Identify the source ofgastrointestinal (GI) bleeding

Identify the source ofgastrointestinal (GI) bleeding: Excerpt from Avoiding Common Pediatric Errors

Author: Mindy Dickerman, MD

What to Do - Gather Appropriate Data

GI bleeding can be divided into upper GI hemorrhage (bleeding proximal to the ligament of Treitz) and lower GI hemorrhage (bleeding distal to that point). It is helpful to try and identify the site in the GI tract where the bleeding may originate from based on the color and nature of the bleeding, in context with the other presenting signs and symptoms.

The evaluation of a potential GI bleed should first establish the hemodynamic stability of the patient. Second, it is necessary to ensure that blood is present because many foods and drinks can discolor stool and vomit. The next step is to identify the bleeding source. A detailed history and physical examination with attention to the patient's age can clarify the source.

Upper gastrointestinal bleeding (UGIB) is an uncommon but potentially serious problem in children. Acute UGIB can present with hematemesis, which is defined as the vomiting of gross blood or coffee ground material, or with the passage of melena, maroon colored stools, or tarry stools. Occasionally, UGIB may present with hematochezia, blood per rectum, because the bleeding is very rapid and, therefore, not altered by the transit time through the digestive system. A nasogastric tube lavage that yields blood or coffee ground material confirms the diagnosis of an UGIB.

An initial priority when evaluating a child with suspected GI bleed is to assess both the hemodynamic stability and the severity of the bleeding, followed by resuscitation if necessary. A nasogastric tube may be helpful to assess extent of bleeding. Significant losses may be caused by hemorrhagic gastritis, esophageal varices, peptic ulcers, and vascular malformations. Both a gastroenterologist and a surgeon should be notified early on if a patient is suspected to have severe acute bleeding.

Many substances, such as red food coloring, fruit juices, beets, iron, and spinach, may color the stool or emesis red or black, and when ingested by childrenmaybemistakenforblood.Ifunsureandifthecolorindicatesblood, one should test the stool or the gastric contents by a guaiac test. Swallowed blood from the nasopharynx or respiratory tract may also be mistaken for UGIB and a physical exam may help clarify the source.

In the United States, the most common causes of UGIB are gastric and duodenal ulcers, esophagitis, gastritis, and varices. It is helpful during the diagnostic evaluation to keep in mind the specific etiologies of GI bleeding at different ages. Common causes of UGIB in infants and toddlers include esophagitis, gastritis, ingestion of a foreign body, or swallowed maternal blood. Variceal bleeding is a possibility in a patient with portal hypertension. More rare causes are hemangiomas, aortoesophageal fistulas, hereditary hemorrhagic telangiectasia, Kasabach-Merritt syndrome, duplications cysts, parasites, vasculitis, gastric polyps, and systemic mastocytosis. Etiologies in older children and adolescents are similar to adults and include peptic ulcers, gastritis, Mallory-Weiss tears, varices, Dieulafoy lesions, and pill esophagitis.

Lowergastrointestinalbleeding(LGIB)ismorecommonlyencountered than UGIB. Hematochezia, bright red blood or fresh clots per rectum, is usually a sign of a LGIB, typically from the colon.

As withUGIB,theetiology ofLGIBvariesdependingon age. The most common diagnosis to consider in newborns are swallowed maternal blood, anorectal fissures, necrotizing enterocolitis, malrotation with midgut volvulus, Hirschsprung disease, and coagulopathy. Among older children, rectal polyps are the most common cause of rectal bleeding. Etiologies to consider amonginfantsinclude anorectal fissures, milk/soy-inducedenterocolitis,intussusception, Meckel diverticulum, hemolytic uremic syndrome, Henoch- Schönlein purpura, lymphonodular hyperplasia, and GI duplication. The most common causes of LGIB in the school-age child are infections, polyps, and inflammatory bowel disease. The age of the patients and the history and physical exam will narrow the diagnostic possibilities and guide the evaluation. A rectal exam is important to exclude anal fissures or polyps and obtain stool for guaiac testing. An abdominal examination for signs of portal hypertension, masses, or tenderness will aid in the differential diagnosis. Identifying malrotation is critical because it is life–threatening and requires emergent evaluation and treatment. The classic presentation is abdominal distention, bilious emesis, and melena, but this presentation only occurs in 10% to 20% of cases.

Suggested Readings

Arvola T, Ruuska T, Keränen J, et al. Rectal bleeding in infancy: clinical, allergological, and microbiological examination. Pediatrics. 2006;117(4):e760–e768.
Chawla S, Seth D, Mahajan P, et al. Upper gastrointestinal bleeding in children. Clin Pediatr. 2007;46:16–21.
Silber G. Lower gastrointestinal bleeding. Pediatr Rev. 1990;12(3):85–93.
Squires RH Jr. Gastrointestinal bleeding. Pediatr Rev. 1999;20(3):95–101.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

More About Gastrointestinal bleeding

• Back to disease: Gastrointestinal bleeding: Introduction
• Next Book Extract About Gastrointestinal bleeding: Know that bloody stools can be an anxiety-provoking event to new parents, but is most often a benign finding in an otherwise well-appearing newborn baby. Know when to intervene and when to observe (Avoiding Common Pediatric Errors)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Know that bloody stools can be an anxiety-provoking event to new parents, but is most often a benign finding in an otherwise well-appearing newborn baby. Know when to intervene and when to observe (Avoiding Common Pediatric Errors)

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