Diseases » Rectal bleeding

Gastrointestinal Bleeding

Gastrointestinal Bleeding: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics

Can occuranywhere from nose and mouth to anus.

Bleeding that occurs proximal to ligamentof Treitz is considered upper tract bleeding, whereas bleeding thatoccurs distal to this ligament is considered lower tract bleeding.

Manifestations include hematemesis,hematochezia, melena, bloody diarrhea, and blood mixed with stool.

Hematemesisis vomiting of bright red blood or denatured blood that resemblescoffee grounds.

Hematochezia, passage of bright redblood through the rectum, is usually caused by lower tract bleedingbut also can result from massive upper tract bleeding.

Passage of tarry black material throughthe rectum is called melena and usually results from bleeding instomach or small bowel.

Bloody diarrhea or blood mixed withstool frequently occurs with lower tract bleeding.

Bright red blood that coats stool surfacecomes from rectum or anus.

In some cases, chronic blood loss canonly be revealed by testing stool for presence of heme protein byHemoccult (Smith Kline Diagnostics, San Jose, CA) (guaiac) testing.

Principal Causes of Gastrointestinal Bleeding

1. Uppergastrointestinal bleeding
   1. Nose
   2. Mouth and pharynx
   3. Esophagus
      1. Esophagitis
         1. Gastroesophageal reflux
         2. Caustic ingestion
         3. Infection
      2. Foreign body
      3. Varices
      4. Duplication
   4. Gastroesophageal junction
      1. Mallory-Weisstear
   5. Stomach
      1. Gastritis
      2. Ulcer
      3. Duplication
      4. Vascular malformation
      5. Neoplasm
   6. Duodenum
      1. Ulcer
      2. Foreign body
      3. Varices
      4. Duplication
      5. Vascular malformation
      6. Hemobilia
   7. Other
      1. Swallowed blood
      2. Coagulopathy
         1. Hemorrhagic disease of the newborn(vitamin K deficiency)
         2. Disseminated intravascular coagulation
      3. Drugs
2. Lower gastrointestinal bleeding
   1. Intestine
      1. Cow milk/soyprotein sensitivity
      2. Necrotizing enterocolitis
      3. Infectious colitis
      4. Henoch-Schönlein purpura
      5. Intussusception
      6. Congenital aganglionic megacolon (Hirschsprungdisease)
      7. Meckel diverticulum
      8. Volvulus with malrotation
      9. Inflammatory bowel disease
      10. Intestinal polyps
          1. Solitaryjuvenile polyps/juvenile intestinal polyposis
          2. Adenomatous polyposis of the colon
          3. Peutz-Jeghers syndrome
          4. Benign lymphoid hyperplasia
          5. Duplication
          6. Vascular malformation
          7. Neoplasm
   2. Rectum and anus
      1. Anal fissure
      2. Trauma
      3. Sexual abuse
      4. Hemorrhoids
      5. Other
   3. Swallowed blood
   4. Coagulopathy
   5. Drugs
3. Factitious bleeding

Clinical Features and Diagnosis

Upper Gastrointestinal Bleeding

Nose

See Chap.18, Epistaxis.

Mouth and Pharynx

Trauma orforeign body may produce bleeding in mouth or pharynx.

History and physical exam are usuallydiagnostic.

Esophagus

Esophagitis

May presentwith hematemesis and sometimes occult blood loss.

Gastroesophageal reflux and causticingestions are common causes. Less common cause is infection, whichusually occurs in immunocompromised individuals. Pathogens includeherpes simplex virus, adenoviruses, cytomegalovirus, VZV, and Candidaspecies.

Diagnosis of esophagitis may be confirmedby endoscopy and biopsy. These infections may be diagnosed by specificcultures.

Foreign Body

Foreignbody lodged in esophagus may cause difficulty swallowing, pain,and bleeding.

Chest radiography may show radiopaqueforeign body.

Endoscopy is definitive procedure forremoval.

Varices

Consequenceof portal hypertension.

Major causes of portal hypertensionare parenchymal liver disease and anatomic obstruction of portalvein or its major branches.

Acute painless GI bleeding that occasionallycan be massive is often presenting sign. Other findings may includevisible abdominal wall collateral vessels, splenomegaly, and ascites.Hepatomegaly usually indicates liver parenchymal disease, but acirrhotic liver may be small and shrunken.

Endoscopic exam visualizes varices.

Duplication

Usuallyinvolves lower esophagus and may cause dysphagia.

Large duplication also may cause respiratorydistress.

If duplication contains ectopic gastricmucosa, bleeding can occur.

Diagnosis can usually be made by chestCT with oral contrast.

Gastroesophageal Junction

Tears inmucosa at gastroesophageal junction can result from continued forceful vomitingand retching; condition is called Mallory-Weiss syndrome.

Bleeding is usually self-limited.

Endoscopy can confirm diagnosis.

Stomach

Gastritis

In neonates,gastritis may be due to perinatal asphyxia, septicemia, or hypotension, butoften it is unexplained.

In infancy and childhood, epigastricpain and vomiting are frequent findings with gastritis. Viral illnessand drugs (e.g., aspirin and NSAIDs) are predisposing factors.

In adolescence, chronic alcohol intakemay cause gastritis.

In any age group, causes of stressgastritis include head injury, burns, septicemia, and shock.

Gastric aspirate may contain materialresembling coffee grounds or bright red blood.

Ulcer

Gastriculcer may cause acute bleeding with hematemesis or melena.

Another presentation is finding bloodin stool associated with chronic blood loss and anemia.

See Chap.2, Abdominal Pain.

Duplication

Duplicationof stomach usually involves greater curvature near antrum or pylorus.

Neonates may have vomiting, abdominalmass, and abdominal distension.

Vomiting, intermittent abdominal pain,and GI bleeding may occur in childhood.

Abdominal U/S is usually diagnostic.

Vascular Malformation

Angiodysplasticlesions and arteriovenous malformations can occur in stomach and insmall and large intestine.

Any of these lesions can present withrecurrent painless upper or lower GI tract bleeding.

Endoscopy and angiography are bestavailable diagnostic tools.

Neoplasm

Gastricneoplasms are extremely rare in pediatric population, yet can causeGI bleeding.

Benign tumors include teratoma andleiomyoma, whereas malignant tumors include gastric carcinoma, lymphoma,and leiomyosarcoma.

Combination of abdominal U/S,CT, and endoscopy with biopsy are diagnostic.

Duodenum

In addition to conditions detailed below,varices and vascular malformations can cause GI bleeding.

Ulcer

Duodenalulcer can have similar presentation as gastric ulcer.

See Chap.2, Abdominal Pain.

Foreign Body

Occasionallysharp objects may pass from stomach into duodenum and cause bleeding.Swallowed foreign body may be held up in C loop of duodenum or atpoint of constriction (e.g., ligament of Treitz) and cause obstructivesymptoms and hematemesis.

Combination of plain abdominal radiography,abdominal U/S, and endoscopy is usually diagnostic.

Duplication

Tends tocompress first or second portions of duodenum, producing partialobstruction. Presence of ectopic gastric mucosa predisposes to GIbleeding.

Abdominal U/S is usually diagnostic.

Hemobilia

Most commoncause of bleeding into biliary tract in children is abdominal trauma withinjury to liver and biliary tree.

Abdominal U/S and CT are usefulin locating and defining extent of injury. Duodenal endoscopy mayshow blood oozing from ampulla. If this is negative, celiac angiographymay locate site of bleeding if brisk. If bleeding is slower, technetium-sulfurcolloid scan may detect bleeding.

Other

Swallowed Blood

Maternalblood can be swallowed during passage through birth canal or frombreast-feeding if nipples are cracked.

Apt test can determine whether RBCsare fetal or maternal in origin and can be performed on either NGaspirate or stool.

In this test, small amount of NG contents orstool is mixed with tap water (1 part stool:5 parts water).

After centrifugation, 1 mL of 0.25NNaOH is added to 5 mL of pink supernatant fluid; mixture is leftfor 5 mins.

Pink color signifies fetal Hgb, whereasbrownish yellow color signifies maternal Hgb.

Coagulopathy

Bruising,purpura, and bleeding from sites other than GI tract are clues topresence of systemic bleeding disorder.

See Chap.52, Purpura and Bleeding.

Hemorrhagic Disease of the Newborn (Vitamin K Deficiency)

Becauseneonates have low vitamin K stores, they often fail to develop effectivecoagulation function.

At 2–4 days of age, if vitaminK has not been given at birth, hematochezia, melena, or hematemesismay develop. Bleeding also may occur from other sites beside GItract.

Lack of vitamin K administration atbirth, normal platelet count, and reversal of prolonged prothrombintime (PT) and activated partial thromboplastin time (aPTT) withdecreased bleeding after vitamin K administration confirm diagnosis.

Every newborn should receive 0.5–1.0mg IM of vitamin K at birth so this problem can be prevented.

Disseminated Intravascular Coagulation

Predisposingcauses include bacterial meningitis, septicemia, severe hypoxia,necrotizing enterocolitis, and shock.

Patients are seriously ill and havediffuse bleeding from multiple sites from consumption of clottingfactors and destruction of platelets.

Certain lab findings help confirm diagnosis:low platelet count, fragmented RBCs on blood smear, prolonged PTand aPTT, low plasma fibrinogen, and increase in fibrin-split products.

Drugs

GI bleeding may occur with chronic ingestionof aspirin, which causes a defect in platelet aggregation and aprolonged bleeding time. Excessive use of NSAIDs and anticoagulantsalso may cause significant GI bleeding.

Lower Gastrointestinal Tract Bleeding

Intestine

Cow Milk/Soy Protein Sensitivity

Infantsoften present with diarrhea that contains blood. Practical way tomanage this problem is to eliminate cow milk or soy protein fromdiet and monitor for whether symptoms disappear.

See Chap.14, Diarrhea.

Necrotizing Enterocolitis

Common disorderin preterm infants that can occur in term infants. History of perinatalstress (asphyxia, hypotension, septicemia) often exists.

Clinical findings include poor feeding,lethargy, abdominal distension, bilious vomiting, and bloody orblood-streaked stools.

Abdominal radiography that shows gasin bowel wall or in portal venous system helps confirm diagnosis.

Infectious Colitis

Most frequentpathogens in infancy and childhood are Salmonella, Shigella, Campylobacter,and E. coli. Less common is infection with C. difficile and Y. enterocolitica.Most common pathogen associated with HUS is E. coli 0157:H7.

Usual presenting manifestations arefever and bloody diarrhea.

Positive stool culture is diagnostic,except for infection with C. difficile, for which toxin must beidentified.

Henoch-Schönlein Purpura

Lower GIbleeding from the small intestine or colon can be occult or obvious.Typical purpuric rash occurs on buttocks and lower legs.

See Chap.28, Hematuria.

Intussusception

Common causeof lower GI bleeding in children 2 mos–5 yrs of age.

Most common type is ileocolic, whichinvolves telescoping of distal ileum into ascending or transversecolon.

History of intermittent cramping abdominalpain is usually presenting symptom. Vomiting and bloody (currantjelly) stools also may occur. Abdominal mass may be palpable anywherein abdomen.

Abdominal radiography that shows leadingedge of intussusceptum outlined by air is diagnostic, but oftenradiographs are nonspecific. Air-contrast enema can be diagnosticas well as therapeutic. Contraindications to its use are free abdominalair, intestinal obstruction with fluid levels on abdominal radiography,and clinical peritonitis. With any of these findings, surgery shouldbe performed immediately.

Congenital Aganglionic Megacolon (Hirschsprung Disease)

Enterocolitismay occur as complication.

Most common manifestations are abdominaldistension, diarrhea that is often bloody, fever, and vomiting.

See Chap.9, Constipation, and Chap. 14, Diarrhea.

Meckel Diverticulum

Remnantof omphalomesenteric duct that is located in distal ileum.

Usually presents in infancy with painless,episodic, bright red rectal bleeding, which may be massive.

Most diverticula contain gastric mucosa,and technetium 99m–pertechnetate scan can be diagnostic.

False-positive scans are uncommon butsometimes occur with ulcer, hemangioma, or bowel duplication.

Laparoscopy or laparotomy may sometimesbe necessary to confirm diagnosis.

Volvulus with Malrotation

Usuallypresents with intestinal obstruction; however, lower GI bleedingalso can occur.

Abdominal radiography shows dilatedloops of bowel with air-fluid levels. Upper GI series is usuallyperformed; however, with suspected bowel infarction, contrast studiesare unnecessary, and surgery should be performed immediately.

Inflammatory Bowel Disease

Occult GIblood loss or obvious lower GI tract bleeding may occur. Chronicdiarrhea with lower GI bleeding and weight loss should suggest IBD.

Crohn disease and ulcerative colitisare types of IBD.

See Chap.14, Diarrhea.

Intestinal Polyps

Definedas protrusion of tissue above normal GI surface that can cause bleedingand occasionally intussusception.

Number and location of polyps, theirhistopathology, and family history of colorectal cancer helps determineproper management.

This section focuses on common polyposissyndromes in pediatric population.

Solitary Juvenile Polyps/Juvenile Intestinal Polyposis

Solitaryjuvenile polyps usually present with painless rectal bleeding oranal prolapse of polyp in children 2–10 yrs of age. Mostchildren have single polyp, which should be removed for histopathologicexam.

Children with ≥2 rectosigmoid polypsand family history of polyps should be suspected of having juvenileintestinal polyposis, which is transmitted as autosomal-dominanttrait.

Manypolyps occur in the colon, but they also may be found in small intestineand stomach.

Age of presentation is usually in school-agedchildren.

Clinical manifestations include abdominalpain, rectal bleeding, and anemia.

There is high incidence of colorectalneoplasia in individuals with this disorder.

Adenomatous Polyposis of Colon

Autosomal-dominantdisorder caused by mutations in adenomatous polyposis coli gene,whose locus has been mapped to chromosome 5q21-q22.

Characterized by premalignant adenomaslocated primarily in colon and rectum and less commonly in stomachand small intestine.

Onset is usually in adolescence, whenhundreds to thousands of adenomas may appear. Other manifestationsinclude osteomas (jaw, long bones), skin lesions (cysts, lipomas),and pigmented retinal lesions.

Diagnosis is confirmed by colonoscopyand biopsy.

Peutz-Jeghers Syndrome

Autosomal-dominantdisorder in which hamartomatous polyps occur primarily in smallintestine but also may be found in colon and stomach. Gene locushas been mapped to chromosome 19p13.3.

Besides GI bleeding, characteristicfeature is presence of hyperpigmentation, which is seen most commonlyon buccal mucosa and lips.

Upper and lower GI endoscopy and upperGI radiographic series should be performed.

These individuals are at increasedrisk for adenocarcinoma, especially of stomach, duodenum, and colon.

Benign Lymphoid Hyperplasia

Large aggregatesof lymphoid tissue occur in colon and rectum. Rectal bleeding and sometimesintermittent diarrhea occur.

Proctosigmoidoscopy, colonoscopy, andhistologic exam confirm diagnosis.

Duplication

May be foundin jejunum and ileum. Abdominal pain, partial intestinal obstruction, orGI bleeding can be presenting feature. Sometimes small bowel intussusceptionor volvulus occurs.

May also involve colon and rectum,but bleeding rarely occurs because colonic duplications rarely containgastric mucosa. Affected individuals may present with abdominalpain and partial intestinal obstruction or they may be asymptomatic.

Abdominal U/S is usually diagnostic,although abdominal CT may be useful in some cases.

Vascular Malformation

Althoughrare, angiodysplastic lesions and arteriovenous malformations cancause lower GI bleeding.

Diagnosis is usually made by angiography.

Neoplasm

GI tumorsare rare in children.

Hemangiomas can be found anywhere insmall or large intestine but usually involve sigmoid colon and rectum.Endoscopy is usually diagnostic.

Adenocarcinoma of colon usually appearsafter 10 yrs of age. Persistent vomiting, anorexia, weight loss,abdominal pain, and GI bleeding are common manifestations. Contrastenema and colonoscopy with biopsy are diagnostic.

Rectum and Anus

Anal Fissure

Common causeof blood-streaked stools in neonates and young infants. Common causesare trauma from passage of hard stool and frequent use of rectalthermometer.

Stretching anal skin enables fissureto be visualized.

Trauma

Any foreignbody placed in rectum may cause trauma and bleeding.

History and physical exam are usuallydiagnostic, but proctoscopy may be needed in some cases. Plain radiographsof lower abdomen and pelvis can demonstrate radiopaque objects.

Sexual Abuse

Rectal trauma and bleeding may occur as resultof sexual abuse. History, physical exam, and proctoscopy are diagnostic.

Hemorrhoids

Defined as thrombosed collections of bloodvessels in anal area, which are uncommon in infancy and childhood.Usual cause is chronic constipation.

Other

Other causes of GI bleeding are swallowedblood, coagulopathy, and drugs.

Factitious Bleeding

Factitioushematemesis, hematochezia, or melena may be seen with various foods, medications,and artificial food colorings.

Commercial dyes no. 2 and no. 3 foundin breakfast cereals and fruit drinks may produce reddish colorof vomitus or stool.

Certain substances produce blackishcolor of stools: iron preparations, licorice, blueberries, beets,lead, charcoal, and bismuth.

In Munchausen syndrome by proxy, emesisor stool may be contaminated with blood that is not the child's.

Diagnostic Approach

Determination of Gastrointestinal Bleeding

Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).

Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool.

Severity of Bleeding

If GI bleedingis obvious, most important task is to determine severity.

Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.

In such cases, first note vital signsand perform any necessary resuscitation.

Immediate fluid replacement is requiredto stabilize BP.

Site of the Bleeding

Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.

Except in these instances, NG tubeshould be placed to document level and rate of bleeding.

Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum.

Specific Diagnosis

Importantfactors to consider in diagnosis are

Age

Clinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)

History of aspirin, NSAID, or alcoholingestion

Presence of known diseases (e.g., IBDor liver disease)

Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.

If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.

If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.

Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.

If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.

Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.

If the bleeding is massive or uncontrolled,immediate surgery should be considered.

In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.

With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.

Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.

Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception.

With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.

Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including Crohndisease

Selective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern.

References

1. Altschuler SM, Liacouras CA, eds. Clinicalpediatric gastroenterology. Philadelphia: Churchill Livingstone,1998.
2. Kharasch SJ. Gastrointestinal bleeding. In: FleischerGR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4thed. Philadelphia: Lippincott Williams & Wilkins, 2000:275–282.
3. Kirks DR. Practical pediatric imaging: diagnostic radiologyof infants and children, 3rd ed. Philadelphia: Lippincott-Raven,1998.
4. Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2001. World Wide Web URL: http://www.ncbi.nlm.nih.gov/omim.
5. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996
6. Squires RH Jr. Gastrointestinal bleeding. In: AltschulerSM, Liacouras CA, eds. Clinical pediatric gastroenterology. Philadelphia:Churchill Livingstone, 1998:31–42.
7. Walker WA, et al., eds. Pediatric gastrointestinaldisease, 3rd ed. Hamilton, Ontario, Canada: BC Decker, 2000.

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Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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