INTRODUCTION AND EPIDEMIOLOGY
GI bleeding varies in its epidemiology and presentation depending on whether it originates from the upper or lower GI tract. Upper GI (UGI) bleeding is bleeding proximal to the ligament of Treitz, whereas lower GI (LGI) bleeding originates distal to this ligament. UGI bleeding is a relatively uncommon presentation in pediatrics, with one population-based survey reporting an incidence of 1 to 2 per 10,000 children/year.1 LGI bleeding is more common, but most cases are benign and self-limited.2 In one study, LGI bleeding constituted the chief complaint of 0.3% of children presenting to a pediatric ED, but only 4.2% of these patients had bleeding considered to be life-threatening.3
The signs and symptoms of GI bleeding in children vary: bright red blood in small strands or clots in emesis or bowel movements, vomiting of gross blood (hematemesis), black tarry stools (melena), or the passage of bright red or maroon-colored blood from the rectum (hematochezia). Occult bleeding may result in unexplained pallor, fatigue, and anemia. Severity is assessed by vital signs, physical appearance, and the hemodynamic status of the patient, all of which lead to an estimation of the volume of blood loss. Worrisome symptoms and signs include pallor, diaphoresis, lethargy, abdominal pain, tachycardia, hypotension, and altered mental status. GI bleeding can be life threatening. Advances in endoscopy, radiology, and newer therapeutic modalities have helped identify the causes of bleeding more accurately and have provided more treatment options.
CLINICAL APPROACH
Assess bleeding and institute resuscitation if the child has signs of hemorrhagic shock. Next, obtain a history and perform a physical examination, and try to establish the level of bleeding as UGI or LGI, because the subsequent diagnostic and treatment steps differ. Then, narrow the differential diagnosis based on history, physical examination, laboratory studies, and the categorization of age-related causes of UGI and LGI bleeding. The presence of any one of melena, hematochezia, unwell appearance, or moderate to large volume of fresh blood in the vomitus was associated with a clinically significant UGI bleed (defined as a hemoglobin drop of >20 g/L, need for blood transfusion, need for emergent endoscopy, or need for surgical procedure).4
There are several important questions to consider. Is the patient stable or unstable? Is this really blood, and is it coming from the GI tract? Is it a small amount of blood or a large volume? Has the child had prior episodes of bleeding, and if so, do the parents know the cause and prior treatment?5
The presence of tachycardia, pallor, tachypnea, prolonged capillary refill time, altered mental status, metabolic acidosis, and/or hypotension indicates significant GI bleeding. Tachycardia and tachypnea are the first clinical signs, followed by delayed capillary refill, decreased urine output, altered mental status, metabolic acidosis, and pallor. Orthostatic changes in heart rate and blood pressure indicate that significant bleeding has occurred. Hypotension is a late sign and indicates uncompensated hemorrhagic shock. Any signs of hemorrhagic shock require simultaneous resuscitation, diagnosis, and treatment. Maintain the airway, monitor oxygen saturation and provide oxygen, place two large-bore IVs (20 gauge or larger), and administer boluses of crystalloid and, if necessary, blood products.
Determine whether or not the vomit or stool really contains blood. Beets, food coloring, and fruit juices can look like blood. Black and tarry stools can result from vitamins with iron, bismuth (Pepto-Bismol®), spinach, cranberries, blueberries, or licorice. Urinary (urate) crystals in the neonatal diaper are often orange in color and may be interpreted by a caregiver as blood. The Gastroccult® and Hemoccult® tests (Beckman Coulter, Brea, CA) can be used to document the presence of blood in gastric contents or stool, respectively. These guaiac-based tests rely on the peroxidase activity of the heme portion of hemoglobin. False–positive results are associated with foods that have peroxidase activity such as red meat, melons, grapes, radishes, turnips, cauliflower, and broccoli. False-negative results can result from the ingestion of vitamin C due to its antioxidant properties.
Evaluate the child for epistaxis, recent dental work, or gingival bleeding, because swallowed blood may lead to hematemesis. The neonate can swallow maternal blood during delivery or from breastfeeding if the mother has fissures on her nipples. In the toddler, blood could come from an injury to the oropharynx or nose. Make sure that blood does not originate from the throat or lungs. Distinguish whether the blood in the diaper is from a GU or GI source. Examine the perineum and urethra. Neonatal girls may develop some vaginal bleeding from maternal hormone withdrawal.
It is difficult to gauge the amount of bleeding from caretaker descriptions, because even small amounts of blood can appear alarmingly large. Assess the clinical status of the patient, vital signs, results of laboratory studies, and results of serial clinical examinations to determine the amount of bleeding. The hemoglobin and hematocrit are unreliable indicators of blood loss in the early stages.
See Tables 131-1, 131-2, and 131-3, for potential recurrent causes of GI bleeding organized by age and symptoms.2,5
| Upper GI Bleeding | ||
|---|---|---|
| Neonate | Infant/Toddler | Child/Adolescent |
| Common | Common | Common |
| Swallowed maternal blood | Non-GI source (e.g., epistaxis) | Mallory-Weiss tear |
| Milk/soy protein allergy | Mallory-Weiss tear | Gastritis (especially Helicobacter pylori gastritis) |
| Trauma (nasogastric tube in NICU) | Esophagitis | Esophagitis |
| Uncommon | Gastritis | Peptic ulcer disease |
| Stress ulcer/gastritis | Uncommon | Uncommon |
| Esophagitis | Stress gastritis or ulcer | Esophageal varices |
| Vascular malformation | Peptic ulcer disease | Toxic/caustic ingestion |
| Hemorrhagic disease of newborn (vitamin K deficiency) | Vascular malformation | Foreign body |
| Coagulopathy/bleeding diathesis | GI duplication | Vasculitis |
| Coagulopathy associated with infection | Gastric/esophageal varices Bowel obstruction Toxic/caustic ingestion Coagulopathy/bleeding diathesis Foreign body | Vascular malformation Bowel obstruction Crohn’s disease Coagulopathy/bleeding diathesis GI stromal tumors Dieulafoy’s lesion |
| Lower GI Bleeding | ||
| Neonate | Infant/Toddler | Child/Adolescent |
| Common | Common | Common |
| Swallowed maternal blood | Anal fissure | Anal fissure |
| Anal fissure | Milk/soy protein allergy | Infectious gastroenteritis |
| Milk/soy protein allergy | Infectious gastroenteritis | Polyps; benign, familial |
| Infectious gastroenteritis | Uncommon | Uncommon |
| Uncommon | Intussusception | Henoch-Schönlein purpura |
| Meckel’s diverticulum* | Meckel’s diverticulum* | Hemorrhoids |
| Necrotizing enterocolitis | GI duplication | Inflammatory bowel disease |
| Vascular malformation | Hemolytic-uremic syndrome | Meckel’s diverticulum* |
| Hemorrhagic disease of newborn (vitamin K deficiency) | Henoch-Schönlein purpura | Hemolytic-uremic syndrome |
| Intussusception | Malrotation with volvulus | Vascular malformation |
| Malrotation with volvulus | Polyps; benign, familial | Celiac disease |
| Hirschsprung’s-associated enterocolitis (toxic megacolon) | Coagulopathy/bleeding diathesis | |
| GI duplication | Vascular malformation | |
| Hematemesis | |
| Infant | Swallowed maternal blood Vitamin K deficiency Vascular malformation |
| Child/adolescent | Swallowed blood from epistaxis, dental work, oral trauma Mallory-Weiss tear Esophagitis/gastritis Peptic ulcer disease Esophageal varices Vascular malformation Toxic ingestion Foreign body Coagulopathy/bleeding diathesis |
| Hematochezia and melena | |
| Infant | Upper GI sources Anal fissure Milk/soy protein allergy Infectious gastroenteritis Meckel’s diverticulum Intussusception Malrotation with volvulus Ischemic bowel |
| Child/adolescent | Upper GI sources Anal fissure Infectious gastroenteritis Polyps Henoch-Schönlein purpura Hemorrhoids Inflammatory bowel disease Intussusception Meckel’s diverticulum Malrotation with volvulus Ischemic bowel Hemolytic-uremic syndrome Celiac disease Vascular malformation |
| Symptom Complex | Differential Diagnosis |
|---|---|
| Painless hematemesis | Swallowed blood (non-GI source) Coagulopathy/bleeding diathesis |
| Hematemesis and abdominal, epigastric, or chest pain | Peptic ulcer disease Helicobacter pylori–associated gastritis Esophagitis/gastritis |
| Hematemesis, hematochezia, or melena with underlying systemic disease | Esophageal varices Inflammatory bowel disease |
| Vomiting, hematochezia, or melena with abdominal pain | Intussusception Malrotation with volvulus Ischemic bowel Henoch-Schönlein purpura Necrotizing enterocolitis |
| Vomiting, hematochezia, or melena with fever | Infectious gastroenteritis Inflammatory bowel disease |
| Painless rectal bleeding | Polyp Meckel’s diverticulum GI duplication Vascular malformation |
Ask whether the child had prior episodes of bleeding. If so, ask whether the caregivers know the cause and prior treatments. There are many causes of UGI and LGI bleeding in children, and the causes vary significantly by age (Tables 131-1 and 131-2). In addition to the age-based approach to the differential diagnosis of GI bleeding, the clinical presentation and constellation of associated symptoms are often useful in narrowing the differential diagnosis for a particular child. Table 131-3 describes symptom complexes along with the differential diagnosis of GI bleeding.
The type and implications of questioning differ depending on the age of the child (Tables 131-1 and 131-2). If the child is verbal, obtain the history from both the child and the parent or caregiver. Elicit an accurate chronology of events, and ask questions to help frame the differential diagnosis (Table 131-4). Vomiting of bright red blood or coffee-ground emesis is the classic presentation of UGI bleeding. Bloody diarrhea and bright red blood mixed with or coating normal stool are the classic presentations of LGI bleeding. Hematochezia, melena, or occult GI blood loss could represent UGI or LGI bleeding.6
| Chief complaint | Frequency and volume of vomiting Blood-streaked, coffee-ground, or bloody vomitus Frequency and volume of diarrhea Bloody diarrhea Constipation with blood-streaked stool Blood on toilet paper or blood in toilet bowl Abdominal pain along with bloody vomitus or stool Dyspepsia; heartburn; dysphagia Fever |
| Review of systems | Rashes; joint pain; oral ulcers; perianal lesions; ocular symptoms; weight loss; fatigue; delayed puberty; failure to thrive; abnormal bleeding; dehydration |
| Medications |
