Pediatric emergency medicine trisk 0699 0699
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (71.64 KB, 1 trang )
(temperature instability, apnea, and/or bradycardia) and with specific GI tract findings,
such as vomiting, abdominal distention, tenderness, and abdominal wall erythema.
It is also important to elicit a history of blood-streaked firm stools compared to bloody
diarrhea and whether pain is present. A history of constipation in a young infant with
explosive stool and/or gas on digital examination suggests Hirschsprung disease. If that
same infant then develops acute onset of bloody diarrhea, Hirschsprung-associated
enterocolitis (toxic megacolon) should be considered. Bloody diarrhea with pain may
indicate infectious or allergic colitis, intussusception, IBD, or HUS. Paroxysmal pain of
intussusception may be associated with occult blood, hematochezia, or “currant jelly
stools.” Lethargy alone (without pain) has been recognized as a presenting symptom of
intussusception in young children. Firm stool streaked with bright red blood or blood
seen on the toilet paper characterizes anal fissures associated with constipation. Colonic
polyps often present with painless rectal bleeding. Extraintestinal manifestations of
inflammatory bowel disease, including weight loss, anorexia, and arthralgias, may be
predominant symptoms in school-age children.
Eliciting a dietary history in the setting of bloody diarrhea may suggest features of
milk or soy protein intolerance and/or FPIES. These infants can present with chronic
diarrhea and failure to thrive, with stools containing blood or mucus, or less commonly,
with fulminant colitis and shock. FPIES presents with profuse vomiting, lethargy, pallor,
and bloody diarrhea that develop within a few hours of food ingestion. Up to 20% of
these infants present in hypovolemic shock with need for fluid resuscitation and 26%
have hypothermia.
A detailed family history (bleeding diathesis, familial polyposis) and drug history
(NSAIDs, salicylates, iron) or antibiotics (pseudomembranous colitis) are important in
patients with lower GI bleeding. A past medical history of abnormal bleeding may
signify a coagulopathy.
Physical examination to detect abdominal obstruction (abdominal tenderness,
distention, palpable mass, peritoneal signs, hyperactive [early] or hypoactive [late]
bowel sounds) is the most urgent task of the evaluating physician. Careful separation of
the buttocks with eversion of the anal mucosa may reveal a fissure. Prominent or
multiple perianal skin tags may raise suspicion of Crohn disease. Between 30% and 40%
of rectal polyps are palpable on rectal examination. Cutaneous lesions may provide
important diagnostic clues in patients with GI bleeding. Eczema may be associated with
milk allergy, whereas erythema nodosum is the most common skin manifestation of
IBD. Mucocutaneous pigmentation (Peutz–Jeghers syndrome) and cutaneous or
subcutaneous tumors (Gardner syndrome) indicate intestinal polyposis. Petechiae or
bruising is seen in HUS and palpable purpura in HSP.
Laboratory Evaluation
Many causes of lower GI tract bleeding are easily identifiable and do not require
laboratory testing. Similar to upper GI tract bleeding, if concerned about significant
