GI

Abdominal Trauma

  • Common and potentially lethal injury in children.
  • Most often injured organs: spleen and liver.
  • Least frequently injured organ: pancreas.

Abdominal Differences in Children

  • Greater body surface area:
    • Allows for greater distribution of injury.
    • Energy force distributes over a larger surface area.
  • Abdominal organs are more anterior, with less subcutaneous fat:
    • Organs are less protected.
  • Smaller blood volume:
    • Less blood loss can result in hypovolemia.

Blunt vs. Penetrating Abdominal Trauma

Blunt Trauma
  • More common in pediatric patients.
  • Results from compression of solid or hollow viscous organs against the spine.
  • Usually due to rapid acceleration-deceleration forces.
  • Can see:
    • Contusions, lacerations, hemorrhage.
    • Increased abdominal pressure due to hemorrhage.
    • Significant intra-abdominal injury without external signs.
Penetrating Abdominal Trauma
  • Results from direct intra-abdominal injury.
  • Examples: gunshot wound, stab wound.
  • Can see:
    • Major vascular injuries.
    • Rapid onset of peritonitis, especially if a dirty item is involved.
    • Hemorrhage, perforation, infarct.

Clinical Manifestations of Abdominal Trauma

  • Can be subtle, with no external signs of injury.
  • Rebound tenderness: pain upon release of pressure.
  • Guarding of the abdomen.
  • Increased abdominal girth.
  • Abdominal rigidity.
  • Respiratory distress with grunting respirations due to increased girth limiting diaphragm expansion.
  • Pallor and hypotension due to blood loss.
  • Liver injury: right upper quadrant pain radiating to the shoulder.
  • Spleen injury: left upper quadrant pain.
  • Pancreatic injury: deep epigastric pain radiating to the back.
  • Cullen's sign: bruising around the umbilicus (hemorrhagic pancreatitis).
  • Turner's sign: bruising along the flank area (retroperitoneal hemorrhage).
  • Care's sign: acute pain in the shoulder when lying down with legs elevated (blood or irritants in the peritoneal cavity).

Diagnostic Studies

  • Abdominal CT scan: contusions, lacerations, blood in the abdomen.
  • Abdominal ultrasound with FAST (Focused Assessment with Sonography for Trauma) study: looks for blood in the abdomen.
  • Chest X-ray.
  • Abdominal X-rays.
  • Lab studies:
    • CBC (hemoglobin and hematocrit for signs of bleeding).
    • Liver and pancreatic function tests.
    • Coagulation studies.
    • Urinalysis (blood in the urine indicates kidney or bladder injury).

Management of Abdominal Trauma

  • ABCs and vital signs first.
  • Monitor serial abdominal girths to detect increases.
  • Nasogastric tube for gastric decompression (use oral gastric tube if concern for basilar skull fracture).
  • Follow serial hemoglobin and hematocrit to assess for ongoing bleeding.
  • Most solid abdominal injuries are managed non-operatively with bed rest and monitoring.
  • Surgery may be needed for massive bleeding, penetrating trauma, or severe blunt abdominal injuries.

Acute Abdominal Pain

  • Sudden onset with tenderness suggests abdominal inflammation, obstruction, perforation, or hemorrhage.
  • Requires evaluation for potential surgical intervention.
  • Concerns:
    • Leaking of GI contents.
      • Upper GI perforations: leakage of hydrochloric acid, digestive enzymes, or bile causing peritonitis.
      • Lower GI tract perforations: leakage of fecal material and bacteria into the peritoneum leading to sepsis.
    • Injury to the peritoneum: decreased bowel motility leading to ileus (failure in peristalsis).

Clinical Signs

  • Bowel infarction: signs of sepsis due to dead bowel.
  • Bowel obstruction: abdominal distension, absent bowel sounds, vomiting, fever.
  • Perforation: respiratory distress, acidosis, signs of sepsis.
  • Third spacing and large abdominal ascites: fluid leaking into the abdominal area.
  • Peritonitis: pain, guarding, rebound tenderness.

Management

  • Ongoing assessments and monitoring.
  • Diagnostic studies: X-rays, abdominal CT scan, radionucleotide studies, lab monitoring (CBC, electrolytes).
  • Potential surgical intervention.
  • Gastric decompression: nasogastric or orogastric tube to watch amount and color of drainage.
  • IV maintenance fluids and volume replacement for dehydration or GI losses.
  • Monitor and treat respiratory distress.
  • Pain management.
  • Nutritional support if bowel needs extended rest.

Gastrointestinal Hemorrhage

  • Acute bleeding from anywhere in the GI tract.
  • Categorized by location: upper vs. lower tract.

Definitions

  • Upper GI hemorrhage: bleeding proximal to the ligament of Treitz.
  • Lower GI hemorrhage: bleeding distal to the ligament of Treitz.

Causes

  • Vary based on the patient’s age.
    • Neonate/Infant:
      • Swallowed maternal blood, esophagitis, vascular malformations, stress ulcer, esophageal varices, hemorrhagic newborn disease
    • Preschool:
      • Esophagitis, gastritis, stress ulcers, peptic ulcers, foreign body, caustic ingestion.
    • School age/Adolescents:
      • Portal hypertension, trauma, nasopharyngeal lesions
  • Lower GI Bleeds:
    • Neonates: Necrotizing enterocolitis.
    • Preschool/Older children: Hemolytic uremic syndrome and inflammatory bowel disease

Physiologic Response

  • 15% blood volume loss: stimulation of autonomic cardiovascular response to maintain blood pressure and perfusion (vasoconstriction, stronger heart contraction).

  • >20% blood volume loss: decreased systolic pressure (late sign of large volume loss), metabolic acidosis.
  • Severe hemorrhage: shock, cardiovascular collapse, death.
  • Slower onset of bleeding: weakness, faintness, fatigue.

Signs & Symptoms

  • Acute bleeding: hematemesis (bright red or coffee grounds), melena (dark, flat, tarry stool), hematochezia (bright red blood from the rectum).
  • Chronic/occult bleeding: trace amounts of blood in normal stools or gastric secretions (detected with guaiac test).

Diagnostic Tests

  • ABG to monitor for metabolic acidosis.
  • CBC to monitor for anemia and thrombocytopenia.
  • Type and screen for potential blood transfusion.
  • Evaluation for coagulopathies or DIC.
  • Electrolytes and enzymes for liver and pancreatic dysfunction.
  • Abdominal X-ray to evaluate for bowel gas pattern, obstruction, air-fluid levels, or pneumoperitoneum.
  • Endoscopy for direct visualization of the GI tract.

Management

  • Depends on clinical manifestations and degree of blood loss.
  • Support ABCs.
  • Two large bore IVs, fluid resuscitation, and possibly blood transfusion.
  • Insert NG tube and lavage with room temperature saline until bleeding stops.
  • Vasopressin or octreotide infusions to decrease bleeding.
  • Endoscopy for diagnosis and management of bleeding.
  • Ongoing monitoring for deterioration in labwork and signs of continued bleeding

Liver Disease and Failure

  • Can be acute or chronic/decompensated.
  • Etiologies: hepatitis viruses (A, B, C), autoimmune processes, drug-induced (monitor liver function tests with hepatotoxic drugs), acetaminophen ingestion, fatty acid disease.

Clinical Manifestations

  • Hepatossplenomegaly: enlarged liver and spleen.
  • Varices and ascites: third spacing of fluid into the peritoneal space.
  • Malnutrition and itching.
  • Telangiectasis (spider veins): dilation of capillaries.
  • Jaundice.
  • Hepatic encephalopathy, renal failure, coagulopathy.

Management

  • Monitor for neurologic dysfunction with hepatic encephalopathy.
  • Decrease serum ammonia levels with medications and restrict dietary protein intake.
  • Manage hepatorenal syndrome by monitoring fluid and electrolyte status, correcting electrolyte imbalances, and potentially dialysis.
  • Portal hypertension: obstruction of normal blood flow, GI bleeding and coagulopathies.
  • Replacement of blood products and IV vitamin K therapy for coagulopathy.
  • Manage ascites with sodium restriction and diuretic therapy; paracentesis if significant respiratory compromise.

Liver Transplantation

  • Children with end-stage liver failure may be candidates.
  • Biliary atresia is the most common reason.
  • Transplants can come from deceased donors or living donors (whole liver or segment).
  • Postoperatively:
    • Excellent pulmonary toilet to prevent lung complications.
    • Hypertension must be monitored and treated.
    • Monitor drain output and correct coagulopathies.

Intussusception

  • Commonly affects healthy infants and children, usually preceded by gastroenteritis.
  • Telescoping of intestinal segments (ileum into the cecum).
  • Entrapped bowel develops venous obstruction, then arterial obstruction, compromising blood supply.
  • Can lead to intestinal perforation, intestinal infarction, and shock if untreated.

Clinical Manifestations

  • Severe abdominal pain.
  • Bloody stools described as currant jelly (mixture of mucus and blood).
  • Signs of obstruction: bilious emesis and abdominal distension.
  • Sausage-shaped mass in the right upper quadrant.

Management

  • NPO and IV fluids.
  • Air or barium enema to push the bowel back to its normal length.
  • Urgent surgical correction if enema is unsuccessful.
  • After surgery:
    • Maintain IV hydration until tolerating oral fluids.
    • Pain management.
    • Monitor for signs of infection, especially if perforation occurred.

Necrotizing Enterocolitis (NEC)

  • Most common in premature infants, particularly those with very low birth weight.
  • Widespread inflammation of the neonatal gut.
  • Results in bowel necrosis and occurs in infants being fed enterally.

Clinical Manifestations

  • Temperature instability.
  • Feeding intolerance.
  • Abdominal distension.
  • Guaiac-positive stools (blood in the stool).
  • Apnea and bradycardia.
  • Later in the disease process:
    • Metabolic acidosis.
    • Thrombocytopenia.
    • Coagulopathy.
    • Shock.

Diagnosis

  • Abdominal X-ray: pneumatosis intestinalis (air present in the submucosal intestinal layer), dilated loops of small bowel, pneumoperitoneum (gas in the peritoneal cavity).
  • Abdominal ultrasound: intra-abdominal free fluid.

Treatment

  • Bowel rest (NPO).
  • Gastric decompression with an oral or nasogastric tube.
  • Monitor fluid balance and electrolyte levels.
  • Antibiotics, especially if perforation has occurred.
  • Surgery indicated for perforation, signs of peritonitis, or significant clinical deterioration.
  • High mortality rate (30-45%), especially if large amounts of necrotic bowel must be removed.