Diagnosis of Diabetic Gastroparesis
Diagnostic Test list for Diabetic Gastroparesis:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Diabetic Gastroparesis
includes:
Diabetic Gastroparesis Diagnosis: Book Excerpts
Tests and diagnosis discussion for Diabetic Gastroparesis:
The diagnosis of gastroparesis is confirmed
through one or more of the following tests:
- Barium x-ray: After fasting for 12 hours, you will drink a
thick liquid called barium, which coats the inside of the stomach,
making it show up on the x-ray. Normally, the stomach will be empty of
all food after 12 hours of fasting. If the x-ray shows food in the
stomach, gastroparesis is likely. If the x-ray shows an empty stomach
but the doctor still suspects that you have delayed emptying, you may
need to repeat the test another day. On any one day, a person with
gastroparesis may digest a meal normally, giving a falsely normal test
result. If you have diabetes, your doctor may have special instructions
about fasting.
- Barium beefsteak meal: You will eat a meal that contains
barium, thus allowing the radiologist to watch your stomach as it
digests the meal. The amount of time it takes for the barium meal to be
digested and leave the stomach gives the doctor an idea of how well the
stomach is working. This test can help detect emptying problems that do
not show up on the liquid barium x-ray. In fact, people who have
diabetes-related gastroparesis often digest fluid normally, so the
barium beefsteak meal can be more useful.
- Radioisotope gastric-emptying scan:You will eat food that
contains a radioisotope, a slightly radioactive substance that will show
up on the scan. The dose of radiation from the radioisotope is small and
not dangerous. After eating, you will lie under a machine that detects
the radioisotope and shows an image of the food in the stomach and how
quickly it leaves the stomach. Gastroparesis is diagnosed if more than
half of the food remains in the stomach after 2 hours.
- Gastric manometry:This test measures electrical and muscular
activity in the stomach. The doctor passes a thin tube down the throat
into the stomach. The tube contains a wire that takes measurements of
the stomach's electrical and muscular activity as it digests liquids and
solid food. The measurements show how the stomach is working and whether
there is any delay in digestion.
- Blood tests:The doctor may also order laboratory tests to
check blood counts and to measure chemical and electrolyte levels.
To rule out causes of gastroparesis other than diabetes, the doctor may
do an upper endoscopy or an ultrasound.
- Upper endoscopy.After giving you a sedative, the doctor
passes a long, thin, tube called an endoscope through the mouth and
gently guides it down the esophagus into the stomach. Through the
endoscope, the doctor can look at the lining of the stomach to check for
any abnormalities.
- Ultrasound.To rule out gallbladder disease or pancreatitis
as a source of the problem, you may have an ultrasound test, which uses
harmless sound waves to outline and define the shape of the gallbladder
and pancreas.
(Source: excerpt from
Gastroparesis and Diabetes: NIDDK)
Diagnostic Tests for Diabetic Gastroparesis: Online Medical Books
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Diabetes mellitus:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
According to the American Diabetes Association (ADA), DM can be diagnosed if any of the following exist:
❑ symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) plus a random (non-fasting) blood glucose level greater than or equal to 200 mg/dl accompanied by symptoms of diabetes.
❑ a fasting blood glucose level (no caloric intake for at least 8 hours) greater than or equal to 126 mg/dl.
❑ a plasma glucose value in the 2-hour sample of the oral glucose tolerance test greater than or equal to 200 mg/dl. This test should be performed after a glucose load dose of 75 g of anhydrous glucose.
If results are questionable, the diagnosis should be confirmed by a repeat test on a different day. The ADA also recommends the following testing guidelines:
❑ Test every 3 years: people age 45 or older without symptoms
❑ Test immediately: people with the classic symptoms
❑ High-risk groups should be tested frequently: Individuals with impaired glucose tolerance usually have normal blood levels unless challenged by a glucose load, such as a piece of pie or glass of orange juice. Two hours after a glucose load, the glucose level ranges from 140 to 199 mg/dl. These individuals have an abnormal fasting glucose level between 110 and 125 mg/dl. Because the fasting plasma glucose test is sufficient to make the diagnosis of diabetes, it replaces the oral glucose tolerance test. (See Classifying blood glucose levels.)
An ophthalmologic examination may show diabetic retinopathy. Other diagnostic and monitoring tests include urinalysis for acetone and blood testing for glycosylated hemoglobin (Hb A1C), which reflects recent glucose cortisol.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Introduction: Gastrointestinal Disorders:
Diagnostic tests
(Professional Guide to Diseases (Eighth Edition))
After physical assessment, several tests can identify GI malfunction.
❑ A barium or gastrografin swallow is used primarily to examine the esophagus. Gastrografin may be used instead of barium. Like barium, gastrografin facilitates X-ray imaging. However, if gastrografin escapes from the GI tract, it’s absorbed by the surrounding tissue, whereas escaped barium isn’t absorbed and can cause complications.
❑ In an upper GI series, swallowed barium sulfate travels through the esophagus, stomach, and duodenum to reveal abnormalities. The barium outlines stomach walls and delineates ulcer craters and defects.
❑ A small-bowel series, an extension of the upper GI series, visualizes barium flowing through the small intestine to the ileocecal valve.
❑ A barium enema (lower GI series) allows X-ray visualization of the colon.
❑ A stool specimen is useful to detect suspected GI bleeding, infection, or malabsorption as well as the presence of parasites. Guaiac test for occult blood, microscopic stool examination for ova and parasites, and tests for fat require several specimens.
❑ In esophagogastroduodenoscopy, insertion of a fiber-optic scope allows direct visual inspection of the esophagus, stomach, and duodenum. These structures are examined for varices, tumors, inflammation, hernias, polyps, ulcers, and obstruction.
❑ Proctosigmoidoscopy permits inspection of the rectum and distal sigmoid colon; colonoscopy is used for inspection of the descending, transverse, and ascending colon. These tests help visualize tumors, polyps, hemorrhoids, or ulcers.
❑ Gastric analysis examines gastric secretions for the presence of high levels of gastrin and the amount of acid produced.
❑ Endoscopic retrograde cholangiopancreatography directly visualizes the esophagus, stomach, proximal duodenum, and fluoroscopic visualization of the pancreatic, hepatic, and biliary ducts. This test can help visualize duct obstruction, benign structures, cysts, anatomic variations, and malignant tumors.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes Mellitus:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The initial presentation of DM can vary. Either type may present with the insidious onset of the symptoms associated with hyperglycemia (polyuria, polydipsia, and polyphagia) or with the abrupt onset of an acute complication [diabetic ketoacidosis (in type 1 DM) or nonketotic hyperglycemic-hyperosmolar coma (in type 2 DM)].
A. Type 1 diabetes. Patients with type 1 DM typically present before the age of 18 years. The symptoms heralding the disease emerge gradually as hyperglycemia appears and becomes more frequent and profound. Physiologic stress (e.g., an acute illness or trauma), which increases the requirement for insulin, can unmask the insulinopenia and give the impression that the problem is acute. Enuresis may be a clue for polyuria in a child who was previously toilet-trained. Lethargy, weakness, and weight loss are other common features.
B. Type 2 diabetes. Patients with type 2 DM usually present after the age of 40 years. The diagnosis is often made in an asymptomatic patient as a result of routine blood tests that reveal an elevation of plasma glucose. Other patients may present with the symptoms of hyperglycemia. The patient may have a history of recurrent skin infections or persistent vulvovaginitis. Other common symptoms include altered sensations in the extremities, nocturia, erectile dysfunction, and visual disturbances (Chapters 4.6, 5.1, 10.3, and 10.4). The use of glucocorticoids, β-adrenergic agonists, or thiazides can precipitate the symptoms of type 2 DM.
Physical examination
Patients often present with similar physical findings in both type 1 and type 2 DM, owing to hyperglycemia. In the young child, failure to grow and gain weight can occur with type 1 DM. The child may be ill appearing, lethargic, and often have signs of dehydration (tachypnea, tachycardia, and low blood pressure). Ketone production will produce a fruity odor on the patient’s breath. The patient with type 2 DM tends to be obese (especially upper body obesity) and may appear fatigued and have muscle weakness or decreased vision. The neurologic examination may reveal painful feet and numbness. Monilial infections may be found in the vagina and pubic areas.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
Diabetes mellitus:
Diagnosis
(Handbook of Diseases)
In nonpregnant adults, diabetes mellitus is diagnosed with:
❑ at least two occasions of a fasting plasma glucose level greater than or equal to 126 mg/dl
❑ typical symptoms of uncontrolled diabetes and a random blood glucose level greater than or equal to 200 mg/dl
❑ a blood glucose level greater than or equal to 200 mg/dl at 2 hours after ingestion of 75 grams of oral dextrose.
Two tests are required for diagnosis; they can be the same two tests or any combination and may be separated by more than 24 hours.
An ophthalmologic examination may show diabetic retinopathy. Other diagnostic and monitoring tests include urinalysis for acetone and blood testing for glycosylated hemoglobin, which reflects glucose control over the past 2 to 3 months.
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Source: Handbook of Diseases, 2003
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
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
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