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Pediatric Gastrointestinal Bleeding Workup

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

Approach Considerations

For upper GI bleeding, a nasogastric tube is placed to confirm the presence of fresh blood and to evaluate the degree of active bleeding. If fresh or active bleeding is confirmed, esophagogastroduodenoscopy (EGD) is used to determine the source of upper GI bleeding in 90% of children when performed in the first 24 hours. Alternatively, colonoscopy identifies the cause of bleeding in 80% of children with lower GI bleeding.

In general, trace or small amounts of blood that are a 1- or first-time occurrence are not of emergent concern. Children rarely require an extensive laboratory workup or invasive procedures, and parents can be advised to observe the child at home to see if these situations arise again.

Patients with substantial upper or lower GI bleeding, as determined from their history or examination, should receive a complete blood count (CBC), coagulation studies, and a chemistry panel. The CBC reveals anemia and thrombocytopenia.

A normal hematocrit may provide false reassurance regarding some children with hypovolemia and hemoconcentration.

Leukocytosis with increased bands may indicate an infectious etiology or complication responsible for the bleeding.

Elevated, abnormal prothrombin time indicates coagulopathy (ie, disseminated intravascular coagulation) or profound impairment of liver synthetic function.

A prolonged activated partial thromboplastin time indicates a hemophiliac patient or coagulopathy.

A chemistry panel may reveal a high blood urea nitrogen (BUN) level, suggesting an upper GI source that has had time to allow the body to reabsorb blood leading to a higher BUN level compared with a lower GI source.

For children who have tenderness in the right upper quadrant or a history suggestive of liver disease, aspartate aminotransferase and alanine aminotransferase enzyme levels may indicate hepatitis and increased risk of portal hypertension.

The history should also be used as a guide with regard to when fecal leukocytes, parasites, or cultures should be ordered, if an infectious etiology is suspected.

In cases of episodic or obscure bleeding, nuclear medicine radionucleotide studies, arteriography, and wireless video capsule endoscopy are used to assist in identifying the site of blood loss.

Radionuclear imaging with technetium-labeled red blood cells can be used to detect bleeding at a rate as low as 0.1 mL per minute. This technique is somewhat imprecise; however, it may direct localization for either selective angiography, suggest a need for video capsule endoscopy, or provide some direction for laparotomy search and resection, a notoriously difficult process for the control of GI bleeding.

Arteriography can be used to detect bleeding at a rate of 0.5 mL per minute and offers the advantage of providing treatment and diagnosis. The treatment consists of embolization and intra-arterial administration of vasoconstrictors.

When arteriography and nuclear scanning fail to diagnose or localize the cause of bleeding, further options remain, including repeat endoscopy and push enteroscopy (often also referred to as double balloon endoscopy or enteroscopy).[4]

In many cases, wireless video capsule endoscopy reveals the cause noninvasively, but its main disadvantage is the inability to collect tissue samples for biopsy examination.[5]

If all else fails, diagnostic laparoscopy and intraoperative endoscopy can be performed as means of last resort.

An age-specific discussion of diagnostic workups for GI bleeding follows.

Go to Imaging of Upper Gastrointestinal Bleeding and Imaging of Esophageal Varices for complete information on these topics.

Neonates

In most neonates with stress gastritis, the diagnosis is presumptive. If necessary, definitive diagnosis is made with upper endoscopy, demonstrating erythema, diffuse bleeding, erosions, or ulcerations of the gastric mucosa.

Upper gastrointestinal bleeding in children aged 1 month to 1 year

Diagnostic workup for GER often begins with a barium swallow. Other diagnostic modalities include pH probes, esophagoscopy, esophageal manometry, and nuclear medicine studies.

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. H pylori is detected using serum immunoglobulin G (IgG) levels, rapid urease testing (CLOtest), or mucosal biopsy.

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

In cases of intussusception, ultrasonography may be used as the initial diagnostic study to avoid a more invasive barium or pneumatic enema. The ultrasonographic finding of a pseudokidney sign is pathognomonic for intussusception. Because ultrasonographic studies are only diagnostic, many clinicians choose to proceed directly to barium, saline, or pneumatic enema, which are diagnostic and potentially therapeutic.

In patients with gangrenous bowel, upper and lower contrast studies aid in diagnosis.

Upper gastrointestinal tract bleeding in children aged 1-2 years

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

Significant upper GI bleeding in patients with ulcer is evaluated and treated with immediate endoscopy. Biopsy samples are taken, if warranted.

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. In cases of polyps, colonoscopy is the diagnostic evaluation of choice, because it allows examination of the entire colon and the potential excision of bleeding polyps when they are identified. Colonoscopy is helpful in diagnosing other polyposis syndromes, such as familial polyposis syndromes and adenomatous polyps.

In patients with Meckel diverticulum, technetium-99m (99m Tc) pertechnetate scanning is used to identify this congenital anomaly, with 90% accuracy. This isotope has a high affinity for parietal cells of gastric mucosa and allows identification of normal and ectopic gastric mucosa. The use of H2 blockers and proton pump inhibitors (PPIs), pentagastrin, and glucagon may enhance the accuracy of this test, since H2 blockers inhibit excretion of the isotope, pentagastrin enhances gastric mucosal uptake, and glucagon inhibits peristalsis.

Upper gastrointestinal tract bleeding in children older than age 2 years

After the initial stabilization of patients with upper GI bleeding, upper endoscopy is the preferred diagnostic and therapeutic tool. The esophagus and stomach are assessed for the presence of varices and in order to exclude gastritis or ulcer disease as the source of bleeding. Gastric varices are most commonly found in the fundus.

Lower gastrointestinal tract bleeding in children older than age 2 years

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 the bleeding impossible. Arteriography assists in localizing the source and embolizing the feeding vessel.

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Peroxide-Based Tests

In all children, the presence of blood can be confirmed by the use of peroxide-based tests, such as the Hemoccult or Hematest for lower GI bleeding and Gastroccult for upper GI bleeding.

Certain ingestions, such as red meat, iron, and peroxidase-containing vegetables (eg, turnips, horseradish, broccoli, cauliflower, and cantaloupe), can give false-positive results.

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Abdominal Radiography

Patients with suspected obstruction should undergo plain abdominal radiography. Abdominal radiography may also be helpful in neonates in whom NEC is a possibility; the images may show free air, pneumatosis intestinalis (bubbles in the bowel wall), or portal air.

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Barium Contrast Studies

Imaging for nonemergency pediatric GI bleeding may begin with barium contrast studies (barium swallows, upper GI series, small bowel follow-throughs, or barium enemas) to point to foreign bodies, esophagitis, IBD, or polyps. For neonates with malrotation with midgut volvulus, it may reveal a corkscrew of small bowel or a bird's beak if complete obstruction is present.

When intestinal malrotation is suspected, an immediate upper GI contrast study should be performed to confirm the diagnosis of malrotation with midgut volvulus.

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Doppler Ultrasonography

For suspected intussusception, color Doppler ultrasonography can be used. Its sensitivity is 98-100%, and its specificity is 89-100%; these rates are operator-dependent.

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Enema Studies

Enema studies are successful in most cases.

Barium enema studies have traditionally been used with success rates of 50-90%. Rates improve when symptoms are present for less than 24 hours. Barium study is contraindicated if perforation is suspected.

Air and water-soluble contrast enemas have also been used with similar success rates. Air enemas require less radiographic exposure but have slightly higher perforation rates, while enemas with a water-soluble (or saline) contrast agent require experienced sonographers.

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Meckel Scan

A Meckel scan uses99m Tc pertechnetate to highlight the ectopic gastric mucosa.

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Arteriography

Arteriography is used to localize lesions when endoscopy has failed or when the patient cannot cooperate. The modality can be helpful for bleeding that is distal to the ligament of Treitz.

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Nasogastric Tube

Children whose history and physical findings suggest significant bleeding from an upper GI source receive a nasogastric tube for diagnostic purposes.

Return of coffee-ground-like material or Gastroccult-positive material confirms an upper GI bleed.

Still, the false-negative rate is 16% if duodenopyloric regurgitation is absent. Therefore, a clear nasogastric aspirate alone cannot be used to rule out of a GI bleed.

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Endoscopy

Patients with severe upper GI bleeding should receive endoscopy within the first 12 hours of the hemorrhagic episode if they are sufficiently stable, because early endoscopy improves the diagnostic index.

The site of upper GI bleeding can be identified in 90% of cases when endoscopy is performed within 24 hours. This modality is also beneficial in predicting the likelihood of continued bleeding.[6]

The Forress classification divides endoscopic findings into the following 3 categories:

  • I - Active hemorrhage (Ia = bright-red bleeding, Ib = slow bleeding)
  • II - Recent hemorrhage (IIa = nonbleeding visible vessel, IIb = adherent clot on base of lesion, IIc = flat pigmented spot)
  • III - No evidence of bleeding.

The incidence of rebleeding decreases dramatically, because less evidence of ulceration or bleeding is seen.

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Enteroscopy

Push enteroscopy in some studies has been shown to have a higher diagnostic yield than standard esophagogastroduodenoscopy (EGD). Essentially, this modality uses a long endoscope that is placed through the mouth into the jejunum and can reach about 160 cm beyond the ligament of Treitz.

In one study, push enteroscopy identified a large number of mucosal lesions that could not be identified by a standard endoscope.[7]

Double-balloon enteroscopy is another technology that has shown high therapeutic and diagnostic yield. This modality employs a high-resolution video endoscope with latex balloons attached at the tip, with an overtube that can be inflated and deflated. It can be inserted either orally or anally.

Wireless capsule endoscopy is under investigation for children, although it can be used only diagnostically, not therapeutically.

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Colonoscopy

For lower GI bleeds, colonoscopy can reveal the source of bleeding more effectively than barium enema can, and it has 80% sensitivity.

Colonoscopy should be performed only when the patient is stable and when blood and feces will not conceal proper visualization.

Sigmoidoscopy alone has also been used in children who have had symptoms of chronic lower GI bleeding for 1 year or longer. The study reveals the most common etiologies, such as juvenile colorectal polyps and nonspecific proctitis.

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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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