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Pediatric Gastrointestinal Bleeding Differential Diagnoses

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

Diagnostic Considerations

Aside from the disorders listed in the Differentials section, below, other conditions to consider in pediatric patients with symptoms of GI bleeding include the following:

  • NEC
  • Portal hypertension (variceal bleeding)
  • Caustic ingestions
  • Salmonella Infection
  • Sexual Assault
  • Epistaxis

Apt-Downey test

Maternal blood ingestion is the most common cause of suspected GI bleeding. Blood can be swallowed during delivery or while an infant is breastfeeding (from a fissure in the mother's breast).

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 hemoglobin level >50% points to a source in the child rather than maternal) can be performed with a spectrophotometric assay.

Differential Diagnoses

 
 
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
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  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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