GI Bleeding and Inflammatory Bowel Disease

● Basics (10 Minutes)
● Main session (2x 15 Minutes) case discussions covering the key points
and evidence
● Advanced session(2 x 20 minutes) case discussions covering grey
areas, diagnostic dilemmas; advanced management and escalation
● Sim scenario (30-60 mins)
● Quiz questions (10 Minutes)
● Infographic sharing (5 Minutes): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline for sharing
admission criteria.

Common IBD and GI bleeding presentations:
Inflammatory Bowel Disease (IBD) is a term that describes Crohn’s Disease and
Ulcerative Colitis. These are both chronic relapsing conditions.

Ulcerative Colitis (UC) is diffuse mucosal inflammation involving colon and rectum.
It usually presents with abdominal pains, bloody diarrhoea and weight loss.
Nocturnal stools are common. Systemic effects can include fatigue, and anaemia. These appear alongside a raised CRP and ESR. There can be extraintestinal
symptoms such as growth failure, erythema nodosum, uveitis and iritis although
these are less common at presentation. Complications of UC can include toxic
megacolon (a surgical emergency) and colon cancer. Where steroids are used
as part of treatment, growth failure and osteoporosis can develop. Incidence in
children range from 1:25,000 to 1:50,000 and it is more common in females than males.
There are genetic associations with DR2, HLA-B27 and HLA-Bw35. A useful objective symptoms monitoring tool is the PUCAI (Paediatric Ulcerative Colitis Activity Index) score as shown below:

Juvenile Polyposis Syndrome is another possible cause of lower GI bleeding and
can occur in 1% of preschool and school age children. Its presence is characterised by multiple benign growths usually in the colon. It can present with painless rectal bleeding and can be associated with or without stool. Abdominal pain and pain around defecation can be a feature. It is autosomal dominant and can be diagnosed on endoscopy. The presence of more than 5 polyps in the colon or at
least one polyp and a positive family history can confirm the diagnosis. In generalised juvenile polyposis the incidence of gastric, colon, duodenal and pancreatic cancer is increased. Diagnosis and treatment can happen simultaneously with endoscopy and polypectomy.

An 8 year old boy presents to A&E with severe generalised abdominal pains.
This has been going on for about 4 months. He also says he has “very runny poos
and they are a bit sticky and sometimes have some blood!”

What other questions would be relevant?
Although PCDAI (Paediatric Crohn’s Disease Activity Index) is specific to Crohn’s, if
there is no histological diagnosis then it is advisable to use the PUCAI (Paediatric
Ulcerative Colitis Activity Index) score even if the history suggests Crohn’s.
This still gives a reasonable objective idea about disease severity.
● Questions can be based on PUCAI, including:
● Abdominal pain
● Rectal bleeding
● Stool consistency
● Number of stools per 24 hours
● Nocturnal stools
● Impact on daily activities

What relevant investigations could you do now?
● Bloods to include FBC, specifically to investigate haematocrit, ESR, U&E to assess electrolytes and LFT to assess albumin.

Do you think he needs admitting?
This decision should be made on the basis of the severity of the symptoms and
the length of the history in addition to the inflammatory markers and electrolytes
on the bloods. If the inflammatory markers are high and consistent with severe
symptoms then admission for Gastroenterology review and urgent endoscopy is
advisable. Additionally if there are electrolyte disturbances with changes such
as hypoalbuminaemia then admission is also advisable. These patients are more
likely to be nutritionally deplete and at risk of more serious complications requiring
more serious interventions. If the history is short, the symptoms do not seem to be
affecting everyday life and the inflammatory markers are not particularly
elevated then the patient may be able to be discharged and then reviewed at
a later date in a paediatric gastroenterology outpatient clinic with a view to
elective admission for endoscopy.

IV antibiotics
The aetiology of Crohn’s Disease is unknown but immunological response to gut
microbiota is thought to play a role. Antibiotics have therefore been used to help
aid induction of remission and to prevent relapse by reducing concentration of
certain bacteria and altering the composition of the microbiota. Ciprofloxacin
and metronidazole are the most commonly used antibiotics for this and can be
started on the advice of the Paediatric Gastroenterologist.

ECCO Guidelines for New Crohn’s Disease
Below is the link to the European Crohn’s & Colitis Organisation (ECCO) guidelines
for Crohn’s disease. This website has a comprehensive collection of informative
guidelines for IBD and is a reliable evidence based source of information.
http://www.e-guide.ecco-ibd.eu/algorithm/new-presentation-1

A 6 year old girl presents with painless fresh blood PR. She is otherwise completely
well. What could this be and what management options would you consider?

Discussion can be based around the paper from the European Society of
Gastroenterology, Hepatology and Nutrition’s “Management of Juvenile Polyposis Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN
Polyposis Working Group”

Summary of paper
Juvenile polyposis syndrome (JPS) is a pre-cancerous condition and carries a
38%-68% risk of GI malignancy. It is diagnosed based on the following three criteria;

1. Five or more JPs of the colon or rectum, or
2. JPs in other parts of the GI tract, or
3. Any number of JPs and a positive family history

In infants it can be diagnosed clinically with symptoms comprising diarrhoea,
failure to thrive and hypoalbuminaemia. The most common type of polyp in
children are solitary juvenile polyps comprising 90% of cases and high grade
dysplasia is rarely encountered.

Although genetics are inconsistent, the SMAD4 gene is associated with more
aggressive disease and can be associated with Hereditary Haemorrhagic
Telangiectasia (HHT).

JPS is autosomal dominant and although no formal guidelines exist it is thought
that children who are at risk of JPS should be screened from the ages of 12 to 15
years although children who are symptomatic (explained anaemia, PR bleeds,
abdominal pains, rectal prolapse or diarrhoea) should undergo colonoscopy
earlier.

Figure 1
Management of Juvenile Polyposis Syndrome in Children and Adolescents: A Position Paper From the ESPGHAN Polyposis Working Group

Colonscopy should aim to remove all polyps >10mm and then be performed
annually until no further polyps are found. If the patient has a single juvenile polyp
then repeat colonoscopy is not usually required. If there is no prior family history
but a new diagnosis is made in a symptomatic child then genetic testing should
be offered to all first-degree relatives.

A 12 year old girl is transferred from another smaller hospital with a year’s history of abdominal pains and PR bleeding with weight loss. She had not previously been referred to tertiary services. She underwent a colonoscopy yesterday afternoon confirming ulcerative colitis. She looks sick with a distended abdomen and peripheral oedema.

How would you manage this patient?

Questions to further discussion

1. What complication(s) do you think this girl may be suffering from?
2. What would you look for on an abdominal xray to confirm your diagnosis and how would this alter your management?
3. What could you do pre surgery to optimise this patient?
4. What do you understand by refeeding syndrome and what are the parameters you would want to correct urgently?
   The major risks here in a patient with a long history of undiagnosed and therefore
   untreated ulcerative colitis, abdominal distention and peripheral oedema are
   toxic megacolon and refeeding syndrome. An abdominal x-ray should be
   performed: a bowel loop with diameter of more than 5.5cm is diagnostic of
   megacolon and should prompt a paediatric surgical review with a consideration
   for theatre and subtotal colectomy.
   
   Refeeding syndrome is associated with electrolyte and metabolic derrangement
   in patients following a period of prolonged starvation which is then followed by
   reintroduction of nutrition. It would be important to correct albumin and electrolyte
   disturbances (the patient is likely hypoalbuminaemic, hypophosphataemic
   and hypokalaemic). The most commonly reported biochemical feature is
   hypophosphataemia although other electrolyte disturbances (including sodium
   imbalance, hypokalaemia, hypo magnesia and changes in glucose, protein,
   thiamine and fat metabolism) are usually present and are equally important.
   Refeeding syndrome is important to recognise as it can result in organ failure and ultimately death.

A one and a half year old boy presents to the paediatric ED. His parents are very frightened and show you his last nappy that contained a large amount of dark black stool. The infant is alert and active but appears to be a little tired. His parents report he is usually a happy baby and has never really been unwell. He has had no vomiting and his parents do not report any concerns around possible abdominal pain. He has had previously normal stools. During examination you notice he is floppy and weak and on opening his nappy you find a large amount of melaena.

1.What are the possible complications of Meckel’s diverticulum? 2.Consider how you might manage shock and stabilise this patient?

This presentation is most likely to represent a Meckel’s Diverticulitis with painless
rectal bleeding in an otherwise previously well child. The ‘rule of 2’ is a useful tool it occurs in 2% of the population, within 2 feet of the ileocecal valve, is 2 inches in
length, there are 2 types of ectopic tissue involved and presentation is generally
before the age of two. Meckels can present in a variety of ways including gastrointestinal bleeding, volvulus, intussusception, adhesions, hernia or perforation. Abdominal pain is sometimes, but not always, a feature. Ectopic gastric mucosa and pancreatic mucosa are the 2 structural possibilities in a Meckel’s Diverticulum. The best imaging modality to use for detecting these is the technetium 99 scan.
In this example the patient is floppy and weak and has a large amount of melaena
in his nappy. This raises the likely possibility of shock secondary to major
haemorrhage. Shock in an infant as a complication of Meckel’s Diverticulum
should be managed as you would any other resuscitation situation – starting with
ABC. Airway and breathing should be able to be cleared reasonably quickly and
oxygen should be applied. The main focus of this scenario is hypovolaemia which
should be treated with fluid resuscitation with emergency blood as quickly as it is
available. Below is a link to a very clear and informative guideline and algorithm
for managing circulation from the Royal Children’s Hospital in Melbourne.
https://www.rch.org.au/trauma-service/manual/circulation-management/

Once this patient is stabilised then it is important for the area of small bowel
containing the Meckle’s Diverticulum to be resected and any ulcer (the likely source
of bleeding) to be oversewn. It is not unusual that in patients who present with
abdominal pain an initial surgical exploration for appendicitis is undertaken only
to find a normal appendix and the diagnosis of Meckel’s Diverticulum is more elusive.
A useful summary for Meckels’s diverticulum:
https://www.ncbi.nlm.nih.gov/books/NBK6918