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Gross Intestinal Hemorrhage in Infants and Children
GROSS INTESTINAL HEMORRHAGE IN INFANTS AND CHILDREN EDWARD
J.
DONOVAN, M.D.,
F.A.C.S. 4
THE cases which I wish to present in this paper represent examples of some of the more common causes of gross intestinal hemorrhage in infants and children. There are many conditions which show various degrees of intestinal bleeding or which may show stools which are positive to the guaiac test, but I wish at this time to discuss only conditions in which the patient may be admitted to the hospital showing severe loss of blood from intestinal hemorrhage. Intussusception is a common surgical emergency in children and almost always bloody stools or the characteristic currant-jelly stools are found, but rarely if ever is the amount of blood lost sufficient to affect the child seriously. In the order of their importance the con· ditions to be presented here are: (1) Meckel's diverticulum containing heterotopic gastric mucous membrane with ulceration; (2) duplication of the small intestine; (3) polyp of the colon (not multiple polyposis); (4) duodenal ulcer. M~CKEL'S
DIVERTICULUM
CASE L-R. P., aged eight months, was admitted to Babies' Hospital with a history of severe intestinal hemorrhage during the preceding ten hours and with the diagnosis of intussusception. He had been perfectly well until the onset of his present illness ten hours before. Upon admission to the hospital the physical examination was entirely negative except for marked pallor and the presence of considerable dark blood in the rectum. The laboratory tests were as follows: bleeding and coagulation time normal, red blood count 3,400,000, hemoglobin 55 per cent, Kline test negative. With a provisional diagnosis of Meckel's diverticulum, the patient was given a transfusion immediately. It was felt that intussusception could be ruled out for the following reasons: (1) no history of abdominal pain; (2) failure to palpate an abdominal mass; (3) the obvious extent of the bleeding which would be quite unusual for an intussusception. Bleeding stopped shortly after the transfusion and the hemoglobin rose to 90 per cent in the next few days. On the sixteenth day proctoscopic examination was entirely negative. Barium enema also failed to reveal pathologic condition. In view of the rapid cessation of the bleeding and the apparently complete recov· ery in a few days' time the baby was discharged home. The mother was warned that if he bled again he would have to be operated upon and she was advised to bring him back immediately if he had a tarry stool. The wisdom of this course .. Associate Professor of Surgery, College of Physicians and Surgeons, Columbia University; Attending Surgeon, St. Luke's and Babies' Hospitals, New York City. 443
444
EDWARD
J.
DONOVAN
ot treatment may be questioned, but one hesitates to perform an exploratory laparotomy on an eight month old baby without sufficient proof that there is no other course to pursue. One month later the baby was readmitted with a history ot having had tarry stools a few hours before admission for the first time since discharge. He was given two transfusions in the next few hours and operated upon. At operation a Meckel's diverticulum was found two feet above the ileocecal Junction and was removed. His recovery was uneventful. Pathological examination of the Meckel's diverticulum showed that it contained heterotopic gastric mucous membrane with ulceration.
Unfortunately, Meckel's diverticulum and duplication of the small intestine are not demonstrable by x-ray examination and, as with most of the conditions I wish to discuss, the diagnosis often must be made by the process of exclusion. Duodenal ulcers frequently are not demonstrable by x-ray (particularly the posterior wall ulcer which is the type most apt to, bleed) and single polyps of the colon can easily be missed by barium enema, even though double contrast media are used. DUPLICATION OF TERMINAL ILEUM
Duplications of the small intestines are frequently the cause of gross intestinal hemorrhage in infants and children because they frequently contain heterotopic gastric mucous membrane with ulceration. The most common site of duplications of the intestine is in the region of the terminal ileum at the same site where Meckel's diverticulum is found. They differ from the latter in that they lie in the mesentery and have the same blood supply as the gut they parallel, while Meckel's diverticulum is always found arising from the antimesenteric border of the gut. A duplication may be but a few inches long or may exist as a tube 12 to 30 inches long, looking exactly like the loop of gut it parallels. It probably is the result of development of embryonic rests and in this form is often called an enterogenous cyst. Duplications often communicate with the loop of bowel they parallel but may be completely blind at both ends. CASE H.-The patient was a male baby, nine weeks old, born in a hospital outside of New York. He seemed to be perfectly well for the first seven weeks of life and then rather suddenly looked quite pale and the mother noted that he had passd a tarry stool. He then passed large quantities of tarry material by rectum and was given several transfusions. He seemed to pass the blood by rectum just about as fast as it could be given by transfusion. Two weeks before admission here, at the age of nine weeks, after numerous transfusions, he was operated upon at the hospital where he was born. The surgeon found a duplication of the terminal ileum but, believing that the baby's condition was not good enough to permit a resection, he closed the abdomen.
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INTESTINAL HEMORRHAGE IN INFANTS AND CHILDREN
445
The baby continued to pass large quantities of blood per rectum and in the next ten days required numerous transfusions. About ten days after the exploratory laparotomy his condition seemed good enough to transfer him to Babies' Hospital. Upon admission he was given another transfusion and operated upon, just two weeks after the previous laparotomy. A duplication of the terminal ileum was found 45 em. long, the lower end of which was 25 em. from the ileocecal junction. Since the duplication had the same blood supply as the terminal ileum which it paralleled, it could not be resected without compromising the blood supply of the ileum. Consequently, it was resected with the loop of ileum and a side-to-side anastomosis of the terminal ileum was performed, using two rows of fine chromic gut and one row of interrupted "c" silk. The baby's convalescence was uneventful. The incision healed by primary union and he was discharged home twelve days after the operation. Pathological examination of the duplication showed that it contained gastric mucous membrane with ulceration. He has had no further bleeding and is developing normally.
POLYP OF THE DESCENDING COLON CASE III.-This case is that of a six and one-half year old girl who had had "small amounts" of bright red blood in the stools on several occasions during the three years previous to her admission to St. Luke's Hospital. She had not had a severe hemorrhage until the present admission. Physical examination was essentially negative except for marked pallor. Rectal examination revealed nothing of a pathologic nature. The erythrocite count was 2,100,000, hemoglobin 44 per cent, and the guaiac test of the stool 4 plus positive. The girl was given an immediate transfusion of 400 cc. of whole blood and showed great improvement. After the bleeding had stopped proctoscopic examination revealed no pathologic lesion. Barium enema (double contrast media) also was negative. The patient was discharged home and the mother was advised that if the child had any further bleeding she would have to be examined and she was told to bring the patient to the hospital at the first sign of tarry stools. One month later the patient was readmitted with a history of tarry stools which had been noted during the last three days before readmission. Her general condition was so good that the mother did not think it necessary to bring her in sooner. The red blood count was 3,500,000, hemoglobin 62 per cent upon admission, barium enema again was negative. Proctoscopic examination also failed to reveal any lesion. With a provisional diagnosis of Meckel's diverticulum or duplication of the intestine, exploratory laparotomy was performed. A careful examination of the small bowel from the pylorus to the ileocecal junction gave negative results. The large bowel was also carefully palpated over its entire length and it was found to be normal. The abdomen was then closed, no cause for the bleeding having been found. Convalescence was uneventful and the girl remained well for the next five months when she was readmitted with a history of having had tarry stools for three days. Proctoscopic examination was again negative, but at this time the barium enema showed a polyp of the descending colon. Laparotomy was repeated and by careful pal patioII' and transillumination of the unopened bowel the polyp was located, but not until some time had been spent in trying to find it. The colon was opened at a point just above the left iliac crest and the entire polyp excised
446
EDWARD
J.
DONOVAN
with its base. It had a very long pedicle and this was probably the reason that it was so elusive. The colon was closed with two rows of chromic sutures and one row of interrupted "c" silk mattress sutures. Convalescence was uneventful and the patient was discharged home ten days after the operation with her incision well healed by primary union. She has had no further bleeding.
The lessons to be learned from this case are: (1) A single polyp may be difficult to locate by x-ray examination, even though double contrast media are used. (2) Even with the abdomen open a polyp may be difficult to find, particularly if it has a long pedicle. I have found transillumination of the unopened colon with a Cameron light quite helpful in locating polyps. It is understood of course th'at if the patient is properly prepared for operation the colon will be empty of all fecal masses. BLEEDING DUODENAL ULCER CASE IV.-I. F., a 12 year old boy, was admitted to Babies' Hospital because of weakness, pallor and tarry stools. Two years previously he had awakened early one morning feeling faint and had vomited a large quantity of bright red blood. He later passed tarry stools. This bleeding episode subsided in a few days' time but during the next two years the boy frequently complained of upper abdominal pain. Ten days before his first admission to Babies' Hospital he again had tarry stools, was quite pale and felt weak. The diagnosis upon admission was bleeding duodenal ulcer. The red blood count was 3,416,000, hemoglobin 67 per cent. Mter conservative treatment the bleeding ceased and a gastrointestinal x-ray series showed a duodenal ulcer. He was treated on a Sippy regimen for five weeks and discharged greatly improved. Five years later the patient was admitted to Presbyterian Hospital (he was over the age limit for Babies' Hospital then) with a history of seven or eight episodes of bleeding since his discharge from Babies' Hospital. These episodes were always marked by pallor, a feeling of weakness and the passage of tarry stools. His blood count averaged 3,400,000, hemoglobin 65 per cent. He. was again treated conservatively and discharged home after the bleeding stopped. Two months later he was readmitted with the same complaint-pallor, weakness and tarry stools. The boy was operated upon at this time, the duodenal ulcer excised and a pyloroplasty performed. His convalescence was uneventful. About one year after operation he was again admitted to Presbyterian Hospital with a recurrence of the bleeding. Conservative treatment seemed quite successful and he was discharged home. Twice in the following year he was readmitted and each time was treated conservatively. He was last seen in Follow-Up Clinic free from all symptoms during the preceding five year period.
While duodenal ulcers occur much less frequently in children than in adults, they occur often enough so that one must. always bear in mind the possibility when considering the ca~se of gross intestinal hemorrhage in children.
J.
DONOVAN, M.D.,
F.A.C.S. 4
THE cases which I wish to present in this paper represent examples of some of the more common causes of gross intestinal hemorrhage in infants and children. There are many conditions which show various degrees of intestinal bleeding or which may show stools which are positive to the guaiac test, but I wish at this time to discuss only conditions in which the patient may be admitted to the hospital showing severe loss of blood from intestinal hemorrhage. Intussusception is a common surgical emergency in children and almost always bloody stools or the characteristic currant-jelly stools are found, but rarely if ever is the amount of blood lost sufficient to affect the child seriously. In the order of their importance the con· ditions to be presented here are: (1) Meckel's diverticulum containing heterotopic gastric mucous membrane with ulceration; (2) duplication of the small intestine; (3) polyp of the colon (not multiple polyposis); (4) duodenal ulcer. M~CKEL'S
DIVERTICULUM
CASE L-R. P., aged eight months, was admitted to Babies' Hospital with a history of severe intestinal hemorrhage during the preceding ten hours and with the diagnosis of intussusception. He had been perfectly well until the onset of his present illness ten hours before. Upon admission to the hospital the physical examination was entirely negative except for marked pallor and the presence of considerable dark blood in the rectum. The laboratory tests were as follows: bleeding and coagulation time normal, red blood count 3,400,000, hemoglobin 55 per cent, Kline test negative. With a provisional diagnosis of Meckel's diverticulum, the patient was given a transfusion immediately. It was felt that intussusception could be ruled out for the following reasons: (1) no history of abdominal pain; (2) failure to palpate an abdominal mass; (3) the obvious extent of the bleeding which would be quite unusual for an intussusception. Bleeding stopped shortly after the transfusion and the hemoglobin rose to 90 per cent in the next few days. On the sixteenth day proctoscopic examination was entirely negative. Barium enema also failed to reveal pathologic condition. In view of the rapid cessation of the bleeding and the apparently complete recov· ery in a few days' time the baby was discharged home. The mother was warned that if he bled again he would have to be operated upon and she was advised to bring him back immediately if he had a tarry stool. The wisdom of this course .. Associate Professor of Surgery, College of Physicians and Surgeons, Columbia University; Attending Surgeon, St. Luke's and Babies' Hospitals, New York City. 443
444
EDWARD
J.
DONOVAN
ot treatment may be questioned, but one hesitates to perform an exploratory laparotomy on an eight month old baby without sufficient proof that there is no other course to pursue. One month later the baby was readmitted with a history ot having had tarry stools a few hours before admission for the first time since discharge. He was given two transfusions in the next few hours and operated upon. At operation a Meckel's diverticulum was found two feet above the ileocecal Junction and was removed. His recovery was uneventful. Pathological examination of the Meckel's diverticulum showed that it contained heterotopic gastric mucous membrane with ulceration.
Unfortunately, Meckel's diverticulum and duplication of the small intestine are not demonstrable by x-ray examination and, as with most of the conditions I wish to discuss, the diagnosis often must be made by the process of exclusion. Duodenal ulcers frequently are not demonstrable by x-ray (particularly the posterior wall ulcer which is the type most apt to, bleed) and single polyps of the colon can easily be missed by barium enema, even though double contrast media are used. DUPLICATION OF TERMINAL ILEUM
Duplications of the small intestines are frequently the cause of gross intestinal hemorrhage in infants and children because they frequently contain heterotopic gastric mucous membrane with ulceration. The most common site of duplications of the intestine is in the region of the terminal ileum at the same site where Meckel's diverticulum is found. They differ from the latter in that they lie in the mesentery and have the same blood supply as the gut they parallel, while Meckel's diverticulum is always found arising from the antimesenteric border of the gut. A duplication may be but a few inches long or may exist as a tube 12 to 30 inches long, looking exactly like the loop of gut it parallels. It probably is the result of development of embryonic rests and in this form is often called an enterogenous cyst. Duplications often communicate with the loop of bowel they parallel but may be completely blind at both ends. CASE H.-The patient was a male baby, nine weeks old, born in a hospital outside of New York. He seemed to be perfectly well for the first seven weeks of life and then rather suddenly looked quite pale and the mother noted that he had passd a tarry stool. He then passed large quantities of tarry material by rectum and was given several transfusions. He seemed to pass the blood by rectum just about as fast as it could be given by transfusion. Two weeks before admission here, at the age of nine weeks, after numerous transfusions, he was operated upon at the hospital where he was born. The surgeon found a duplication of the terminal ileum but, believing that the baby's condition was not good enough to permit a resection, he closed the abdomen.
-
""-"
--..
..
INTESTINAL HEMORRHAGE IN INFANTS AND CHILDREN
445
The baby continued to pass large quantities of blood per rectum and in the next ten days required numerous transfusions. About ten days after the exploratory laparotomy his condition seemed good enough to transfer him to Babies' Hospital. Upon admission he was given another transfusion and operated upon, just two weeks after the previous laparotomy. A duplication of the terminal ileum was found 45 em. long, the lower end of which was 25 em. from the ileocecal junction. Since the duplication had the same blood supply as the terminal ileum which it paralleled, it could not be resected without compromising the blood supply of the ileum. Consequently, it was resected with the loop of ileum and a side-to-side anastomosis of the terminal ileum was performed, using two rows of fine chromic gut and one row of interrupted "c" silk. The baby's convalescence was uneventful. The incision healed by primary union and he was discharged home twelve days after the operation. Pathological examination of the duplication showed that it contained gastric mucous membrane with ulceration. He has had no further bleeding and is developing normally.
POLYP OF THE DESCENDING COLON CASE III.-This case is that of a six and one-half year old girl who had had "small amounts" of bright red blood in the stools on several occasions during the three years previous to her admission to St. Luke's Hospital. She had not had a severe hemorrhage until the present admission. Physical examination was essentially negative except for marked pallor. Rectal examination revealed nothing of a pathologic nature. The erythrocite count was 2,100,000, hemoglobin 44 per cent, and the guaiac test of the stool 4 plus positive. The girl was given an immediate transfusion of 400 cc. of whole blood and showed great improvement. After the bleeding had stopped proctoscopic examination revealed no pathologic lesion. Barium enema (double contrast media) also was negative. The patient was discharged home and the mother was advised that if the child had any further bleeding she would have to be examined and she was told to bring the patient to the hospital at the first sign of tarry stools. One month later the patient was readmitted with a history of tarry stools which had been noted during the last three days before readmission. Her general condition was so good that the mother did not think it necessary to bring her in sooner. The red blood count was 3,500,000, hemoglobin 62 per cent upon admission, barium enema again was negative. Proctoscopic examination also failed to reveal any lesion. With a provisional diagnosis of Meckel's diverticulum or duplication of the intestine, exploratory laparotomy was performed. A careful examination of the small bowel from the pylorus to the ileocecal junction gave negative results. The large bowel was also carefully palpated over its entire length and it was found to be normal. The abdomen was then closed, no cause for the bleeding having been found. Convalescence was uneventful and the girl remained well for the next five months when she was readmitted with a history of having had tarry stools for three days. Proctoscopic examination was again negative, but at this time the barium enema showed a polyp of the descending colon. Laparotomy was repeated and by careful pal patioII' and transillumination of the unopened bowel the polyp was located, but not until some time had been spent in trying to find it. The colon was opened at a point just above the left iliac crest and the entire polyp excised
446
EDWARD
J.
DONOVAN
with its base. It had a very long pedicle and this was probably the reason that it was so elusive. The colon was closed with two rows of chromic sutures and one row of interrupted "c" silk mattress sutures. Convalescence was uneventful and the patient was discharged home ten days after the operation with her incision well healed by primary union. She has had no further bleeding.
The lessons to be learned from this case are: (1) A single polyp may be difficult to locate by x-ray examination, even though double contrast media are used. (2) Even with the abdomen open a polyp may be difficult to find, particularly if it has a long pedicle. I have found transillumination of the unopened colon with a Cameron light quite helpful in locating polyps. It is understood of course th'at if the patient is properly prepared for operation the colon will be empty of all fecal masses. BLEEDING DUODENAL ULCER CASE IV.-I. F., a 12 year old boy, was admitted to Babies' Hospital because of weakness, pallor and tarry stools. Two years previously he had awakened early one morning feeling faint and had vomited a large quantity of bright red blood. He later passed tarry stools. This bleeding episode subsided in a few days' time but during the next two years the boy frequently complained of upper abdominal pain. Ten days before his first admission to Babies' Hospital he again had tarry stools, was quite pale and felt weak. The diagnosis upon admission was bleeding duodenal ulcer. The red blood count was 3,416,000, hemoglobin 67 per cent. Mter conservative treatment the bleeding ceased and a gastrointestinal x-ray series showed a duodenal ulcer. He was treated on a Sippy regimen for five weeks and discharged greatly improved. Five years later the patient was admitted to Presbyterian Hospital (he was over the age limit for Babies' Hospital then) with a history of seven or eight episodes of bleeding since his discharge from Babies' Hospital. These episodes were always marked by pallor, a feeling of weakness and the passage of tarry stools. His blood count averaged 3,400,000, hemoglobin 65 per cent. He. was again treated conservatively and discharged home after the bleeding stopped. Two months later he was readmitted with the same complaint-pallor, weakness and tarry stools. The boy was operated upon at this time, the duodenal ulcer excised and a pyloroplasty performed. His convalescence was uneventful. About one year after operation he was again admitted to Presbyterian Hospital with a recurrence of the bleeding. Conservative treatment seemed quite successful and he was discharged home. Twice in the following year he was readmitted and each time was treated conservatively. He was last seen in Follow-Up Clinic free from all symptoms during the preceding five year period.
While duodenal ulcers occur much less frequently in children than in adults, they occur often enough so that one must. always bear in mind the possibility when considering the ca~se of gross intestinal hemorrhage in children.