Pediatric Gastrointestinal Bleeding

Updated: Mar 09, 2017
  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Robert K Minkes, MD, PhD  more...
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Overview

Background

Gastrointestinal (GI) bleeding in infants and children occurs frequently.  Fortunately, the majority of cases do not result in serious health consequences.

The initial approach to patients with significant GI bleeding should be 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. Typically, bright red blood 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.

Other 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 a 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.)

Evidence is emerging that IBD presenting in children less than two years of age may have significant differences from IBD presenting in older aged children [1]

Intussusception is a cause of lower GI bleeding in infants.

Gangrenous bowel is another, less 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 a 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 a 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) is often summarized by clinicians by "The Rule of Twos": it occurs in 2% of the population, it usually presents prior to 2 years of age, it usually is located within 2 feet of the ileocecal valve, is 2 inches in length, and has 2 types of heterotrophic mucosa. 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

A common cause of lower GI bleeding in children older than 2 years is juvenile polyps; 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. Two common pathogens producing 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%). [2]

Since most patients with GI bleeding are not hospitalized, Emergency Department (ED) visits may provide more insight into epidemiology of GI bleeding. A recent report used ICD-9-CM codes for GI Bleeding to extract data from a large United States database. Between 2006-2011, a total of 437,283 ED visits were coded for GI Bleeding. The greatest number of visits occurred in patients 15-19 years of age (39.2%); the second greatest number of visits occurred in children less than five years of age (38.2%). [3]

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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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