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Pediatric Gastrointestinal Bleeding Treatment & Management

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

Approach Considerations

Provide hydration and volume support in patients with gastrointestinal (GI) bleeding. Transfusion may be required.

If an acute bleed is suspected and there is hemodynamic instability, access with 2 large-bore intravenous (IV) catheters must be obtained.

Patients with severe GI bleeds should be admitted to the pediatric ICU.

For variceal bleeds, GI consultants may endoscopically control active hemorrhage with sclerotherapy, an 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.

Significant GI bleeding that cannot be controlled (eg, 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.

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.

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.

Age-specific treatment and management strategies are discussed below.

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

Upper gastrointestinal tract bleeding in neonates

Treatment for stress gastritis in neonates is supportive and includes adequate resuscitation to reduce the underlying hypoxemia, nasogastric suction, and IV H2 blockers or PPIs. Studies have advocated identifying high-risk neonates and treating them prophylactically with acid-reducing agents. Extremely rarely, continued or massive hematemesis despite medical therapy leads to operative interventions, such as gastric resection, vagotomy and pyloroplasty, or antrectomy and vagotomy.

Hemorrhagic disease of the newborn is a bleeding disorder resulting from a deficiency in vitamin K–dependent coagulation factors. Although it is normally self limited, in 0.25%-0.5% of neonates, severe hemorrhage may result.

Prophylactic vitamin K administration in the newborn period virtually eliminates hemorrhagic disease. If the disorder occurs, IV administration of 1 mg of vitamin K generally stops the hemorrhage within 2 hours. If the clinical condition warrants, fresh frozen plasma and packed red blood cells are administered in addition to the vitamin K.

Lower gastrointestinal tract bleeding in neonates

For neonates with NEC, the standard treatment is aggressive medical resuscitation with bowel rest, antibiotics, total parenteral nutritional, and nasogastric decompression.

Nonoperative management of NEC yields a 70-80% recovery rate, but urgent laparotomy or drain placement is required in neonates in whom conservative therapy is unsuccessful owing to progressive sepsis, bowel perforation, or persistent bleeding. Recurrent bleeding in a baby who has recovered from NEC may indicate a second occurrence of the disease or an enterocolitis stricture.

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

Peptic esophagitis caused by GER is the most common cause of bleeding in this age group. Treatment begins with acid-reducing agents, thickened feeds, upright positioning, and prokinetic agents.

Antireflux procedures are rarely performed to control bleeding but may be necessary to treat complications of GER (eg, apnea, esophageal stricture, lung disease) that are refractory to medical therapy.

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. Treatment is a combination of H2 blockage, antibiotic therapy, and bismuth.

Secondary gastritis occurs in association with severe systemic illnesses that result in mucosal ischemia and produce diffuse erosive and hemorrhagic gastric mucosa. Correction of the underlying metabolic derangements and acid reduction are successful treatment measures in most patients.

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

Treatment for anal fissures consists of the administration of stool softeners and the use of rectal dilation.

In patients with intussusception, barium, saline, and pneumatic enema, while diagnostic, are potentially therapeutic as well. Successful reduction in intussusception is achieved in up to 90% of cases. Unsuccessful enema necessitates laparotomy and manual reduction or resection of the intussusception.

In cases of gangrenous bowel, laparotomy is usually necessary for definitive treatment.

The symptoms of milk protein allergy generally resolve in 48 hours to 2 weeks after withdrawal of the offending milk product.

Upper gastrointestinal tract bleeding in children aged 1-2 years

Significant upper GI bleeding caused by peptic ulcers is evaluated and treated with immediate endoscopy. Cautery, epinephrine therapy, fibrin sealants, and Endoclips are treatment options for ulcers, and biopsy samples are taken, if warranted.

Therapy for peptic ulcer disease in children mimics that in adults and centers around acid reduction and control of the underlying condition. Obstruction and/or persistent bleeding are indications for surgery.

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. Colonoscopy, the diagnostic evaluation of choice, can be used to excise bleeding polyps when they are identified.

In Meckel diverticulum, bleeding may be brisk, and transfusion is often required. However, the bleeding is usually self-limited and resolves spontaneously with episodic recurrences.

The treatment of ulceration in Meckel diverticulum is surgical resection after preoperative fluid resuscitation and adequate transfusion. A right lower quadrant incision is used, and the diverticulum is mobilized. (A bleeding, ulcerated Meckel diverticulum is seen below.)

Intraoperative view of the bleeding Meckel diverti Intraoperative view of the bleeding Meckel diverticulum. Note the ulceration at the base.

Careful visual inspection and palpation locate the ectopic gastric mucosa and ulceration. If the ulcer is confined to the diverticulum, diverticulectomy alone is performed and closed in a transverse fashion with sutures or a stapling device.

If the diverticulum is broad based or the ulcer cannot be included in the diverticulum specimen, segmental bowel resection is necessary, with an end-to-end anastomosis. An appendectomy is often performed with the resection.

Upper gastrointestinal tract bleeding in children older than 2 years

Esophageal varices result from portal hypertension, regardless of the age group. Once the diagnosis of gastric or esophageal varices has been confirmed, treatment is initiated. Most bleeding episodes stop spontaneously and respond to blood products and careful monitoring.

Pharmacologic therapy, administered as necessary, is directed at reducing portal venous blood flow. Vasopressin, octreotide, and beta blockers have been used systemically to control bleeding varices.

Balloon tamponade with a Sengstaken-Blakemore or Minnesota tube has yielded up to an 80% success rate in controlling bleeding varices, but rebleeding and serious complications, such as pressure necrosis or misplacement, make this technique less useful.

Endoscopic sclerotherapy with injection of sodium morrhuate controls bleeding with a success rate of 90%-95%. Generally, endoscopic sclerotherapy is repeated at 2- to 4-week intervals after the acute bleed to prevent recurrence.

Variceal banding offers results at least comparable to sclerotherapy but is more difficult to perform in children because of the smaller size of the esophagus.

In the approximately 20% of cases in which conservative management fails (defined by multiple transfusion requirements or an inability to maintain hemodynamic stability) with combined pharmacotherapy and endoscopic treatments, shunt and non-shunt surgeries are the definitive treatment.

For intrahepatic portal hypertension, TIPS provides temporary decompression of the intrahepatic portal vein into the hepatic veins. Surgical portosystemic or portoportal shunts are reserved for refractory cases and/or when liver transplantation is not an option.

Nonshunt operations include esophageal transaction and devascularization of the gastroesophageal varices (Sugiura procedure), but neither is commonly performed.

A study reviewed the diagnosis and management of upper gastrointestinal bleeding in children. The study determined that after the diagnosis is established, the physician should start a proton pump inhibitor or histamine 2 receptor antagonist in children with upper gastrointestinal bleeding. The study added that consideration should also be given to the initiation of vasoactive drugs in all children in whom variceal bleeding is suspected.[8]

Lower gastrointestinal tract bleeding in children older than 2 years

In patients with IBD, the occurrence of acute or persistent bleeding with resultant anemia, despite the use of maximal medical therapy, is considered to be an indication for surgery. Therapy for ulcerative colitis is a total proctocolectomy with an ileal pouch–anal pull-through. The goal of surgical treatment in Crohn disease is resection of all grossly diseased bowels with primary anastomosis, provided previous surgery (or the current resection) has not created a short-bowel situation.

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 former should be self-limited and should resolve after cessation of antibiotics, while Clostridium difficile colitis requires therapy with oral metronidazole or vancomycin. Escherichia coli and Shigella species are the two most common pathogens in infectious diarrhea. Treatment is supportive with antibiotic therapy, as indicated.

Vascular lesions include a wide variety of malformations, including hemangiomas, arteriovenous malformations, and vasculitis. If these lesions are located in the colon, colonoscopy may be diagnostic and therapeutic. However, brisk bleeding may obscure the visual field, making localization of the bleeding impossible. Arteriography assists in localizing the source and embolizing the feeding vessel.

Surgery is necessary when bleeding cannot be controlled using these techniques. Localization of hemorrhage in the small bowel is a challenge to surgeons and may require intraoperative endoscopy to find the lesion.

Further inpatient or outpatient care

Critically ill pediatric patients may benefit from receiving prophylactic treatment to prevent upper gastrointestinal bleeding. However, evidence to guide clinical practice remains limited.[9]

Next

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 NEC, a gastroenterologist for presumed ulcer disease).

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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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