History
A complete history can often identify a presumptive GI bleeding source and direct an efficient workup. For example, NEC in most neonates is diagnosed based on history and clinical presentation.
Ask age- and etiology-specific questions. Ask about acuteness or chronicity of bleeding, color and quantity of the blood in stools or emesis, antecedent symptoms, history of straining, abdominal pain, and trauma.
Melena, rather than bright red blood per rectum, is usually a sign of bleeding that comes from a source proximal to the ligament of Treitz. However, massive upper GI bleeding can produce bright red blood per rectum if GI transit time is rapid.
Blood mixed in stool or dark red blood implies a proximal source with some degree of digestion of the blood.
Intestinal malrotation is suspected with the sudden onset of melena in combination with bilious emesis in a previously healthy, nondistended baby.
For complaints of bloody stool, make sure to elicit a history of foods consumed or drugs used that may give a stool bloody appearance. This list includes certain antibiotics, iron supplements, red licorice, chocolate, Kool-Aid, flavored gelatin, or bismuth-containing products (eg, Pepto-Bismol).
A history of vomiting, diarrhea, fever, ill contacts, or travel suggests an infectious etiology.
Bloody diarrhea and signs of obstruction suggest volvulus, intussusception, or necrotizing enterocolitis, particularly in premature infants. Acute bloody diarrhea should be considered a medical emergency. [5]
Recurrent or forceful vomiting is associated with Mallory-Weiss tears.
Familial history or NSAID use may suggest ulcer disease.
Ingested substances, such as NSAIDs, tetracyclines, steroids, caustics, and foreign bodies, can irritate the gastric mucosa enough to cause blood to be mixed with the vomitus. [6]
Ask questions that may reveal underlying, but as yet undiagnosed, organ dysfunction.
Recent jaundice, easy bruising, and changes in stool color may signal liver disease.
Other evidence of coagulation abnormalities elicited from the history may also point to disorders of the kidney or reticuloendothelial system.
The rest of this section provides an age-specific discussion of patient history.
Neonates
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.
Some drugs are implicated in neonatal GI bleeds. These include NSAIDs, heparin, and tolazoline, which are used for persistent fetal circulation.
Indomethacin, which is 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 neonate on delivery. Aspirin, cephalothin, and phenobarbital are well-known causes of coagulation abnormalities in neonates.
Prematurity, neonatal distress, and mechanical ventilation are all associated with stress gastritis.
Lower gastrointestinal tract bleeding in children aged 1 month to 1 year
Episodic abdominal pain that is cramping in nature, vomiting, and currant jelly stools are findings in children with intussusception.
In milk protein allergy, the child displays, in addition to bleeding, such symptoms as fussiness and increased frequency of bowel movements; frank diarrhea is atypical.
Upper gastrointestinal tract bleeding in children aged 1-2 years
NSAID use is one of the factors in the development of peptic ulcer disease in children older than 1 year. However, most of the ulcers occurring in children aged 1-2 years are secondary to systemic diseases, such as burns (Curling ulcer), head trauma (Cushing ulcer), malignancy, or sepsis.
Lower gastrointestinal tract bleeding in children aged 1-2 years
Children with polyps are found to have painless bleeding per rectum, which often streaks the stool with fresh blood.
Lower gastrointestinal tract bleeding in children older than age 2 years
Bleeding is less common in individuals with Crohn disease than in those with ulcerative colitis, but persons with either disease 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.
Physical Examination
Look for signs of shock, and document findings such as heart rate, blood pressure, capillary refill, and orthostatic changes. [7]
During examination of the head, ears, eyes, nose, and throat, look for causes such as epistaxis, nasal polyps, and oropharyngeal erosions from caustics and other ingestions.
Examine abdominal surgical scars and elicit the reason for the surgery.
Specifically include bowel-sound frequency in the abdominal examination. Hyperactive bowel sounds are more common in upper GI bleeding.
Abdominal tenderness, with or without a mass, raises the suspicion of intussusception or ischemia.
Hepatomegaly, splenomegaly, jaundice, or caput medusa suggests liver disease and subsequent portal hypertension.
Inspection of the perianal area may reveal fissures, fistulas, skin breakdown, or evidence of trauma. Gentle digital rectal examination may reveal polyps, masses, or occult blood.
Looking for evidence of child abuse, such as perianal tearing, tags, or irregularities in anal tone and contour, is also important.
Examination of the skin may reveal evidence of systemic disorders, such as IBD, Henoch-Schönlein purpura, and Peutz-Jeghers polyposis.
Anoscopy can be performed (if required in an infant) by gently placing a lubricated red-top or purple-top test tube into the anus to enable visualization of the inner anal anatomy.
Lower gastrointestinal tract bleeding in children aged 1 month to 1 year
Diagnosis of anal fissures is made by anal examination, sometimes performed with a nasal speculum. Further tests are unnecessary. (In older children, as in adults, refractory anal fissures or those located off the midline should raise suspicion for IBD, specifically Crohn disease.)
Symptoms of intussusception include a palpable, sausage-shaped mass.
Children with a gangrenous bowel present with evidence of bowel obstruction, abdominal distension, dehydration, and peritonitis.
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Intraoperative view of a bleeding juvenile polyp.
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Radioactive tracer in stomach, bladder, and the Meckel diverticulum in a 5-year-boy brought in for lower gastrointestinal bleeding.
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Intraoperative view of the bleeding Meckel diverticulum. Note the ulceration at the base.
Tables
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 |
