PM1039: Evaluation and Management of Hematochezia in Congenital Heart Disease Patients Admitted to the Acute Care Cardiology Unit

Background: Neonates with congenital heart disease (CHD) are at increased risk of developing necrotizing enterocolitis (NEC), thought to be due to intestinal hypoperfusion. There is no standardized protocol for the work-up and management of hematochezia in CHD patients. This study aims to define evaluation, management and nutrition of infants admitted to the acute care cardiology unit (ACCU) who develop hematochezia.

Methods: A single-center retrospective review of CHD patients < 6 months old admitted to the ACCU from January 1, 2019 to January 31, 2021. High risk infants defined as: weight < 3kg at time of hematochezia, corrected gestational age < 37 weeks, high risk cardiac lesions (single ventricle physiology, runoff lesions, >moderately diminished ventricular function, >moderate systemic outflow obstruction). Stages of NEC events defined using Bell’s staging.

Results: Thirty-four hematochezia events occurred in 25 patients (77% high risk), with a median age of 38 days [IQR: 25, 78]. Most patients underwent hemoccult testing (68%) and the vast majority were positive (96%). Most hematochezia was benign (Bell’s Stage 1A (53%), 1B (9%)). 38% of patients had NEC (2A (35%), 3A (3%)). A third of patients had recurrent hematochezia. Hematochezia severity was not significantly different between risk groups. Most patients were anticoagulated (71%), with aspirin (68%), Lovenox (15%), Plavix (3%), and >1 anticoagulants (21%). Initial imaging was mostly abdominal x-ray (77%), rarely abdominal ultrasound (4%). Bloodwork included complete blood count (71%), c-reactive protein (CRP) (53%) and blood culture (18%). There was no significant difference in CRP, white count or platelet count results between NEC severity groups. Antibiotics were started in 9 (27%), surgical consultation was obtained in 21% and none required gastrointestinal surgery. More than half (65%) were made nil per os (NPO) with a median of 1 day [0, 5] of NPO and 4 days [1, 16] to reach adequate nutrition following hematochezia. 41% received total parenteral nutrition while NPO. Nutrition at time of NEC was delivered via nasogastric tube (59%), oral (53%) and nasoduodenal tube (30%). Nearly half were fed using fortified formula (41%), fortified breast milk (32%) and unfortified formula (27%). Mean feed volume, kcal/kg and kcal/oz were not significantly different between risk groups or NEC severity.

Conclusion: There was variability in the evaluation, management, and severity of hematochezia in the ACCU. Hematochezia prevalence was three times higher in the high risk group. Although majority of hematochezia was benign, without significant difference in clinical and nutritional variables associated with NEC severity, high index of suspicion is prudent in this population.