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Pediatric Gastrointestinal Bleeding

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

Background

Gastrointestinal (GI) bleeding in infants and children is a fairly common problem, accounting for 10%-20% of referrals to pediatric gastroenterologists. However, it is usually limited in volume, allowing time for diagnosis and treatment.

The initial approach to all patients with significant GI bleeding is to ensure patient stability, to establish adequate oxygen delivery, to place intravenous access, to initiate fluid and blood resuscitation, and to correct any underlying coagulopathies.

A juvenile polyp, one of the causes of GI bleeding, is seen in the image below.

Go to Upper Gastrointestinal Bleeding for complete information on this topic.

Intraoperative view of a bleeding juvenile polyp. Intraoperative view of a bleeding juvenile polyp.
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Etiology

Age-specific etiologies for GI bleeding are discussed below for the following groups:

  • Neonates
  • Children aged 1 month to 1 year
  • Children aged 1-2 years
  • Children older than 2 years

Neonates

Anal fissures are the most common cause of GI bleeding in infants. They produce bright red blood that streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline.

Most common causes of apparent neonatal GI bleeds include bacterial enteritis, milk protein allergies, intussusception, swallowed maternal blood, and lymphonodular hyperplasia. 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.

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 the laxity of gastric sphincters in infants.

Maternal stress in the third trimester has 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 in the neonate on delivery. Aspirin, cephalothin, and phenobarbital are well-known causes of coagulation abnormalities in neonates.

Stress gastritis occurs in up to 20% of patients cared for in neonatal intensive care units (ICUs). Prematurity, neonatal distress, and mechanical ventilation are all associated with stress gastritis.

Stress ulcers in newborns are associated with dexamethasone, which can be used for fetal lung maturation.

Rarer causes of GI bleeding in a neonate include volvulus, coagulopathies, arteriovenous malformations, necrotizing enterocolitis (NEC; especially in preterm infants), Hirschsprung enterocolitis, and Meckel diverticulitis.

Hemorrhagic disease of the newborn is a self-limited bleeding disorder resulting from a deficiency in vitamin K–dependent coagulation factors. levels of clotting factors II, VII, IX, and X decline rapidly after birth, reaching their nadir at 48-72 hours of life. In 0.25%-0.5% of neonates, severe hemorrhage may result.

Upper gastrointestinal bleeding in children aged 1 month to 1 year

Peptic esophagitis caused by gastroesophageal reflux (GER) is the most common cause of bleeding in this age group.

Gastritis is primary or secondary in etiology. Primary gastritis is associated with Helicobacter pylori infection and is the most common cause of gastritis in children. Other causes of primary gastritis include steroidal and nonsteroidal anti-inflammatory drug (NSAID) use, Zollinger-Ellison syndrome, and Crohn disease.

Secondary gastritis occurs in association with severe systemic illnesses that result in mucosal ischemia and produce diffuse erosive and hemorrhagic gastric mucosa.

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

Anal fissures produce bright red blood that streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline. (In older children, as in adults, refractory anal fissures or those located off the midline should raise suspicion for inflammatory bowel disease [IBD], specifically Crohn disease.)

Intussusception is the most likely cause of lower GI bleeding in infants aged 6-18 months.

Gangrenous bowel is another common cause of lower GI bleeding. Causes include malrotation with volvulus, omphalomesenteric remnant with volvulus, internal hernia with strangulation, segmental small-bowel volvulus, and, rarely, sigmoid volvulus.

Milk protein allergy causes a colitis that may be associated with occult or gross lower GI bleeding. It is the most common allergy observed in infancy and is caused by an adverse immune reaction to cow's milk.

Upper gastrointestinal tract bleeding in children aged 1-2 years

In children older than 1 year, peptic ulcer disease is the most common cause of hematemesis. The etiologies, which include NSAID use, are similar to those mentioned in the above discussion of gastritis.

When an ulcer not associated with H pylori infection is diagnosed, a fasting plasma gastrin level is measured to exclude Zollinger-Ellison syndrome.

Most of the peptic ulcers occurring in children of this age range are secondary to other systemic diseases, such as burns (Curling ulcer), head trauma (Cushing ulcer), malignancy, or sepsis.

Lower gastrointestinal tract bleeding in children aged 1-2 years

Most polyps in persons of this age group are the juvenile type and are located throughout the colon. These are benign hamartomas and usually require no treatment, because they autoamputate. (A juvenile polyp is seen below.)

Intraoperative view of a bleeding juvenile polyp. Intraoperative view of a bleeding juvenile polyp.

Meckel diverticulum (see the images below) occurs in 2% of the population. The etiology of GI bleeding due to Meckel diverticulum is ileal ulceration caused by acid secretion from the ectopic gastric mucosa. Erosion into small arterioles leads to painless, brisk rectal bleeding. The site of ulceration is generally at the base of the diverticulum where the ectopic mucosa and the normal ileum join. More rarely, the ulcer appears distally in the ileum.

Intraoperative view of the bleeding Meckel diverti Intraoperative view of the bleeding Meckel diverticulum. Note the ulceration at the base.
Radioactive tracer in stomach, bladder, and the Me Radioactive tracer in stomach, bladder, and the Meckel diverticulum in a 5-year-boy brought in for lower gastrointestinal bleeding.

Upper gastrointestinal tract bleeding in children older than age 2 years

Esophageal varices result can from portal hypertension, regardless of the age group. The increased resistance to blood flow through the portal system is due to prehepatic, intrahepatic, and suprahepatic obstruction, but the most common causes of portal hypertension in children include portal vein thrombosis (prehepatic) and biliary atresia (intrahepatic).

The most common causes of upper GI bleeding in children older than 12 years are duodenal ulcers, esophagitis, gastritis, and Mallory-Weiss tears.

Lower gastrointestinal tract bleeding in children older than age 2 years

The most common cause of lower GI bleeding in children older than 2 years is juvenile polyps, and this remains true until the patients are teenagers.

Inflammatory bowel disease (IBD) also becomes a common cause of GI bleeding in this age group. Bleeding is less common in individuals with Crohn disease than in persons with ulcerative colitis, but both 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. The 2 most common pathogens in infectious diarrhea are Escherichia coli and species of Shigella.

Vascular lesions include a wide variety of malformations, including hemangiomas, arteriovenous malformations, and vasculitis.

Summary

The causes of upper and lower gastrointestinal bleeding, according to age group, are summarized in the table below.

Table. Common Sources of Gastrointestinal Bleeding in Pediatrics (Open Table in a new window)

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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Epidemiology

Severe GI bleeds are rare in the general pediatric population and are therefore not well documented.

In the pediatric ICU population, 6-20% of the general pediatric population 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.

An investigation into the epidemiology of GI bleeding in hospitalized children in the United States reported that there were 23,383 pediatric discharges with a diagnosis of GI bleeding accounting for 0.5% of all discharges. Children with a GI bleeding were more likely to be male (54.5% vs. 45.8%), and older (children ≥11 years; 50.8% vs. 38.7%). Children 11-15 years of age had the highest incidence of GI bleeding (84.2 per 10,000 discharges) and children less than 1 year of age the lowest (24.4 per 10,000 discharges). The highest incidence of GI bleeding was attributable to cases coded as blood in stool (17.6 per 10,000 discharges) followed by hematemesis (11.2 per 10,000 discharges). The highest mortality rates associated with GI bleeding were observed in cases with intestinal perforation (8.7%) and esophageal perforation (8.4%).[1]

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Patient Education

For patient education information, see eMedicineHealth's Digestive Disorders Center, as well as Gastrointestinal Bleeding, Abdominal Pain in Children, Vomiting and Nausea, and Rectal Bleeding.

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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
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  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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