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Toronto Notes 2019 Genetics, Dysmorphisms, and Metabolism Pediatrics P41 Upper Gastrointestinal Bleeding
• seeGastroenterology,G25
Lower Gastrointestinal Bleeding
• seeGastroenterology,G27
Etiology
• acute
■ infectious (bacterial, parasitic)
■ antibiotic-induced (C. difficile)
■ NECinpreterminfants
■ anatomic
■ malrotation/volvulus, intussusception ■ Meckel’s diverticulitis
■ anal fissures, hemorrhoids
■ vascular/hematologic
■ HSP
■ HUS
■ coagulopathy
Physical Exam
• chronic
■ anal fissures (most common) ■ colitis
■ IBD
■ allergic (milk protein)
■ structural
■ polyps (most are hamartomas) ■ neoplasms (rare)
■ coagulopathy
• hemodynamicstatus,evidenceofFTT,fever
• analandrectalexam:tags,fissures,analfistulas,polyps,foreignbody,bloodperrectum • stoolappearance
• NGaspirate
• lowerGIbleedmaypresentasmelena(ifitinvolvesthesmallbowel)orhematochezia
Investigations
• stoolcultures(C&S,C.difficiletoxin)
• urinalysisandmicroscopy
• CBC,smear,differential,ESR,CRP,electrolytes,urea,Cr,INR,PTT,albumin,ironstudies,amoebatiters • radiologicinvestigations(includingabdominalx-raytoruleoutobstruction)
• Meckel’sradionuclidescan
Management
• acutestabilization:ABCs,volumeandbloodreplacement,bowelrest(NPO,NGtube) • oncestable,endoscopyand/orsurgeryasindicated
Genetics, Dysmorphisms, and Metabolism
• seeMedicalGenetics
Hematology
Approach to Anemia
Anemia
Decreased reticulocytes
Increased reticulocytes
Microcytic
Iron deficiency anemia, thalassemia, anemia of chronic disease, lead poisoning, sideroblastic anemia
Production problem
Normocytic
Anemia of chronic disease, renal failure, marrow infiltration
Macrocytic
Megaloblastic anemia, marrow failure
Hemolysis
Intrinsic to RBC
Blood loss
Enzyme problem
G6PD deficiency
Extrinsic to RBC (antibody mediated)
Hemoglobinopathies
SCD, thalassemia
Membrane problem
Hereditary spherocytosis
Immune hemolysis (DAT+)
Non-immune hemolysis (DAT–)
TTP, HUS
Figure 11. Approach to anemia