Gastrointestinal (GI) bleeding in children can range from small amounts of blood in the stool, associated with milk protein allergy or anal fissure, to life-threatening hemorrhage, associated with portal hypertension or peptic ulcer disease. Severe bleeding is a true medical emergency and necessitates prompt diagnostic attention and appropriate management. Hemodynamic stabilization of the patient with severe bleeding should always precede diagnostic studies . An accurate history and thorough physical examination usually allow the physician to categorize the problem as mild or severe and to direct evaluation at the appropriate pace.
Definitions
Children with gastrointestinal bleeding generally present with hematemesis, hematochezia, or melena, although the clinical manifestation can be as subtle as evidence of occult blood loss. An upper gastrointestinal bleed is bleeding from the esophagus, stomach, or duodenum. Upper sources account for the majority of gastrointestinal bleeds in children. If the site of bleeding is distal to the ligament of Treitz, it is a lower gastrointestinal bleed . Blood passed per rectum can originate from either an upper or lower gastrointestinal source. Occult bleeding may occur from disorders at numerous sites.
Hematemesis
Vomited blood can be either red or the color of coffee grounds. Hematemesis is most commonly associated with an upper gastrointestinal bleed, although swallowed blood produces the same clinical picture. Bright red hematemesis suggests active bleeding that has not had prolonged contact with gastric secretions. When gastric secretions interact with the blood, the blood will darken in color as the iron oxidizes and leads to dark red or “coffee ground” emesis.
Hematochezia and melena
The presence of hematochezia (bright red blood) is generally associated with colonic bleeding, although it may result from a brisk upper bleed. Maroon stools from the rectum are generally associated with a lower gastrointestinal bleed. The presence of melena—passage of black, tarry stools—generally results from significant blood loss proximal to the ileocecal valve, including an upper gastrointestinal bleed. The color results from bacterial breakdown of the hemoglobin. Up to 10-15% of upper gastrointestinal bleeds present with melena in the absence of hematemesis. These patients are more likely to have a clinically significant bleed.
Approach to Gastrointestinal Bleeding
(See Nelson Textbook of Pediatrics, p. 1766.)
The first step is to determine whether the problem is actually gastrointestinal bleeding. Many substances and nongastrointestinal sources may simulate gastrointestinal bleeding ( Table 13.1 ). Stool guaiac and the modified guaiac (Gastroccult) test for emesis are used to determine the presence of blood. Recommendations from manufacturers are to avoid red meat, citrus fruits and juices, supplemental vitamin C in excess of 250 mg/day for 3 days prior to testing, and to avoid antacids for at least 60 minutes prior to testing. Nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided for 1 week prior to testing and aspirin exposure should be minimized; however, it is uncertain whether these products affect the reliability of the test. In addition, although iron preparations may blacken stools, they do not lead to false-positive results. Female patients should be told not to collect test samples for 3 days after or during a menstrual period. To avoid potential false-positive or false-negative results, stool should be collected from diapers or from disposable collection devices rather than directly from toilet water. Finally, an alkali denaturation test, also known as the Apt-Downey or Apt test, should be performed when a breast fed infant vomits bright red blood or passes red bloody stools to distinguish whether it is maternal or fetal hemoglobin.
|
Once gastrointestinal bleeding is confirmed, the evaluation, differential diagnosis, and therapeutic interventions will depend on the age of the patient and whether the bleed is coming from the upper or the lower gastrointestinal tract ( Tables 13.2, 13.3, and 13.4 ). A nasogastric (NG) tube may be placed in the appropriate patient when the source of bleeding is not clear. Bloody aspirate from the stomach is confirmation of upper gastrointestinal bleeding. The tube may then be used to lavage the stomach with warm saline. If aspirated saline clears after repeated lavage, the bleeding has likely stopped or is from a different source.
| Infants | Milk protein sensitivity |
| Trauma | |
| Esophagitis | |
| Gastritis | |
| Ulcer | |
| Infection—CMV, herpes, fungal | |
| Sepsis with DIC | |
| Vitamin K deficiency | |
| Anatomic anomalies (duplication) | |
| Vascular malformation | |
| Mallory-Weiss tear | |
| Prolapse gastropathy | |
| Children | Esophagitis including pill ulceration |
Gastritis
| |
Ulcer
Stress | |
| Esophageal varices | |
| Hemobilia | |
Vascular malformation
| |
| Anatomic anomaly | |
| Infection | |
| Sepsis with DIC | |
| Mallory-Weiss Tear | |
| Prolapse gastropathy |
| Infants | Milk protein sensitivity |
| Anal fissure | |
| Infectious— Salmonella, Shigella , Escherichia coli O157:H7 , Campylobacter species, Yersinia species, Entamoeba histolytica, CMV | |
| Ischemia—volvulus or necrotizing enterocolitis | |
| Sepsis with DIC | |
| Vitamin K deficiency | |
| Vascular malformation | |
| Hirschsprung enterocolitis | |
| Lympho-nodular hyperplasia | |
| Intusussception | |
| Trauma | |
| Children | Milk and other protein sensitivity |
| Anal fissure | |
| Infectious—above plus Clostridium difficile | |
Medication
| |
| Intusussception | |
| Meckel diverticulum | |
| Juvenile polyp | |
| Inflammatory bowel disease | |
| Ischemia | |
| Typhlitis | |
| Vascular malformation | |
| Anatomic anomaly | |
| Henoch-Schönlein purpura | |
| Lymphonodular hyperplasia | |
| Trauma |
| Inflammatory Causes |
| Peptic esophagitis |
| Crohn disease |
| Ulcerative colitis |
| Mild enterocolitis |
| Celiac disease |
| Eosinophilic gastroenteritis |
| Meckel diverticulum |
| Solitary rectal ulcer |
| Vascular Causes |
| Angiodysplasia and vascular ectasias |
| Gastroesophageal varices |
| Congestive gastropathy |
| Hemangiomas |
| Drugs |
| Nonsteroidal antiinflammatory drugs |
| Extragastrointestinal Causes |
| Hemoptysis |
| Epistaxis |
| Oropharyngeal bleeding |
| Infectious Causes |
| Hookworm |
| Strongyloidiasis |
| Ascariasis |
| Tuberculosis enterocolitis |
| Amebiasis |
| Tumors and Neoplastic Causes |
| Polyps |
| Lymphoma |
| Leiomyoma |
| Lipoma |
| Carcinoma |
| Artificial Causes |
| Hematuria |
| Menstrual bleeding |
| Nonspecific test positivity |
| Miscellaneous Causes |
| Long-distance running |
| Coagulopathies |
| Factitious |
Hematemesis and Melena: Upper Gastrointestinal Bleed
History
Neonates who did not receive prophylactic vitamin K are at risk for hemorrhagic disease of the newborn (see Chapter 38 ) and additional perinatal factors may place them at risk for sepsis or other stress that could lead to gastritis. Infants who require intensive care may have trauma from an NG tube, and infants with neonatal umbilical vein catheterization or neonatal omphalitis are at risk for portal vein thrombosis and resultant later onset of esophageal varices. In older children, a recent history of vomiting, regurgitation, or abdominal pain suggests a mucosal lesion. Forceful, repeated vomiting may result in a Mallory-Weiss tear or prolapse gastropathy. Reactive gastritis can be due to medications such as NSAIDs as well as alcohol or ingestion of caustic substances. Providers must ask about recent bleeding such as epistaxis or dental procedures, which could lead to hematemesis without a gastrointestinal source of bleeding.
Information regarding chronic pulmonary disease, renal disease, bleeding disorders, and liver disease, including a history of jaundice, should be obtained in all children. Patients with cystic fibrosis are at risk not only for the development of esophageal varices caused by biliary cirrhosis but also for coagulopathies from vitamin K deficiency. They may also have hemoptysis, which can be misinterpreted as hematemesis. In patients with renal disease, uremia will cause platelet dysfunction, which may manifest as a gastrointestinal bleed. The family history should address the presence of bleeding disorders, peptic ulcer disease, and possible Helicobacter pylori exposure.
Physical Examination
Immediate attention must be given to signs of hypovolemia, anemia, or shock. An orthostatic change, such as a pulse rate increase of 20 beats/min or a drop in systolic blood pressure of more than 10 mm Hg when the patient changes from supine to standing is a sensitive index of significant volume depletion. Blood pressure may remain normal up to the point of circulatory collapse in children and a normal blood pressure should not be reassuring in the setting of other signs of hypovolemia such as tachycardia or delayed capillary refill.
In addition to close attention to changes in vital signs, a physical exam with emphasis on potential sources of bleeding is essential ( Table 13.5 ). The oropharynx and nasal canals should be examined for lesions as the cause of bleeding. Palpation to evaluate organomegaly should begin at the iliac crests so as not to miss a hugely enlarged liver or spleen. A prominent venous pattern on the abdomen ( Fig. 13.1 ), splenomegaly, and ascites may suggest portal hypertension. Tenderness and guarding indicate a significant inflammatory process.
| Exam Finding | Associated Disorder |
|---|---|
| Splenomegaly | Portal hypertension and esophageal varices |
| Caput medusae | |
| Palmar erythema | Liver disease |
| Spider angioma | |
| Jaundice | |
| Hemangioma | Vascular malformations in gastrointestinal tract |
| Palpable purpura | Henoch-Schönlein purpura or other vasculitis |
| Hyperpigmented lesions of the oral or anal mucosa | Peutz-Jeghers syndrome (GI polyps) |
| Oral ulcers | Inflammatory bowel disease |
| Perianal fistula | |
| Perianal skin tag | |
| Erythema nodosum | |
| Pyoderma gangrenosum |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
