Pediatric Gastrointestinal Bleeding Differential Diagnoses

Author: Wayne Wolfram, MD, MPH; Chief Editor: Marleta Reynolds, MD more...

Updated: Mar 29, 2011

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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

Proceed to Workup

Contributor Information and Disclosures

Author

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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

Disclosure: Nothing to disclose.

Coauthor(s)

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

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: emedicine Royalty Other

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 College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and Southwestern Surgical Congress

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.

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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.

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, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD Professor of Surgery, Northwestern University, The Feinberg School of Medicine; Head, Department of Surgery and Surgeon in Chief, Head, Division of Pediatric Surgery, Children's Memorial Hospital of Chicago

Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Acknowledgments

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

References

Holtz LR, Neill MA, Tarr PI. Acute bloody diarrhea: a medical emergency for patients of all ages. Gastroenterology. May 2009;136(6):1887-98. [Medline].
Kalyoncu D, Urganci N, Cetinkaya F. Etiology of upper gastrointestinal bleeding in young children. Indian J Pediatr. Sep 2009;76(9):899-901. [Medline].
Foutch PG, Sawyer R, Sanowski RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc. Jul-Aug 1990;36(4):337-41. [Medline].
Voderholzer WA, Ortner M, Rogalla P, Beinhölzl J, Lochs H. Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis. Endoscopy. Dec 2003;35(12):1009-14. [Medline].
[Guideline] Lee KK, Anderson MA, Baron TH, Banerjee S, Cash BD, Dominitz JA, et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc. Jan 2008;67(1):1-9. [Medline].
Darbari A, Kalloo AN, Cuffari C. Diagnostic yield, safety, and efficacy of push enteroscopy in pediatrics. Gastrointest Endosc. Aug 2006;64(2):224-8. [Medline].

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

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

View Table List

Read more about Pediatric Gastrointestinal Bleeding on Medscape