Diagnosis of Crohn's disease
Diagnostic Test list for Crohn's disease:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Crohn's disease
includes:
Crohn's disease Diagnosis: Book Excerpts
Tests and diagnosis discussion for Crohn's disease:
A thorough physical exam and a series of tests
may be required to diagnose Crohn's disease.
Blood tests may be done to check for anemia, which could indicate
bleeding in the intestines. Blood tests may also uncover a high white
blood cell count, which is a sign of inflammation somewhere in the body.
By testing a stool sample, the doctor can tell if there is bleeding or
infection in the intestines.
The doctor may do an upper gastrointestinal (GI) series to look at the
small intestine. For this test, the patient drinks barium, a chalky
solution that coats the lining of the small intestine, before x-rays are
taken. The barium shows up white on x-ray film, revealing inflammation or
other abnormalities in the intestine.
The doctor may also do a colonoscopy. For this test, the doctor inserts
an endoscope--a long, flexible, lighted tube linked to a computer and TV
monitor--into the anus to see the inside of the large intestine. The
doctor will be able to see any inflammation or bleeding. During the exam,
the doctor may do a biopsy, which involves taking a sample of tissue from
the lining of the intestine to view with a microscope.
If these tests show Crohn's disease, more x-rays of both the upper and
lower digestive tract may be necessary to see how much is affected by the
disease.
(Source: excerpt from Crohn's Disease: NIDDK)
Diagnosis of Crohn's disease: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Crohn's disease:
Diagnostic Tests for Crohn's disease: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Crohn's disease.
Bowel sounds, hyperactive:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Crohn's disease:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Barium enema showing the string sign (segments of stricture separated by normal bowel) supports a diagnosis of Crohn’s disease. (See The “string sign,” page 712.) Sigmoidoscopy and colonoscopy may show patchy areas of inflammation, thus helping to rule out ulcerative colitis. However, biopsy is required for a definitive diagnosis.
Laboratory findings commonly indicate increased white blood cell count and erythrocyte sedimentation rate, hypokalemia, hypocalcemia, hypomagnesemia, and a decreased hemoglobin level.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Bowel sounds, hyperactive:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent episodes of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Gastrointestinal Bleeding:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Clinical history accurately points to the source of bleeding in only 40% of cases (3).
A. Upper GI bleeding. Hematemesis and melena are the most common presentations of acute upper GI bleeding. Important questions to ask: Is there a prior history of bleeding (60% rebleed from the same site) (3)? Is there any family history? Does the patient have any comorbid diseases (peptic ulcer disease, pancreatitis, cirrhosis, cancer)? Is the patient taking any medications (especially nonsteroidal antiinflammatory agents)? Does the patient use recreational drugs, cigarettes, or alcohol? What is the character of the pain? Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI cancers are associated with vague epigastric pain, dysphagia, or weight loss. Was there any retching (Mallory–Weiss tear)? Does the patient have a history of prior surgeries? Patients with a history of vascular grafting are at risk for aortoenteric fistulae, which is often associated with a “herald bleed.”
B. Lower GI bleeding. How old is the patient? Age is an important feature in discriminating the source of lower GI bleeding. Patients aged less than 50 years usually bleed from infectious causes, anorectal disease, or inflammatory bowel disease. For patients aged more than 50 years, diverticulosis, angiodysplasia, cancer, and ischemia are most common (4). Are there any associated symptoms? Diverticular disease presents as painless, high volume bleeding. Angiodysplasia and cancer present with symptoms of chronic blood loss (fatigue, dyspnea on exertion). Inflammatory bowel disease presents with bloody diarrhea, cramping, weight loss, and fever. A prior history of inflammatory bowel disease, cancer, or radiation to the abdomen is also important.
Physical examination
A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).
B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.
1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.
2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).
3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Gastrointestinal Bleeding:
Differential Overview
(Field Guide to Bedside Diagnosis)
Upper GI
❑ Peptic ulcer disease
❑ Gastritis
❑ Mallory-Weiss tear
❑ Esophageal varices
❑ Esophagitis
❑ Epistaxis
❑ Esophageal cancer
❑ Gastric cancer
Lower GI
❑ Infectious diarrhea
❑ Diverticular bleeding
❑ Hemorrhoids
❑ Anal fissure
❑ Inflammatory bowel disease
❑ Angiodysplasia
❑ Colon cancer
❑ Mesenteric ischemia
❑ Aortoenteric fistula
DIagnostic Approach
With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.
Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.
Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.
Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.
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Source: Field Guide to Bedside Diagnosis, 2007
Intestinal obstruction:
Diagnosis
(Handbook of Diseases)
Progressive, colicky abdominal pain and distention, with or without nausea and vomiting, suggest bowel obstruction. Plain abdominal radiography confirms the diagnosis.
Clinical tip Small-bowel obstruction must be distinguished from adynamic ileus. Pancreatitis, acute gastroenteritis, appendicitis, and acute mesenteric ischemia must be ruled out.
Abdominal films show the presence and location of intestinal gas or fluid. With small-bowel obstructions, a typical “stepladder” pattern emerges, with alternating fluid and gas levels apparent in 3 to 4 hours. With large-bowel obstructions, a barium enema reveals a distended, air-filled colon or a closed loop of sigmoid with extreme distention (sigmoid volvulus).
Laboratory results that support this diagnosis include:
❑ decreased sodium, chloride, and potassium levels (due to vomiting)
❑ slightly elevated white blood cell count (with necrosis, peritonitis, or strangulation)
❑ increased serum amylase level (possibly from irritation of the pancreas by a bowel loop).
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Source: Handbook of Diseases, 2003
Crohn's disease:
Diagnosis
(Handbook of Diseases)
Upper GI series with small-bowel follow-through may demonstrate ulcerations, stricture, and fistulas. A barium enema showing the string sign (segments of stricture separated by normal bowel) supports the diagnosis. Flexible sigmoidoscopy and colonoscopy may show patchy areas of inflammation, ulcers, strictures, and granulomas, thus helping to rule out ulcerative colitis. However, a definitive diagnosis is possible only after a biopsy.
Laboratory findings usually indicate increased white blood cell count and erythrocyte sedimentation rate, hypokalemia, hypocalcemia, hypomagnesemia, and decreased hemoglobin level related to anemia from chronic inflammation, blood loss from the mucosa, and iron deficiency. Leukocytosis can be related to corticosteroid therapies, inflammation, or abscess formation. Sedimentation rate is increased in patients with active inflammation. Hypoglobulinemia may result from intestinal protein loss.
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Source: Handbook of Diseases, 2003
Bowel sounds, hyperactive:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Determine if there’s a history of hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Determine if there’s a history of IBD, eruptions of gastroenteritis among family members, friends, or coworkers. Ask if the patient has traveled recently, even within the United States.
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.Obtain a full medication history, including
over-the-counter medications.
ALERT: Homosexual males who report acute diarrhea and exhibit negative fecal ova and parasite cultures may be infected with chlamydial proctitis not associated with lymphogranuloma venereum. Because rectal cultures will probably be negative, treatment with tetracycline is appropriate.
Physical examination
Check for fever, which suggests infection. Complete a full GI assessment by inspecting abdominal contour. Stoop at the recumbent patient’s side and then at the foot of his bed to detect localized or generalized distention. Auscultate the abdomen and note bowel sounds. Percuss and palpate the abdomen gently. Palpate for abdominal rigidity and guarding, which suggest peritoneal irritation that can lead to paralytic ileus.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Bowel sounds, hyperactive:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Gastrointestinal Bleeding:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Upper Gastrointestinal Bleeding
Nose
See Chap.18, Epistaxis.
Mouth and Pharynx
Trauma orforeign body may produce bleeding in mouth or pharynx.History and physical exam are usuallydiagnostic. Esophagus
Esophagitis
May presentwith hematemesis and sometimes occult blood loss.Gastroesophageal reflux and causticingestions are common causes. Less common cause is infection, whichusually occurs in immunocompromised individuals. Pathogens includeherpes simplex virus, adenoviruses, cytomegalovirus, VZV, and Candidaspecies.Diagnosis of esophagitis may be confirmedby endoscopy and biopsy. These infections may be diagnosed by specificcultures. Foreign Body
Foreignbody lodged in esophagus may cause difficulty swallowing, pain,and bleeding.Chest radiography may show radiopaqueforeign body.Endoscopy is definitive procedure forremoval. Varices
Consequenceof portal hypertension.Major causes of portal hypertensionare parenchymal liver disease and anatomic obstruction of portalvein or its major branches.Acute painless GI bleeding that occasionallycan be massive is often presenting sign. Other findings may includevisible abdominal wall collateral vessels, splenomegaly, and ascites.Hepatomegaly usually indicates liver parenchymal disease, but acirrhotic liver may be small and shrunken.Endoscopic exam visualizes varices. Duplication
Usuallyinvolves lower esophagus and may cause dysphagia.Large duplication also may cause respiratorydistress.If duplication contains ectopic gastricmucosa, bleeding can occur.Diagnosis can usually be made by chestCT with oral contrast. Gastroesophageal Junction
Tears inmucosa at gastroesophageal junction can result from continued forceful vomitingand retching; condition is called Mallory-Weiss syndrome.Bleeding is usually self-limited.Endoscopy can confirm diagnosis. Stomach
Gastritis
In neonates,gastritis may be due to perinatal asphyxia, septicemia, or hypotension, butoften it is unexplained.In infancy and childhood, epigastricpain and vomiting are frequent findings with gastritis. Viral illnessand drugs (e.g., aspirin and NSAIDs) are predisposing factors.In adolescence, chronic alcohol intakemay cause gastritis.In any age group, causes of stressgastritis include head injury, burns, septicemia, and shock.Gastric aspirate may contain materialresembling coffee grounds or bright red blood. Ulcer
Gastriculcer may cause acute bleeding with hematemesis or melena.Another presentation is finding bloodin stool associated with chronic blood loss and anemia.See Chap.2, Abdominal Pain. Duplication
Duplicationof stomach usually involves greater curvature near antrum or pylorus.Neonates may have vomiting, abdominalmass, and abdominal distension.Vomiting, intermittent abdominal pain,and GI bleeding may occur in childhood.Abdominal U/S is usually diagnostic. Vascular Malformation
Angiodysplasticlesions and arteriovenous malformations can occur in stomach and insmall and large intestine.Any of these lesions can present withrecurrent painless upper or lower GI tract bleeding.Endoscopy and angiography are bestavailable diagnostic tools. Neoplasm
Gastricneoplasms are extremely rare in pediatric population, yet can causeGI bleeding.Benign tumors include teratoma andleiomyoma, whereas malignant tumors include gastric carcinoma, lymphoma,and leiomyosarcoma.Combination of abdominal U/S,CT, and endoscopy with biopsy are diagnostic. Duodenum
In addition to conditions detailed below,varices and vascular malformations can cause GI bleeding.
Ulcer
Duodenalulcer can have similar presentation as gastric ulcer.See Chap.2, Abdominal Pain. Foreign Body
Occasionallysharp objects may pass from stomach into duodenum and cause bleeding.Swallowed foreign body may be held up in C loop of duodenum or atpoint of constriction (e.g., ligament of Treitz) and cause obstructivesymptoms and hematemesis.Combination of plain abdominal radiography,abdominal U/S, and endoscopy is usually diagnostic. Duplication
Tends tocompress first or second portions of duodenum, producing partialobstruction. Presence of ectopic gastric mucosa predisposes to GIbleeding.Abdominal U/S is usually diagnostic. Hemobilia
Most commoncause of bleeding into biliary tract in children is abdominal trauma withinjury to liver and biliary tree.Abdominal U/S and CT are usefulin locating and defining extent of injury. Duodenal endoscopy mayshow blood oozing from ampulla. If this is negative, celiac angiographymay locate site of bleeding if brisk. If bleeding is slower, technetium-sulfurcolloid scan may detect bleeding. Other
Swallowed Blood
Maternalblood can be swallowed during passage through birth canal or frombreast-feeding if nipples are cracked.Apt test can determine whether RBCsare fetal or maternal in origin and can be performed on either NGaspirate or stool.In this test, small amount of NG contents orstool is mixed with tap water (1 part stool:5 parts water).After centrifugation, 1 mL of 0.25NNaOH is added to 5 mL of pink supernatant fluid; mixture is leftfor 5 mins.Pink color signifies fetal Hgb, whereasbrownish yellow color signifies maternal Hgb. Coagulopathy
Bruising,purpura, and bleeding from sites other than GI tract are clues topresence of systemic bleeding disorder.See Chap.52, Purpura and Bleeding. Hemorrhagic Disease of the Newborn (Vitamin K Deficiency)
Becauseneonates have low vitamin K stores, they often fail to develop effectivecoagulation function.At 2–4 days of age, if vitaminK has not been given at birth, hematochezia, melena, or hematemesismay develop. Bleeding also may occur from other sites beside GItract.Lack of vitamin K administration atbirth, normal platelet count, and reversal of prolonged prothrombintime (PT) and activated partial thromboplastin time (aPTT) withdecreased bleeding after vitamin K administration confirm diagnosis.Every newborn should receive 0.5–1.0mg IM of vitamin K at birth so this problem can be prevented. Disseminated Intravascular Coagulation
Predisposingcauses include bacterial meningitis, septicemia, severe hypoxia,necrotizing enterocolitis, and shock.Patients are seriously ill and havediffuse bleeding from multiple sites from consumption of clottingfactors and destruction of platelets.Certain lab findings help confirm diagnosis:low platelet count, fragmented RBCs on blood smear, prolonged PTand aPTT, low plasma fibrinogen, and increase in fibrin-split products. Drugs
GI bleeding may occur with chronic ingestionof aspirin, which causes a defect in platelet aggregation and aprolonged bleeding time. Excessive use of NSAIDs and anticoagulantsalso may cause significant GI bleeding.
Lower Gastrointestinal Tract Bleeding
Intestine
Cow Milk/Soy Protein Sensitivity
Infantsoften present with diarrhea that contains blood. Practical way tomanage this problem is to eliminate cow milk or soy protein fromdiet and monitor for whether symptoms disappear.See Chap.14, Diarrhea. Necrotizing Enterocolitis
Common disorderin preterm infants that can occur in term infants. History of perinatalstress (asphyxia, hypotension, septicemia) often exists.Clinical findings include poor feeding,lethargy, abdominal distension, bilious vomiting, and bloody orblood-streaked stools.Abdominal radiography that shows gasin bowel wall or in portal venous system helps confirm diagnosis. Infectious Colitis
Most frequentpathogens in infancy and childhood are Salmonella, Shigella, Campylobacter,and E. coli. Less common is infection with C. difficile and Y. enterocolitica.Most common pathogen associated with HUS is E. coli 0157:H7.Usual presenting manifestations arefever and bloody diarrhea.Positive stool culture is diagnostic,except for infection with C. difficile, for which toxin must beidentified. Henoch-Schönlein Purpura
Lower GIbleeding from the small intestine or colon can be occult or obvious.Typical purpuric rash occurs on buttocks and lower legs.See Chap.28, Hematuria. Intussusception
Common causeof lower GI bleeding in children 2 mos–5 yrs of age.Most common type is ileocolic, whichinvolves telescoping of distal ileum into ascending or transversecolon.History of intermittent cramping abdominalpain is usually presenting symptom. Vomiting and bloody (currantjelly) stools also may occur. Abdominal mass may be palpable anywherein abdomen.Abdominal radiography that shows leadingedge of intussusceptum outlined by air is diagnostic, but oftenradiographs are nonspecific. Air-contrast enema can be diagnosticas well as therapeutic. Contraindications to its use are free abdominalair, intestinal obstruction with fluid levels on abdominal radiography,and clinical peritonitis. With any of these findings, surgery shouldbe performed immediately. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Enterocolitismay occur as complication.Most common manifestations are abdominaldistension, diarrhea that is often bloody, fever, and vomiting.See Chap.9, Constipation, and Chap. 14, Diarrhea. Meckel Diverticulum
Remnantof omphalomesenteric duct that is located in distal ileum.Usually presents in infancy with painless,episodic, bright red rectal bleeding, which may be massive.Most diverticula contain gastric mucosa,and technetium 99m–pertechnetate scan can be diagnostic.False-positive scans are uncommon butsometimes occur with ulcer, hemangioma, or bowel duplication.Laparoscopy or laparotomy may sometimesbe necessary to confirm diagnosis. Volvulus with Malrotation
Usuallypresents with intestinal obstruction; however, lower GI bleedingalso can occur.Abdominal radiography shows dilatedloops of bowel with air-fluid levels. Upper GI series is usuallyperformed; however, with suspected bowel infarction, contrast studiesare unnecessary, and surgery should be performed immediately. Inflammatory Bowel Disease
Occult GIblood loss or obvious lower GI tract bleeding may occur. Chronicdiarrhea with lower GI bleeding and weight loss should suggest IBD.Crohn disease and ulcerative colitisare types of IBD.See Chap.14, Diarrhea. Intestinal Polyps
Definedas protrusion of tissue above normal GI surface that can cause bleedingand occasionally intussusception.Number and location of polyps, theirhistopathology, and family history of colorectal cancer helps determineproper management.This section focuses on common polyposissyndromes in pediatric population. Solitary Juvenile Polyps/Juvenile Intestinal Polyposis
Solitaryjuvenile polyps usually present with painless rectal bleeding oranal prolapse of polyp in children 2–10 yrs of age. Mostchildren have single polyp, which should be removed for histopathologicexam.Children with ≥2 rectosigmoid polypsand family history of polyps should be suspected of having juvenileintestinal polyposis, which is transmitted as autosomal-dominanttrait.Manypolyps occur in the colon, but they also may be found in small intestineand stomach.Age of presentation is usually in school-agedchildren.Clinical manifestations include abdominalpain, rectal bleeding, and anemia.There is high incidence of colorectalneoplasia in individuals with this disorder. Adenomatous Polyposis of Colon
Autosomal-dominantdisorder caused by mutations in adenomatous polyposis coli gene,whose locus has been mapped to chromosome 5q21-q22.Characterized by premalignant adenomaslocated primarily in colon and rectum and less commonly in stomachand small intestine.Onset is usually in adolescence, whenhundreds to thousands of adenomas may appear. Other manifestationsinclude osteomas (jaw, long bones), skin lesions (cysts, lipomas),and pigmented retinal lesions.Diagnosis is confirmed by colonoscopyand biopsy. Peutz-Jeghers Syndrome
Autosomal-dominantdisorder in which hamartomatous polyps occur primarily in smallintestine but also may be found in colon and stomach. Gene locushas been mapped to chromosome 19p13.3.Besides GI bleeding, characteristicfeature is presence of hyperpigmentation, which is seen most commonlyon buccal mucosa and lips.Upper and lower GI endoscopy and upperGI radiographic series should be performed.These individuals are at increasedrisk for adenocarcinoma, especially of stomach, duodenum, and colon. Benign Lymphoid Hyperplasia
Large aggregatesof lymphoid tissue occur in colon and rectum. Rectal bleeding and sometimesintermittent diarrhea occur.Proctosigmoidoscopy, colonoscopy, andhistologic exam confirm diagnosis. Duplication
May be foundin jejunum and ileum. Abdominal pain, partial intestinal obstruction, orGI bleeding can be presenting feature. Sometimes small bowel intussusceptionor volvulus occurs.May also involve colon and rectum,but bleeding rarely occurs because colonic duplications rarely containgastric mucosa. Affected individuals may present with abdominalpain and partial intestinal obstruction or they may be asymptomatic.Abdominal U/S is usually diagnostic,although abdominal CT may be useful in some cases. Vascular Malformation
Althoughrare, angiodysplastic lesions and arteriovenous malformations cancause lower GI bleeding.Diagnosis is usually made by angiography. Neoplasm
GI tumorsare rare in children.Hemangiomas can be found anywhere insmall or large intestine but usually involve sigmoid colon and rectum.Endoscopy is usually diagnostic.Adenocarcinoma of colon usually appearsafter 10 yrs of age. Persistent vomiting, anorexia, weight loss,abdominal pain, and GI bleeding are common manifestations. Contrastenema and colonoscopy with biopsy are diagnostic. Rectum and Anus
Anal Fissure
Common causeof blood-streaked stools in neonates and young infants. Common causesare trauma from passage of hard stool and frequent use of rectalthermometer.Stretching anal skin enables fissureto be visualized. Trauma
Any foreignbody placed in rectum may cause trauma and bleeding.History and physical exam are usuallydiagnostic, but proctoscopy may be needed in some cases. Plain radiographsof lower abdomen and pelvis can demonstrate radiopaque objects. Sexual Abuse
Rectal trauma and bleeding may occur as resultof sexual abuse. History, physical exam, and proctoscopy are diagnostic.
Hemorrhoids
Defined as thrombosed collections of bloodvessels in anal area, which are uncommon in infancy and childhood.Usual cause is chronic constipation.
Other
Other causes of GI bleeding are swallowedblood, coagulopathy, and drugs.
Factitious Bleeding
Factitioushematemesis, hematochezia, or melena may be seen with various foods, medications,and artificial food colorings.Commercial dyes no. 2 and no. 3 foundin breakfast cereals and fruit drinks may produce reddish colorof vomitus or stool.Certain substances produce blackishcolor of stools: iron preparations, licorice, blueberries, beets,lead, charcoal, and bismuth.In Munchausen syndrome by proxy, emesisor stool may be contaminated with blood that is not the child's. Diagnostic Approach
Determination of Gastrointestinal Bleeding
Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool. Severity of Bleeding
If GI bleedingis obvious, most important task is to determine severity.Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.In such cases, first note vital signsand perform any necessary resuscitation.Immediate fluid replacement is requiredto stabilize BP. Site of the Bleeding
Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.Except in these instances, NG tubeshould be placed to document level and rate of bleeding.Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum. Specific Diagnosis
Importantfactors to consider in diagnosis areAgeClinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)History of aspirin, NSAID, or alcoholingestionPresence of known diseases (e.g., IBDor liver disease) Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.If the bleeding is massive or uncontrolled,immediate surgery should be considered. In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception. With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including CrohndiseaseSelective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern. >
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Bowel sounds, hyperactive:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you've ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient's problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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People with Crohn's and colitis can become malnourished because they can't absorb certain nutrients. Listen to experts discuss the complex...
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