There is a broad clinical spectrum of gastrointestinal bleeding in children, ranging from subtle laboratory findings to dramatic clinical presentations. This review provides a framework for the evaluation and management of gastrointestinal hemorrhage for pediatricians. It outlines strategies for obtaining a tailored patient history and conducting a thorough physical examination that can shed light on the location, severity, and likely etiology of bleeding. It appraises blood tests, radiologic tools, and endoscopic modalities frequently used to identify and control a source of bleeding.
Key points
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There is a broad clinical spectrum of gastrointestinal hemorrhage.
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Obtaining an accurate history and conducting a thorough physical examination can provide important clues about the location, severity, and likely etiology of gastrointestinal bleeding.
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There are blood tests, radiologic tools, and endoscopic methods to identify a bleeding source.
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Early consultation with a gastroenterologist is recommended, as endoscopy is often required for evaluation and may be needed to control hemorrhage.
Introduction
The presentation of gastrointestinal bleeding in children can vary from subtle findings of pallor and iron-deficiency anemia to obvious episodes of vomiting frank blood. Children present with this chief complaint in a variety of clinical settings, but there is a paucity of literature capturing the epidemiology of pediatric gastrointestinal hemorrhage. Gastrointestinal bleeding can manifest in several ways. Hematemesis is the expulsion of bright red or “coffee-ground” colored material from the mouth. This usually indicates bleeding proximal to the Ligament of Treitz, as fresh red blood exposed to an acidic environment turns brown. Melena typically correlates with an esophageal, gastric, or proximal small intestinal bleeding source and leads to passage of black, tarry stool per rectum. This appearance can be attributed to oxidization by intestinal bacteria that convert hemoglobin to hematin. In contrast, hematochezia is bright red or maroon-colored material that passes from the rectum. Although hematochezia most often occurs with lower small intestinal or colonic bleeding sources, a brisk upper gastrointestinal bleed may present as bright red blood per rectum, with blood in the intestinal lumen acting as a cathartic agent and accelerating transit. Obscure gastrointestinal bleeding is blood loss that is not identified by upper endoscopy, colonoscopy, and radiologic evaluation of the small intestine. It can be further classified into obscure overt and obscure occult bleeding, based on extent of clinically obvious bleeding. There are many exhaustive reviews of etiologies of pediatric gastrointestinal bleeding. Our goal is to provide a framework for evaluation of patients with gastrointestinal bleeding and to review management principles.
Introduction
The presentation of gastrointestinal bleeding in children can vary from subtle findings of pallor and iron-deficiency anemia to obvious episodes of vomiting frank blood. Children present with this chief complaint in a variety of clinical settings, but there is a paucity of literature capturing the epidemiology of pediatric gastrointestinal hemorrhage. Gastrointestinal bleeding can manifest in several ways. Hematemesis is the expulsion of bright red or “coffee-ground” colored material from the mouth. This usually indicates bleeding proximal to the Ligament of Treitz, as fresh red blood exposed to an acidic environment turns brown. Melena typically correlates with an esophageal, gastric, or proximal small intestinal bleeding source and leads to passage of black, tarry stool per rectum. This appearance can be attributed to oxidization by intestinal bacteria that convert hemoglobin to hematin. In contrast, hematochezia is bright red or maroon-colored material that passes from the rectum. Although hematochezia most often occurs with lower small intestinal or colonic bleeding sources, a brisk upper gastrointestinal bleed may present as bright red blood per rectum, with blood in the intestinal lumen acting as a cathartic agent and accelerating transit. Obscure gastrointestinal bleeding is blood loss that is not identified by upper endoscopy, colonoscopy, and radiologic evaluation of the small intestine. It can be further classified into obscure overt and obscure occult bleeding, based on extent of clinically obvious bleeding. There are many exhaustive reviews of etiologies of pediatric gastrointestinal bleeding. Our goal is to provide a framework for evaluation of patients with gastrointestinal bleeding and to review management principles.
Discussion
Historical Report
A careful history may shed light on the source of bleeding and rate of blood loss. It is important to inquire about the color, quantity, and location of bleeding. The temporal association of the bleeding episode to other signs and symptoms, including abdominal pain, vomiting, and fevers should be characterized. Eliciting this history in an emergency scenario with distraught patients or unwitnessed events can be challenging. For instance, hemoptysis can be mistaken for hematemesis. However, unveiling key historical details may provide critical clues to localize the bleeding source. A history of recent tonsillectomy, dental procedure, epistaxis, or nasogastric tube placement may indicate nasopharyngeal or oropharyngeal bleeding. An underlying anxiety disorder may be accompanied by chronic cheek chewing (morsicatio buccarum) with bleeding from the mouth or vomiting swallowed blood. Ingestion of a button battery or sharp foreign body may cause mucosal tears, ulcerations, or even life-threatening aortoenteric fistulae. Discovery of prior intestinal operation could heighten concern for a bleeding ulcer from a surgical anastomosis ( Fig. 1 ). A thorough medication history may reveal use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) that could increase bleeding risk. Many substances can give the false appearance of red blood (beets, food coloring, gelatin, candy ) or black, tarry stool (iron supplements, bismuth). Cefdinir, a third-generation cephalosporin, has been reported to cause maroon or red discoloration to stool in pediatric patients due to formation of a precipitate with iron-containing supplements. Additional historical clues and corresponding etiologic sources in children and adolescents are summarized in Table 1 .
| Site of Suspected Bleed | Historical Clues and Physical Examination Findings ( Potential Etiology in Italics ) |
|---|---|
| No gastrointestinal bleeding source |
|
| Esophageal mucosal injury |
|
| Esophageal/gastric variceal disease or portal gastropathy |
|
| Gastric or duodenal mucosal injury |
|
| Iatrogenic causes |
|
| Vascular issue |
|
| Polyps and tumors |
|
| Infectious and inflammatory conditions |
|
| Intestinal ischemia |
|
| Mucosal injury in immunosuppressed state |
|
| Anorectal bleeding source |
|
Special Considerations in Neonates and Infants
There are unique etiologies of gastrointestinal bleeding in neonates and infants younger than 12 months. Common causes of gastrointestinal bleeding in an otherwise healthy infant are anal fissures and swallowed maternal blood (from delivery or from fissured nipples). To distinguish between fetal and maternal origin of blood, the Apt-Downey test can be applied, which capitalizes on the different denaturing properties of fetal and maternal hemoglobin in the presence of sodium hydroxide. Occult gastrointestinal bleeding, hematochezia, or hematemesis may be presenting signs of cow’s milk protein allergy in an infant. Gastrointestinal bleeding can be a presenting symptom of an underlying coagulopathy. Vitamin K deficiency bleeding should be considered in neonates, particularly those with maternal exposure to antiepileptic medications that affect vitamin K, dysbiosis from antibiotic exposure, cholestasis, short bowel syndrome, or failure to receive perinatal vitamin K prophylaxis (eg, home delivery). Clinically unstable, premature, or very low birth weight infants should be evaluated for necrotizing enterocolitis. Bilious emesis warrants consideration of intestinal malrotation, as midgut volvulus can progress quickly to intestinal ischemia, sepsis, and death. Hematochezia is a late clinical sign in many surgical emergencies, from volvulus to intussusception, and can herald compromise of vascular supply.
Clinical Assessment
The clinician’s physical examination serves to stratify the patient’s illness severity and localize the source of bleeding. It is important to identify a patient who is ill-appearing, in pain, or has an altered sensorium. Assessment of the vital signs is an important early step. Children are known to have increased physiologic reserve compared with elderly patients and may maintain normal vital signs after an acute blood loss. Studies in pediatric trauma patients have demonstrated that hypotension may not be present until up to 25% of the circulating blood volume (80 mL/kg in children) has been compromised. Therefore, heart rate, capillary refill, and pulse pressure may be more sensitive markers of hemodynamic instability than blood pressure soon after an acute blood loss. Careful consideration of the patient’s other comorbidities prevents clinicians from being falsely reassured by normal vital signs. For instance, tachycardia may not be a reliable marker of hemodynamic decompensation in a patient on beta-blocker therapy.
The head and neck examination should screen for scleral icterus, conjunctival pallor, dental trauma, active bleeding in the oral cavity, epistaxis, or abnormal pigmentation of lips or buccal mucosa. The abdominal examination should evaluate for distension, tenderness to palpation, enlarged liver or spleen, and other stigmata of chronic liver disease (eg, ascites, prominent abdominal veins). A rectal examination may reveal perianal skin tags suspicious for Crohn disease, a palpable polyp in the rectal vault, fissures, hemorrhoids, or an anorectal vascular anomaly ( Fig. 2 ). There also may be subtle clues to the chronicity of an illness. In addition to jaundice, bruising, and rashes, skin findings such as telangiectasias, blue nodules, hemangiomas, or pigmented macules (lentigines) could also raise suspicion for multisystem vascular disorders such as hereditary hemorrhagic telangiectasia, blue rubber bleb nevus syndrome, and cutaneovisceral angiomatosis with thrombocytopenia, or polyposis disorders, such as Peutz-Jeghers syndrome and juvenile polyposis syndrome ( Fig. 3 ).
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