraintestinal sources of hematochezia. Necrotizing enterocolitis (NEC, 20.9%), structural abnormalities of gastrointestinal tract (SAGT, 12.4%), and suspected food allergy (sFA, 10.6%) were the most common causes of neonatal hematochezia. It indicated that FOBT-positive neonates with NEC were more likely to suffer due to a younger gestational age, lower birth weight, and lower weight on admission than the neonates with other conditions. The proportions of neonates with bloody stool (90.0%) and diarrhea (63.3%) in the sFA group were markedly higher than those in the other groups. However, in the SAGT group, emesis (94.3%) and abdominal distension (80.0%) were evidently higher, usually accompanied by a relatively poor response (60.0%) and weakened bowel sounds (48.6%). Furthermore, the higher incidences of poor response (72.1%), abdominal distension (71.2%), bloody stools (64.4%), and weakened bowel sounds (62.7%) were observed in the NEC group. Due to the complicated etiology associated with a positive FOBT, the analyzed indexes were combined with other clinical features to identify the likely causes of neonatal hematochezia. Because NEC, sFA and SAGT show similar clinical manifestations and can occasionally transform into each other, close and frequent observation is crucial for timely intervention to achieve a better prognosis. Although it failed to provide an early warning of severe disease through FOBT, and the early intervention for FOBT might not decrease NEC, sFA, structural bowel injuries, or any other complications, newborn FOBT positive reminds medical staff to be alert to the related diseases including NEC, SAGT and sFA, by closer observation and follow-up.
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Affiliation(s)
- Qiuping Wen
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China
| | - Kaizhen Liu
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China
| | - Weihong Yue
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shiqi Shao
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shu Zhang
- Scientific Research Office, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiaoqing Li
- Department of Gastrointestinal Surgery and Neonatal Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ziyu Hua
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China. .,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China.
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Green DS, Abdel‐Latif ME, Jones LJ, Lui K, Osborn DA. Pharmacological interventions for prevention and treatment of upper gastrointestinal bleeding in newborn infants. Cochrane Database Syst Rev 2019; 7:CD011785. [PMID: 31265739 PMCID: PMC6605977 DOI: 10.1002/14651858.cd011785.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding is typically a mild, self-limiting condition that can affect both preterm and term neonates, although it can be severe particularly when associated with co-morbidities. Pharmacological interventions with a proton pump inhibitor (PPI), H2 receptor antagonist (H2RA), antacid, bismuth and sucralfate may have effects on both the prevention and treatment of upper gastrointestinal bleeding in infants. OBJECTIVES To assess how different pharmacological interventions (PPIs, H2RAs, antacids, sucralfate or bismuth salts) administered to preterm and term neonates for the prevention or treatment of upper gastrointestinal bleeding to reduce morbidity and mortality compare with placebo or no treatment, supportive care, or each other. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 6), MEDLINE via PubMed (1966 to 12 July 2018), Embase (1980 to 12 July 2018), and CINAHL (1982 to 12 July 2018). We also searched clinical trial databases, conference proceedings, the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials, and online for Chinese literature articles. SELECTION CRITERIA We selected randomised, quasi-randomised and cluster-randomised trials involving preterm and term neonates. Trials were included if they used a proton pump inhibitor, H2 receptor antagonist, antacid, sucralfate or bismuth either for the prevention or treatment of upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. We conducted meta-analysis using a fixed-effect model. We used the GRADE approach to assess quality of evidence. MAIN RESULTS Eleven studies with 818 infants met the criteria for inclusion in this review.Four trials with 329 infants assessed the use of an H2 receptor antagonist for prevention of upper gastrointestinal bleeding in high-risk newborn infants. Meta-analysis of these four trials identified a reduction in any upper gastrointestinal bleeding when using an H2 receptor antagonist (typical risk ratio (RR) 0.36, 95% confidence interval (CI) 0.22 to 0.58; typical risk difference (RD) -0.20, 95% CI -0.28 to -0.11; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 9). The quality of evidence was moderate. A single trial with 53 infants assessing prevention of upper gastrointestinal bleeding reported no difference in mortality in infants assigned H2 receptor antagonist versus no treatment; however the quality of evidence was very low.Seven trials with 489 infants assessed an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) for treatment of gastrointestinal bleeding in newborn infants. Meta-analysis of two trials (131 infants) showed no difference in mortality from use of a H2 receptor antagonist compared to no treatment. The quality of evidence was low. Meta-analysis of two trials (104 infants) showed a reduction in duration of upper gastrointestinal bleeding from use of an inhibitor of gastric acid compared to no treatment (mean difference -1.06 days, 95% CI -1.28 to -0.84). The quality of evidence was very low. Meta-analysis of six trials (451 infants) showed a reduction in continued upper gastrointestinal bleeding from use of any inhibitor of gastric acid compared to no treatment (typical RR 0.36, 95% CI 0.26 to 0.49; typical RD -0.26, 95% CI -0.33, -0.19; NNTB 4, 95% CI 3 to 5). The quality of evidence was low. There were no significant subgroup differences in duration of upper gastrointestinal bleeding or of continued upper gastrointestinal bleeding according to type of inhibitor of gastric acid. A single trial (38 infants) reported no difference in anaemia requiring blood transfusion from use of a H2 receptor antagonist compared to no treatment.Although no serious adverse events were reported from the use of a H2 receptor antagonist or proton pump inhibitor, some neonatal morbidities - including necrotising enterocolitis, ventilator-associated pneumonia, duration of ventilation and respiratory support, and duration of hospital stay - were not reported. Long-term outcome was not reported. AUTHORS' CONCLUSIONS There is moderate-quality evidence that use of an H2 receptor antagonist reduces the risk of gastrointestinal bleeding in newborn infants at high risk of gastrointestinal bleeding. There is low-quality evidence that use of an inhibitor of gastric acid (H2 receptor antagonist or proton pump inhibitor) reduces the duration of upper gastrointestinal bleeding and the incidence of continued gastric bleeding in newborn infants with gastrointestinal bleeding. However, there is no evidence that use of an inhibitor of gastric acid in newborn infants affects mortality or the need for blood transfusion. As no study reported the incidence of necrotising enterocolitis, ventilator- or hospital-associated pneumonia, sepsis, or long-term outcome, the safety of inhibitors of gastric acid secretion is unclear.
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Affiliation(s)
- Daniel Stephen Green
- Australian National UniversityThe Medical School, College of Health and MedicineActon, CanberraACTAustralia2601
- Concord Repatriation General HospitalHospital RoadConcord, SydneyNSWAustralia2139
| | - Mohamed E Abdel‐Latif
- Australian National UniversityDiscipline of Neonatology, The Medical School, College of Medicine and Health54 Mills RoadActon, CanberraACTAustralia2601
- Centenary Hospital for Women and Children, Canberra HospitalDepartment of NeonatologyBuilding 11, Level 2, 77 Yamba DriveGarranACTAustralia2605
| | - Lisa J Jones
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownNSWAustralia
| | - Kei Lui
- Royal Hospital for WomenDepartment of Newborn CareBarker StreetRandwickNew South WalesAustralia2031
- Lei LuiSchool of Women's and Children's HealthSydneyNSWAustralia2052
| | - David A Osborn
- Central Clinical School, School of Medicine, The University of SydneySydneyAustralia2006
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Abstract
BACKGROUND There is a lack of clarity about the approach to and management of upper gastrointestinal (UGI) bleeding in children. AIM To examine the recent literature on UGI bleeding in children in order to outline the diagnostic approach and management. METHODS The English language literature was searched for articles on UGI bleeding in children. Special attention was paid to its prevalence, risk factors, clinical approach and management. RESULTS Although UGI bleeding is a common complication (10%) in paediatric intensive care units (PICU), clinically significant UGI bleeding (haemodynamic instability, fall in haemoglobin by 2 g/dL and/or a requirement for blood transfusion) is less common (1.6%). In low- and middle-income countries, clinically significant UGI bleeding is commonly owing to variceal bleeding whereas non-variceal aetiologies (e.g. peptic ulcer disease) are common in high-income countries. The fundamental clinical principles of managing UGI bleeding are immediate assessment of severity, detecting possible causes and stabilising the haemodynamic status. In suspected cases of variceal bleeding, intravenous octreotide and, in non-variceal bleeding, administration of a proton pump inhibitor (PPI) should be commenced immediately. UGI endoscopy plays a vital role in diagnosis and management. Over-transfusion should be avoided (target haemoglobin 7-9 g/dL). Stress ulcer prophylaxis is recommended in a select group of patients in PICUs (e.g. respiratory failure, coagulopathy and paediatric risk of mortality score ≥10). CONCLUSIONS In clinically significant UGI bleeding, the primary goal is to restore the haemodynamic status, followed by early endoscopy. Intravenous octreotide in suspected variceal and PPI in non-variceal bleeding should be administered early. Stress ulcer prophylaxis should be restricted to high-risk children only.
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Affiliation(s)
- Ujjal Poddar
- a Department of Pediatric Gastroenterology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
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32
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Gaiani F, De'Angelis N, Kayali S, Manfredi M, Di Mario F, Leandro G, Ghiselli A, Fornaroli F, De'Angelis GL. Clinical approach to the patient with acute gastrointestinal bleeding. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:12-19. [PMID: 30561412 PMCID: PMC6502216 DOI: 10.23750/abm.v89i8-s.7861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Indexed: 12/03/2022]
Abstract
Gastrointestinal bleeding (GIB) is a very common condition at all ages, with high rates of morbidity and mortality, especially in case of acute presentation. The optimal management of acute GIB requires a timely overview of vital signs and clinical presentation to stabilize the patient if necessary and set up the most adequate diagnostic and therapeutic approach, based on the suspected etiology. Endoscopy plays a major role both in diagnosis and treatment of acute GIB, as allows the application of several hemostasis techniques during the diagnostic session, which should preferably be performed within 24 hours from the acute event. The hemostasis technique should be chosen based on type, etiology of the bleeding and the operator preference and expertise. Nevertheless, several challenging cases need the cooperation of radiology especially in the diagnostic phase, and even in the therapeutic phase for those bleedings in which medical and endoscopic techniques have failed. Imaging diagnostic techniques include mainly CT angiography, scintigraphy with labeled erythrocytes and arteriography. This last technique plays also a therapeutic role in case arterial embolization is needed. Only those patients in which the previous techniques have failed, both in diagnosis and treatment, are candidates for emergency surgery. (www.actabiomedica.it)
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Affiliation(s)
- Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Chen J, Zhang B, Yan Z, Zhao H, Yang K, Yin Y, Jiang L. Exploratory laparoscopy combined with pathological examination in the diagnosis of obscure gastrointestinal bleeding in a child: a case report. BMC Pediatr 2018; 18:371. [PMID: 30482204 PMCID: PMC6260701 DOI: 10.1186/s12887-018-1339-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/12/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The diagnosis of obscure gastrointestinal bleeding (OGIB) which is defined as bleeding of unknown origin of the small bowel by routine evaluation in childhood is a challenge. CASE PRESENTATION Here we report a one-year-old Chinese girl who was suspected with idiopathic pulmonary haemosiderosis (IPH) and referred to our department for further diagnosis. Finally she was diagnosed with vascular malformations (VM) by exploratory laparoscopy combined with pathological examination. CONCLUSIONS Children OGIB could be easily misdiagnosed in the beginning, and OGIB children with active ongoing bleeding may benefit from proceeding directly to exploratory laparoscopy, followed by pathological confirmation of the diagnosis.
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Affiliation(s)
- Jiande Chen
- Department of Respiratory Medicine, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Bin Zhang
- Department of Gastroenterology, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Zhilong Yan
- Department of General Surgery, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Huaying Zhao
- Department of General Surgery, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Kaihua Yang
- Department of Gastroenterology, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Yong Yin
- Department of Respiratory Medicine, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
| | - Lirong Jiang
- Department of Gastroenterology, Shanghai Children’s Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, No.1678 Dongfang Road, Pudong, 200127 Shanghai China
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Dipasquale V, Corica D, Gramaglia SMC, Valenti S, Romano C. Gastrointestinal symptoms in children: Primary care and specialist interface. Int J Clin Pract 2018; 72:e13093. [PMID: 29691962 DOI: 10.1111/ijcp.13093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/18/2018] [Indexed: 12/19/2022] Open
Abstract
AIMS Gastrointestinal symptoms and diseases represent one of the major reasons for paediatricians' requests for specialist consultations and hospital admissions. One fourth of annual medical consultations for children younger than 6 years can be attributed to gastrointestinal symptoms. High-quality guidelines have been validated worldwide to provide clinical recommendations and support healthcare providers' practice. Nevertheless, overall compliance to standards of care is unsatisfactory, and children with gastrointestinal symptoms frequently undergo expensive, useless specialist consultations and laboratory evaluations. The aim of this study is to review the main epidemiological and clinical aspects, together with management strategies, of the most common gastrointestinal symptoms in children, pointing out pitfalls and practical tips in primary care management, and providing correct indications for specialist consultations. METHODS For this review, articles published in English from 2000 to January 2018 were identified from the PubMed/Medline (http://www.ncbi.nlm.nih.gov/pubmed/) database and selected on the basis of quality, relevance to the illness and importance in illustrating current management pathways. The search used the following keywords: gastrointestinal symptoms, functional gastrointestinal symptoms, children, primary care, specialist consultations and management. Particular emphasis was placed on evidence-based guidelines and high-quality studies. RESULTS Functional gastrointestinal symptoms have a high impact on the quality of life of children and families and on healthcare costs. A complete medical history and clinical examination are often sufficient to guide the primary care provider in the diagnosis, further workup or referral to a paediatric gastroenterologist. CONCLUSION Paediatric gastroenterology outpatients' clinics are among the most crowded specialists, and functional gastrointestinal symptoms and disorders are the most frequent reason for counselling. The number of specialist consultations could be reduced if guidelines were applied in primary care settings.
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Affiliation(s)
- Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Domenico Corica
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Simone M C Gramaglia
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Simona Valenti
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
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