Gastrointestinal Emergencies

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Chapter 35 Gastrointestinal Emergencies

Susan Fuchs, MD

1 What is the most common cause of vomiting in older children?

Acute gastroenteritis. Although usually associated with diarrhea, vomiting can occur alone in the early stages of gastroenteritis. The most common infectious viral etiology is rotavirus. Salmonella, Shigella, Yersinia, Campylobacter spp. and Escherichia coli can also cause bacterial gastroenteritis with vomiting.

Stevens MW, Henretig FM: Vomiting. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 681–689.

2 What are other medical causes of vomiting in children?

Metabolic disorders, such as galactosemia, fructose intolerance, or amino acid or organic acid defects (phenylketonuria, urea cycle defects) usually present in infancy. Along with vomiting, symptoms such as lethargy, seizures, or coma may occur. Diabetes mellitus can cause vomiting because of ketoacidosis or slowed gastric motility (gastroparesis may occur after 10 years of diabetes mellitus). Other causes include milk/soy protein allergies, pancreatitis, urinary tract infection, neurologic disorders associated with increased intracranial pressure (tumor, hydrocephalus), migraines, pregnancy, and psychological causes (rumination, bulimia).

Stevens MW, Henretig FM: Vomiting. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 681–689.

3 What are the most common anatomic regions to find a coin that has not passed?

In the esophagus, the cricopharyngeus/thoracic inlet (proximal third) is the most common place, followed by the level of the aortic arch (middle third), then the gastroesophageal junction/sphincter (lower third). Other areas of the gastrointestinal (GI) tract include the stomach, pylorus, ligament of Treitz, and ileocecal valve. Objects larger than 2 cm in diameter or longer than 5 cm are more likely to get “caught” at the pylorus.

Karaman A, Cavusoglu YH, Karaman I, et al: Magill forceps technique for removal of safety pins in upper esophagus: A preliminary report. Int J Pediatr Otorhinolaryngol 68:1189–1191, 2004.

4 What is the best way to remove an esophageal coin?

This is a highly controversial topic. One study demonstrated that when the foreign body is lodged for less than 24 hours, no respiratory symptoms are present, and the child has no prior esophageal disease or surgery, 28% pass spontaneously, including 22–33% of those in the upper esophagus and midesophagus. In such cases, observation for 12–24 hours with repeat radiography may be appropriate.

There are several methods of coin removal in infants and children with no respiratory symptoms and no history of esophageal disease. Some advocate the use of Foley catheter extraction under fluoroscopic guidance for coins that have been lodged less than 24 hours, while others extend this time to 3 days. Others use esophageal bougienage for coins lodged in the distal esophagus less than 24 hours. Laryngoscopy with Magill forceps removal, esophagoscopy, or endoscopy under general anesthesia are also options. In the presence of respiratory symptoms, a history of esophageal disease, esophageal edema, or focal narrowing of the adjacent trachea (seen on the lateral neck radiograph), the best way to remove the foreign body is under direct vision via esophagoscopy or endoscopy. The choice of method is often based upon the expertise and availability of the specialists (radiology, otolaryngology, surgery, or gastroenterology) at a particular hospital.

Harned RK, Strain JD, Hay TC, et al: Esophageal foreign bodies: Safety and efficacy of Foley catheter extraction of coins. AJR 168:443–446, 1997.

Karaman A, Cavusoglu YH, Karaman I, et al: Magill forceps technique for removal of safety pins in upper esophagus: A preliminary report. Int J Pediatr Otorhinolaryngol 68:1189–1191, 2004.

Macpherson RI, Hill JG, Othersen HB, et al: Esophageal foreign bodies in children: Diagnosis, treatment and complications. AJR 166:919–924, 1996.

Schunk JE, Harrison M, Corneli HM, et al: Fluoroscopic Foley catheter removal of esophageal foreign bodies in children: Experience with 415 episodes. Pediatrics 94:709–714, 1994.

Soprano JV, Fleisher GR, Mandl KD: The spontaneous passage of esophageal coins in children. Arch Pediatr Adolesc Med 153:1073–1076, 1999.

5 What is the “big deal” about button batteries?

Although they are small (watch or hearing aid batteries), the risk is corrosion of the ingested battery. If the battery remains in the esophagus, there is fear of tissue damage, with resultant erosions, tracheoesophageal fistulas, and strictures. When a child swallows a button battery, obtain a radiograph to determine the battery’s location. If it remains in the esophagus, it should be removed under direct visualization (not a Foley catheter) to assess for any damage to the esophageal mucosa. The proposed mechanisms of injury include electrolyte leakage, alkali production, mercury toxicity, and pressure necrosis.

Fun fact: Many batteries are made of mercuric oxide. There is little risk of mercury poisoning, however, because mercuric oxide is poorly absorbed from the GI tract.

Lin VYW, Daniel SJ, Papsin BC: Button batteries in the ear, nose and upper aerodigestive tract. Int J Pediatr Otorhinolaryngol 68:473–479, 2004.

6 How should a caustic ingestion be managed?

First, ensure that there is a patent airway. Next, determine what was ingested. This may require calling the poison control center (1-800-222-1222) or going to a computer-based system that determines treatment, signs/symptoms, and toxicity in the emergency department. The child may have symptoms such as drooling, mouth pain, pain on swallowing, chest pain, or cough. Examine the mouth for mucosal and oral burns. Alkali ingestions (lye, drain cleaners) are more damaging to the oropharynx and esophagus than are acid burns because they cause deeper injury. In addition, after an alkali burn, esophageal burns can occur without an oral burn. The amount of caustic ingested does not correlate with the degree of burns, or the symptoms. Induced vomiting is contraindicated in these children because of the risk of injury and aspiration. After a thorough examination, if any burns are seen, or if the child ingested alkali, the child should undergo endoscopy under general anesthesia. If there are no burns and no symptoms, and if a weak or very dilute formulation of an acid was ingested, observation is indicated.

Erickson TB: Toxicology: Ingestions and smoke inhalation. In Gausche-Hill M, Fuchs S, Yamamoto L (eds): APLS: The Pediatric Emergency Medicine Resource, 4th ed. Sudbury, MA, Jones & Bartlett Publishers, 2004, pp 244–245.

7 Distinguish among hematemesis, hematochezia, and melena

image Hematemesis is the vomiting of bright red or denatured blood (“coffee-ground” appearance). The source of the blood is proximal to the ligament of Treitz.

image Hematochezia is bright red blood or maroon-colored stools per rectum and implies a lower GI source (colon).

image Melena is the rectal passage of black tarry stools (black from the bacterial breakdown of blood); the source is proximal to the ileocecal valve.

Squires RH: Gastrointestinal bleeding. In Altschuler SM, Liacouras CA (eds): Clinical Pediatric Gastroenterology. Philadelphia, Churchill Livingstone, 1998, pp 31–42.

8 Distinguish between upper GI and lower GI bleeding in terms of site of bleeding

image Upper GI bleeding occurs when the site of bleeding is proximal to the ligament of Treitz or the second portion of the duodenum.

image Lower GI bleeding implies a site distal to the ligament of Treitz, or those structures supplied by mesenteric vessels.

Squires RH: Gastrointestinal bleeding. In Altschuler SM, Liacouras CA (eds): Clinical Pediatric Gastroenterology. Philadelphia, Churchill Livingstone, 1998, pp 31–42.

9 What are some of the common tests used to determine the presence of blood? What causes them to be falsely positive or falsely negative?

The Hematest is a qualitative stool test that uses orthotolidine (a leukodye). False-positive results occur when the patient has ingested red meats, iron preparations, or plant peroxidases (found in horseradish, turnips, tomatoes, and fresh red cherries). False-negative results occur in the presence of ascorbic acid (vitamin C). The Hemoccult test is a qualitative stool test that uses guaiac (also a leukodye). False-positive results occur with red meats, broccoli, grapes, cauliflower, iron preparations, plant peroxidases, and cimetidine. False-negative results occur with hard stool, penicillamine, antacids, and ascorbic acid. The HemoQuant test is the only quantitative test (2 mg hemoglobin/gm stool) and uses a fluorescent antibody to porphyrin. It is falsely positive with red meat. Gastroccult tests check gastric fluids for blood.

Cadranel S, Scaillon M. Approach to gastrointestinal bleeding. In Guandalini S (ed): Textbook of Pediatric Gastroenterology and Nutrition. London, Taylor & Francis, 2004, pp 639–654.

Squires RH: Gastrointestinal bleeding. In Altschuler SM, Liacouras CA (eds): Clinical Pediatric Gastroenterology. Philadelphia, Churchill Livingstone, 1998, pp 31–42.

10 What ingested foods can cause red stools?

Fruit punch, Kool-Aid beverage (especially cherry or strawberry), red beets, tomatoes, and gelatin. Note that commercial dyes can also be found in breakfast cereals.

Cadranel S, Scaillon M: Approach to gastrointestinal bleeding. In Guandalini S (ed): Textbook of Pediatric Gastroenterology and Nutrition. London, Taylor & Francis, 2004, pp 639–654.

Markel H, Oski JA, Oski FA, McMillan JA: The Portable Pediatrician. Philadelphia, Hanley & Belfus, 1992.

11 What foods or items can cause black stools?

Bismuth (Pepto-Bismol), iron preparations, charcoal, licorice, beets, spinach, blueberries, grape juice, dark chocolate, and swallowed blood.

Cadranel S, Scaillon M: Approach to gastrointestinal bleeding. In Guandalini S (ed): Textbook of Pediatric Gastroenterology and Nutrition. London, Taylor & Francis, 2004, pp 639–654.

12 What is the APT-Downey test? How is it used?

This test is for fetal red cells and is used when an infant spits up blood. If the infant is breast-feeding, it is often unclear if the blood is from the baby’s GI tract or maternal milk. Adult hemoglobin, eluted from erythrocytes, is denatured to alkaline globin hematin in an alkaline solution (sodium hydroxide), resulting in a yellow-brown color. Fetal hemoglobin resists the effect of alkali and stays pink. However, if the blood you use for the test is coffee-ground color (not red), it will be read falsely as adult blood.

Cadranel S, Scaillon M: Approach to gastrointestinal bleeding. In Guandalini S (ed): Textbook of Pediatric Gastroenterology and Nutrition. London, Taylor & Francis, 2004, pp 639–654.

13 What is another test that can help localize the source of GI bleeding?

The blood urea nitrogen (BUN)–to–creatinine ratio can help. A BUN–creatinine ratio > 30 indicates upper GI bleeding. In a study done at the Children’s Hospital of Los Angeles, the specificity was 100% (although the sensitivity was 39%). The BUN level is thought to rise after upper GI bleeding as a result of increased hepatic catabolism of the absorbed amino acid load from the intraluminal blood. Therefore, the bleeding must occur proximal to the ligament of Treitz. A BUN–creatinine ratio of 30 can occur with upper or lower GI bleeding.

Markel H, Oski JA, Oski FA, McMillan JA: The Portable Pediatrician. Philadelphia, Hanley & Belfus, 1992.

14 What are some common causes of upper GI bleeding in infants and children?

image Neonates:

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