INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Pediatric gastrointestinal (GI) bleeding is a fairly common, anxiety-provoking chief complaint. Most etiologies are self-limited and benign, but it is crucial not to miss conditions that may lead to severe consequences if undiagnosed.

Frequency

United States

The incidence of severe GI bleeds is rare entity in the general pediatric population and is therefore not well documented. In the pediatric ICU population, a tiny fraction of the general pediatric population, 6-20%, has upper GI bleeds. The incidence of lower GI bleeding has not been well established. In one report, rectal bleeding alone accounted for 0.3% of the chief complaints in more than 40,000 patients presenting to a major urban emergency department.

Age

Age-specific variances occur and often help to determine the diagnostic workup and management (see Causes).

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

A complete history often can identify a presumptive bleeding source and direct an efficient workup.

• Ask both age- and etiology-specific questions.
• • Ask about acuteness or chronicity of bleeding, color and quantity of the blood in stool or emesis, antecedent symptoms, history of straining, abdominal pain, or trauma.
  • Anorectal disorders, fissures, and distal polyps produce bright red blood.
  • Melena rather than bright red blood per rectum is usually a sign of bleeding that comes from a source proximal to the ligament of Treitz.
  • Massive upper GI bleeding, however, can produce bright red blood per rectum if GI transit time is rapid.
  • Blood mixed in stool or dark red blood implies a proximal source with some degree of digestion of the blood.
  • A history of vomiting, diarrhea, fever, ill contacts, or travel suggests an infectious etiology.
  • Bloody diarrhea and signs of obstruction suggest volvulus, intussusception, or necrotizing enterocolitis, particularly in the ex-premature infant.
  • Recurrent or forceful vomiting is associated with Mallory-Weiss tears.
  • Familial history or nonsteroidal anti-inflammatory drug (NSAID) use may suggest ulcer disease. Ingested substances, such as NSAIDs, tetracyclines, steroids, caustics, and foreign bodies, can irritate the gastric mucosa enough to cause blood to be mixed with the vomitus.
• Ask questions that may reveal underlying but yet undiagnosed organ dysfunction.
• • Recent jaundice, easy bruising, and changes in stool color may signal liver disease.
  • Other evidence of coagulation abnormalities elicited from the history may also point to disorders of the kidney or reticuloendothelial system.
• For complaints of bloody stool, make sure to elicit on history foods or drugs that may give a stool bloody appearance. This list includes certain antibiotics, iron supplements, red licorice, chocolate, Kool-Aid, flavored gelatin, or bismuth-containing products (eg, Pepto-Bismol).

Physical

• Look for signs of shock, and document findings such as heart rate, blood pressure, capillary refill, and orthostatic changes.
• During examination of the head, ears, eyes, nose, and throat, look for causes such as epistaxis, nasal polyps, and oropharyngeal erosions from caustics and other ingestions.
• Examine abdominal surgical scars and elicit the reason for the surgery.
• Specifically include bowel sound frequency in the abdominal examination. Hyperactive bowel sounds are more common in upper GI bleeding.
• Abdominal tenderness, with or without a mass, raises the suspicion of intussusception or ischemia.
• Hepatomegaly, splenomegaly, jaundice, or caput medusa suggests liver disease and subsequent portal hypertension.
• Inspection of the perianal area may reveal fissures, fistulas, skin breakdown, or evidence of trauma.
• • Gentle digital rectal examination may reveal polyps, masses, or occult blood.
  • Looking for evidence of child abuse, such as perianal tearing, tags, or irregularities in anal tone and contour, is also important.
• Examination of the skin may reveal evidence of systemic disorders, such as inflammatory bowel disease, Henoch-Schönlein purpura, and Peutz-Jeghers polyposis.
• Anoscopy can be performed (if required in an infant) by gently placing a lubricated redtop or purple-top test tube into the anus to enable visualization of the inner anal anatomy.

Causes

• Neonates
• • Most common causes of apparent neonatal GI bleeds include bacterial enteritis, milk protein allergies, intussusception, swallowed maternal blood, anal fissures, and lymphonodular hyperplasia.
  • • Maternal blood ingestion is the most common cause of suspected GI bleeding. Blood is swallowed during delivery or while breastfeeding (from a fissure in the mother's breast).
    • Milk or soy enterocolitis, or allergic colitis, is also a cause for vomiting with blood staining after the introduction of these food products into the diet.
  • Erosions of the esophageal, gastric, and duodenal mucosa are also a frequent cause for true neonatal GI bleeding.
  • • Presumably, this damage is caused by the dramatic increase in gastric acid secretion and laxity of gastric sphincters in infants.
    • Maternal stress in the third trimester has also been proposed to increase maternal gastrin secretion and enhance infantile peptic ulcer formation.
    • Neonatal peptic ulcer disease has not been associated with mode of feeding or hyperalimentation.
  • Some drugs are implicated in neonatal GI bleeds.
  • • These include NSAIDs, heparin, and tolazoline, which are used for persistent fetal circulation.
    • Indomethacin, used for patent ductus arteriosus in neonates, may cause GI bleeding through intestinal vasoconstriction and platelet dysfunction.
    • Maternal medications can cross the placenta and cause problems in the developing fetus and neonate on delivery. Aspirin, cephalothin, and phenobarbital are well-known causes of coagulation abnormalities in neonates.
    • Stress ulcers in newborns are associated with dexamethasone, which can be used for fetal lung maturation. Whether any association exists with betamethasone is unknown at the time of release.
  • Rarer causes of GI bleeding in a neonate include volvulus, coagulopathies, arteriovenous malformations, necrotizing enterocolitis (especially in pre-term infants), Hirschsprung enterocolitis, and Meckel diverticulitis.
• Infants
• • GI mucosal lesions and irritations are the most common causes of GI bleeding in infants and children. This category includes esophagitis, gastritis, duodenitis, ulcers, colonic polyps, and anorectal disorders.
  • Intussusception is a frequent and important etiology of GI bleeding in this age group. The incidence of intussusception is greatest in infants aged 3 months to 1 year, but can happen at up to 5 years of age as well. About 80% of all cases of intussusception occur in infants younger than 2 years.
  • Other causes include infectious diarrhea, midgut volvulus, Meckel diverticulum, arteriovenous malformation, and GI duplication.
  • Rare causes include foreign body ingestions, variceal disease, irritable bowel disease, and acquired thrombocytopenia.
• Children
• • Patients may present with any of the above conditions.
  • Duodenal ulcer, Mallory-Weiss tear, and nasopharyngeal bleeding are important causes of bleeding in older children.
  • Juvenile polyps also occur frequently in children of the age group between 2 and 8 years old (with a peak from 3-4 years) causing painless rectal bleeding usually from polyps in the rectosigmoid region.
  • Less common causes include gastritis or ulcers induced by salicylates or NSAIDs, Henoch-Schönlein purpura, caustic ingestions, hemolytic uremic syndrome, inflammatory bowel disease, and vasculitis.
  • Helicobacter pylori has been associated with peptic ulcer disease in children. However, H pylori infection is common and usually asymptomatic.
• Adolescents
• • The most common causes of upper GI bleeding in children older than 12 years are duodenal ulcers, esophagitis, gastritis, and Mallory-Weiss tears.
  • Lower GI bleeding most likely is caused by inflammatory bowel disease, colonic polyps, hemorrhoids, anal fissures, or infectious diarrhea.
• Other causes
• • Gastroesophageal reflux disease (GERD) can be caused by transient lowered esophageal sphincter tone, delayed or defective gastric emptying, increased abdominal pressure, or increased production of pepsin or acid.
  • Stress ulcers can be caused by chronic systemic disease, shock, respiratory failure, sepsis, hypoglycemia, burn (Curling ulcer), or increased intracranial pressure (Cushing ulcers).
  • Sexual trauma can also be a cause of anorectal bleeding.
• Infectious causes
• • Infectious causes account for numerous GI bleeds.
  • Hepatitis B and C can cause cirrhosis, leading to portal hypertension with subsequent esophageal and gastric varices.
  • Microbes (eg, Rotavirus, Salmonella species, Shigella species, Yersinia enterocolitica, Campylobacter jejuni, enteroinvasive Escherichia coli, enterohemorrhagic E coli, Clostridium difficile, Entamoeba histolytica, Aeromonas hydrophila) can cause bloody diarrhea.
  • Other pathogens known to occasionally cause bloody stools include Neisseria gonorrhoeae, Chlamydiae trachomatis, and herpes simplex virus.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Maternal blood ingestion
Necrotizing enterocolitis
Portal hypertension (variceal bleeding)
Caustic ingestions

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• In general, trace or small amounts of blood that are a one- or first-time occurrence are not of emergent concern. Most common causes of GI bleeding in neonates and children are benign and self-limiting. Children rarely require an extensive laboratory workup or invasive procedures, and parents can be advised to observe the child at home to see if these situations arise again.
• If a neonate is actively spitting up or vomiting blood, or if it is significant enough to require placement of a nasogastric tube, one can use the Apt-Downey test to differentiate between maternal and fetal blood.
• • The blood is placed in a test tube; sterile water is added to hemolyze the RBCs, yielding free hemoglobin.
  • This solution then is mixed with 1% sodium hydroxide. If the solution turns yellow-brown, the hemoglobin is maternal or adult hemoglobin, which is less stable than fetal hemoglobin.
  • If the solution remains the same color, it is the more stable fetal hemoglobin; therefore, the newborn is the source of the bleeding.
  • If the sample is taken from stool that has been exposed to air longer than 30 minutes, even fetal hemoglobin has the yellow-brown color change of adult hemoglobin. In this situation, the quantification of hemoglobin (fetal Hb > 50% points to a source in the child rather than maternal) can be performed with a spectrophotometric assay.
• In all children, presence of blood can be confirmed by use of peroxide-based tests such as the Hemoccult or Hematest for lower GI bleeding and Gastroccult for upper GI bleeding.
• • Certain ingestions such as red meat, iron, and peroxidase-containing vegetables (eg, turnips, horseradish, broccoli, cauliflower, and cantaloupe) can give false-positive results.
• Patients with substantial upper or lower GI bleeding, as determined from their history or examination, should receive a complete blood count, coagulation studies, and a chemistry panel.
• • The CBC reveals anemia and thrombocytopenia.
  • A normal hematocrit may provide false reassurance in some children who with hypovolemia and hemoconcentration.
  • Leukocytosis with increased bands may indicate an infectious etiology or complication responsible for the bleeding.
  • Elevated abnormal prothrombin time indicates coagulopathy (ie, disseminated intravascular coagulation) or profound impairment of liver synthetic function.
  • A prolonged activated partial thromboplastin time indicates a hemophiliac patient or coagulopathy.
  • A chemistry panel may reveal a high BUN level, pointing more to an upper GI source that has had time to allow the body to reabsorb blood leading to a higher BUN level compared with a lower GI source.
• For children who have tenderness in the right upper quadrant or a history suggestive of liver disease, aspartate aminotransferase and alanine aminotransferase enzymes may indicate hepatitis and increased risk of portal hypertension.
• The history should also be used as a guide for when to order fecal leukocytes, parasites, or cultures, when an infectious etiology is suspected.

Imaging Studies

• In general, imaging studies are not helpful in cases of acute bleeding.
• Patients with suspected obstruction should undergo plain abdominal radiography. Abdominal radiography may also be helpful in those neonates in whom necrotizing enterocolitis is a possibility; the images may show free air, pneumatosis intestinalis (bubbles in the bowel wall), or portal air.
• Imaging for nonemergency pediatric GI bleeding may begin with barium contrast studies (barium swallows, upper GI series, small bowel follow-throughs, or barium enemas) to point to foreign bodies, esophagitis, inflammatory bowel disease, or polyps. For neonates with malrotation with midgut volvulus, it may show a corkscrew of small bowel or a bird's beak if complete obstruction is present.
• For suspected intussusception, color Doppler ultrasonography can be used. Its sensitivity is 98-100% sensitivity, and its specificity is 89-100%, but these rates are operator dependent.
• Enema studies are successful in most cases.
• • Barium enema studies have traditionally been used with success rates of 50-90%. Rates improve when symptoms are present for less than 24 hours. Barium study is contraindicated if perforation is suspected.
  • Air and water-soluble contrast enemas have also been used with similar success rates, with air enemas requiring less radiographic exposure but having slightly higher perforation rates (0.14-2.8% vs for barium enema) and enemas with water-soluble (or saline) contrast agent requiring experienced sonographers.
• A Meckel scan uses technetium-99m pertechnetate to highlight the ectopic gastric mucosa.
• Arteriography is used to localize lesions when endoscopy has fails or when the patient cannot cooperate, and it can be helpful for bleeding that is distal to the ligament of Treitz.

Procedures

• Children whose history and physical findings suggest significant bleeding from an upper GI source receive a nasogastric tube for diagnostic purposes.
• • Return of coffee-ground-like material or Gastroccult-positive material confirms an upper GI bleed.
  • Still, the false-negative rate is 16% if duodenopyloric regurgitation is absent; therefore, a clear nasogastric aspirate alone cannot be used to rule out of a GI bleed.
• Endoscopy reveals the source in 90% of patients with upper GI bleeding, and endoscopy is beneficial in predicting the likelihood of continued bleeding.
• • Patients with severe upper GI bleeding should receive endoscopy within the first 12 hours of the hemorrhagic episode if they are sufficiently stable because early endoscopy improves the diagnostic index.
  • The site of upper GI bleeding can be identified in 90% of cases when endoscopy is performed within 24 hours.
  • The Forress classification divides endoscopic findings into 3 categories
  • • I - Active hemorrhage (Ia = bright red bleeding, Ib = slow bleeding)
    • II - Recent hemorrhage (IIa, = nonbleeding visible vessel, IIb = adherent clot on base of lesion, IIc = flat pigmented spot)
    • III - No evidence of bleeding.
  • The incidence of rebleeding decreases dramatically because less evidence of ulceration or bleeding is seen.
• Newer tests
• • Push enteroscopy in some studies has been shown to have a higher diagnostic yield than standard esophagogastroduodenoscopy (EGD). Essentially, this is a long endoscope that is placed through the mouth into the jejunum and can reach about 160 cm beyond the ligament of Treitz. One study has shown that push enteroscopy identified a large number of mucosal lesions that could not be identified by a standard endoscope.¹
  • Double-balloon enteroscopy is another new technology that has shown high therapeutic and diagnostic yield. This is a high-resolution video endoscope with latex balloons attached at the tip, with an overtube that can be inflated and deflated. It can be inserted either orally or anally.
  • Wireless capsule endoscopy is also under investigation for children, although it can only be used diagnostically and not therapeutically.
• For lower GI bleeds, colonoscopy can reveal the source of bleeding more effectively than barium enema, and it has 80% sensitivity.
• • Colonoscopy should be performed only when the patient is stable and when blood and feces will not conceal proper visualization.
  • Sigmoidoscopy alone has also been used in children who have had symptoms of chronic lower GI bleeding for 1 year or longer; the study reveals the most common etiologies, such as juvenile colorectal polyps and nonspecific proctitis.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Emergency Department Care

• Provide hydration and volume support.
• Transfusion may be required.
• If an acute bleed is suspected and there is hemodynamic instability, access with 2 large-bore IV catheters must be obtained.

Consultations

Direct consultation toward the discipline appropriate to the diagnosis (eg, a radiologist for a barium enema study in intussusception, a pediatric ICU specialist and a pediatric surgeon for necrotizing enterocolitis, a gastroenterologist for presumed ulcer disease).

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Histamine-2 blockers or proton-pump inhibitors are used to inhibit gastric acid production in peptic ulcer disease, GERD, and duodenal ulcer disease. Alkaline suspensions are used to directly neutralize gastric acid secretions. Bleeding from esophageal varices may be prevented with vasoconstrictors, such as octreotide. Those with the etiology of infectious diarrhea should not be given antimotility agents, though some may benefit from antibiotics.

Somatostatin is not currently available in the United States for pediatric use. It is a hormone produced by the body that inhibits adenylate cyclase and therefore the production of cyclic AMP. Although it decreases pituitary secretion of growth hormone and thyrotropin, it also has physiologic effects of inhibiting secretion of serotonin, gastrin, vasoactive intestinal peptide (VIP), and many other hormones (eg, insulin, glucagon). It decreases intestinal motility and gastric emptying, but it is not recommended for use. Octreotide, a somatostatin analog, has been more widely adopted for the indication of variceal bleeding as secondary prophylaxis and, in some, primary prophylaxis.

Drug Category: Acid suppressive therapies

H2 blockers are reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells where they inhibit acid secretion. The H2 antagonists are highly selective, they do not affect the H1 receptors, and they are not anticholinergic agents. Some gastroenterologists recommend proton-pump inhibitors as being more effective than H2 blockers in promoting lesion cicatrization for hemorrhagic esophagitis and gastroesophageal reflux. Studies with omeprazole (Prilosec) and pantoprazole (Protonix) in IV forms have been encouraging, but they are not yet approved by the US Food and Drug Administration for use in children.

Drug Category: Antacid-alkaline suspension

This agent is used to neutralize gastric acidity.

Drug Category: Hormones/ hormone analogs

For bleeding from esophageal varices, pharmacologic treatment to reduce portal pressure is important. Although propranolol has been studied for both primary and secondary prophylaxis of esophageal varices and though it is helpful for adults, studies in children are limited. Therefore, these drugs are not currently considered the standard of care for this population. In addition, vasopressin had been used as a splanchnic vasoconstrictor, but its many adverse effects (eg, bowel-wall or cutaneous ischemia, hypertension, abdominal pain) have made it less desirable than other options, even when tempered with the vasodilatory effects of nitroglycerin. As a result, octreotide has emerged as the recommended treatment, especially in conjunction with sclerotherapy for patients with variceal bleeding because it blunts the sudden increases in pressure due to postprandial hyperemia.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Patients with severe GI bleeds should be admitted to the pediatric ICU.
• For variceal bleeds, GI consultants may endoscopically control active hemorrhage with sclerotherapy, use of elastic ligature (for esophageal varices or for hemorrhoids), or (in rare cases) a transjugular intrahepatic portosystemic shunt (TIPS).
• • Failure to control bleeding may require the placement of a Sengstaken-Blakemore balloon for temporary tamponade if endoscopic treatment fails or is not possible at the time due to the massive bleeding.
  • Other modalities of treatment for severe esophageal varices are being considered but not yet commonly used; these include fibrin sealants or tissue glues such as cyanoacrylate, as well as electrocoagulation with argon plasma coagulation.
• Significant GI bleeding that cannot be controlled (eg, that due to duodenal ulcers or varices in the proximal GI tract, vascular malformations, nonreducible points of intussusception) by using the previously mentioned techniques may require surgical intervention, such as laparoscopy.

Further Outpatient Care

• Patients with first-time occurrences of nonsignificant amounts of bleeding who are discharged should be followed by their primary care pediatrician for further episodes. Again, most of these cases are benign and self-limiting.

Transfer

• Children who present with upper or lower GI hemorrhage to hospitals without a pediatric ICU should be transferred to such a facility when sufficiently stable.

Complications

• Shock
• Disseminated intravascular coagulation
• Azotemia

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastrointestinal Bleeding, Abdominal Pain in Children, Vomiting and Nausea, and Rectal Bleeding.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• As with any ED visit, failure to identify life-threatening causes of GI bleeding in pediatric patients carries a high medicolegal risk.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, N Ewen Wang, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Mar 26, 2008