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Pediatric Gastrointestinal Bleeding Clinical Presentation

  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Robert K Minkes, MD, PhD  more...
 
Updated: Aug 05, 2015
 

History

A complete history can often identify a presumptive GI bleeding source and direct an efficient workup. For example, NEC in most neonates is diagnosed based on history and clinical presentation.

Ask age- and etiology-specific questions. Ask about acuteness or chronicity of bleeding, color and quantity of the blood in stools or emesis, antecedent symptoms, history of straining, abdominal pain, and trauma.

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. However, massive upper GI bleeding 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.

Intestinal malrotation is suspected with the sudden onset of melena in combination with bilious emesis in a previously healthy, nondistended baby.

For complaints of bloody stool, make sure to elicit a history of foods consumed or drugs used 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).

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 premature infants. Acute bloody diarrhea should be considered a medical emergency.[2]

Recurrent or forceful vomiting is associated with Mallory-Weiss tears.

Familial history or 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.[3]

Ask questions that may reveal underlying, but as 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.

The rest of this section provides an age-specific discussion of patient history.

Neonates

Milk or soy enterocolitis, or allergic colitis, is a cause for vomiting with blood staining after the introduction of these food products into the diet.

Some drugs are implicated in neonatal GI bleeds. These include NSAIDs, heparin, and tolazoline, which are used for persistent fetal circulation.

Indomethacin, which is 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.

Prematurity, neonatal distress, and mechanical ventilation are all associated with stress gastritis.

Lower gastrointestinal tract bleeding in children aged 1 month to 1 year

Episodic abdominal pain that is cramping in nature, vomiting, and currant jelly stools are findings in children with intussusception.

In milk protein allergy, the child displays, in addition to bleeding, such symptoms as fussiness and increased frequency of bowel movements; frank diarrhea is atypical.

Upper gastrointestinal tract bleeding in children aged 1-2 years

NSAID use is one of the factors in the development of peptic ulcer disease in children older than 1 year. However, most of the ulcers occurring in children aged 1-2 years are secondary to systemic diseases, such as burns (Curling ulcer), head trauma (Cushing ulcer), malignancy, or sepsis.

Lower gastrointestinal tract bleeding in children aged 1-2 years

Children with polyps are found to have painless bleeding per rectum, which often streaks the stool with fresh blood.

Lower gastrointestinal tract bleeding in children older than age 2 years

Bleeding is less common in individuals with Crohn disease than in those with ulcerative colitis, but persons with either disease may have bloody diarrhea as part of the clinical scenario. These children generally have the diagnosis of IBD well established before acute or chronic bleeding necessitates intervention.

Infectious diarrhea is suspected when lower GI bleeding occurs in association with profuse diarrhea. Recent antibiotic use raises suspicion for antibiotic-associated colitis and Clostridium difficile colitis.

Next

Physical Examination

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 IBD, Henoch-Schönlein purpura, and Peutz-Jeghers polyposis.

Anoscopy can be performed (if required in an infant) by gently placing a lubricated red-top or purple-top test tube into the anus to enable visualization of the inner anal anatomy.

Lower gastrointestinal tract bleeding in children aged 1 month to 1 year

Diagnosis of anal fissures is made by anal examination, sometimes performed with a nasal speculum. Further tests are unnecessary. (In older children, as in adults, refractory anal fissures or those located off the midline should raise suspicion for IBD, specifically Crohn disease.)

Symptoms of intussusception include a palpable, sausage-shaped mass.

Children with a gangrenous bowel present with evidence of bowel obstruction, abdominal distension, dehydration, and peritonitis.

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Contributor Information and Disclosures
Author

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Medical Director and Chief of Surgical Services, Children's Medical Center of Dallas-Legacy Campus

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Lisa P Abramson, MD Fellow, Department of Pediatric Surgery, Children's Memorial Hospital of Chicago

Lisa P Abramson, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Surgeons

Disclosure: Nothing to disclose.

Robert M Arensman, MD Consulting Staff, Section of Pediatric Surgery, University of Illinois at Chicago College of Medicine

Robert M Arensman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, and Southern Medical Association

Disclosure: Nothing to disclose.

Denis Bensard, MD Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery, Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University of Colorado School of Medicine

Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of University Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

Gail E Besner, MD John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research, Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine

Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, American Surgical Association, Association for Academic Surgery, Federation of AmericanSocieties for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons

Disclosure: Nothing to disclose.

John Halpern, DO, FACEP Clinical Assistant Professor, Department of Family Medicine, Nova Southeastern University College of Osteopathic Medicine; Medical Director, Health Career Institute; Medical Director Emergency Department, Palms West Hospital

John Halpern, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Renee Y Hsia, MD, MSc Clinical Instructor, Division of Emergency Medicine, University of California at San Francisco; Attending Physician, Department of Emergency Medicine, San Francisco General Hospital

Renee Y Hsia, MD, MSc is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, American Heart Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Oscar Loret de Mola, MD, FAAP Director, Division of Pediatric Gastroenterology, Miami Children's Hospital

Oscar Loret de Mola, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, and American Medical Association

Disclosure: Nothing to disclose.

Debra Slapper, MD Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Daniel J Stephens, MD Resident Physician, Department of Surgery, University of Minnesota Medical School

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Pant C, Sankararaman S, Deshpande A, Olyaee M, Anderson MP, Sferra TJ. Gastrointestinal bleeding in hospitalized children in the United States. Curr Med Res Opin. 2014 Jun. 30(6):1065-9. [Medline].

  2. Holtz LR, Neill MA, Tarr PI. Acute bloody diarrhea: a medical emergency for patients of all ages. Gastroenterology. 2009 May. 136(6):1887-98. [Medline].

  3. Kalyoncu D, Urganci N, Cetinkaya F. Etiology of upper gastrointestinal bleeding in young children. Indian J Pediatr. 2009 Sep. 76(9):899-901. [Medline].

  4. Foutch PG, Sawyer R, Sanowski RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc. 1990 Jul-Aug. 36(4):337-41. [Medline].

  5. Voderholzer WA, Ortner M, Rogalla P, Beinhölzl J, Lochs H. Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis. Endoscopy. 2003 Dec. 35(12):1009-14. [Medline].

  6. [Guideline] Lee KK, Anderson MA, Baron TH, Banerjee S, Cash BD, Dominitz JA, et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc. 2008 Jan. 67(1):1-9. [Medline].

  7. Darbari A, Kalloo AN, Cuffari C. Diagnostic yield, safety, and efficacy of push enteroscopy in pediatrics. Gastrointest Endosc. 2006 Aug. 64(2):224-8. [Medline].

  8. Owensby S, Taylor K, Wilkins T. Diagnosis and management of upper gastrointestinal bleeding in children. J Am Board Fam Med. 2015 Jan-Feb. 28 (1):134-45. [Medline].

  9. Reveiz L, Guerrero-Lozano R, Camacho A, Yara L, Mosquera PA. Stress ulcer, gastritis, and gastrointestinal bleeding prophylaxis in critically ill pediatric patients: a systematic review. Pediatr Crit Care Med. 2010 Jan. 11(1):124-32. [Medline].

  10. Lazzaroni M, Petrillo M, Tornaghi R, et al. Upper GI bleeding in healthy full-term infants: a case-control study. Am J Gastroenterol. 2002 Jan. 97(1):89-94. [Medline].

  11. Vinton NE. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 1994 Mar. 23(1):93-122. [Medline].

 
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Intraoperative view of a bleeding juvenile polyp.
Radioactive tracer in stomach, bladder, and the Meckel diverticulum in a 5-year-boy brought in for lower gastrointestinal bleeding.
Intraoperative view of the bleeding Meckel diverticulum. Note the ulceration at the base.
Table. Common Sources of Gastrointestinal Bleeding in Pediatrics
Age Group Upper Gastrointestinal Bleeding Lower Gastrointestinal Bleeding
Neonates Hemorrhagic disease of the newborn



Swallowed maternal blood



Stress gastritis



Coagulopathy



Anal fissure



Necrotizing enterocolitis



Malrotation with volvulus



Infants aged 1 month to 1 year Esophagitis



Gastritis



Anal fissure



Intussusception



Gangrenous bowel



Milk protein allergy



Infants aged 1-2 years Peptic ulcer disease



Gastritis



Polyps



Meckel diverticulum



Children older than 2 years Esophageal varices



Gastric varices



Polyps



Inflammatory bowel disease



Infectious diarrhea



Vascular lesions



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