Lower GI Bleeding

Maria R. Mascarenhas, MBBSKristin N. Fiorino, MD

Lower GI Bleeding - BASICS

Lower GI Bleeding - description

• Lower GI bleeding refers to bleeding from the lower GI tract, distal to the ligament of Treitz.
• Can be hematochezia (passage of bright red or dark blood per rectum) or melena (passage of dark, black, or tarry stools)

Lower GI Bleeding - etiology

Reasons for lower GI bleeding at different ages:

• Neonatal period (birth to 1 month):
  • Anorectal fissure
  • Necrotizing enterocolitis
  • Enteric infections
  • Allergic colitis
  • Upper GI source
  • Duplication cyst
  • Enterocolitis with Hirschsprung disease
  • Meckel diverticulum
  • Malrotation with volvulus
  • Hemorrhagic disease of the newborn
• Infancy (1 month to 2 years):
  • Anorectal fissure
  • Enteric infections
  • Allergic colitis
  • Intussusception
  • Meckel diverticulum
  • Malrotation with volvulus
  • Lymphonodular hyperplasia
  • Upper GI source
  • Duplication cyst
  • Enterocolitis with Hirschsprung disease
  • Vascular malformation
• Preschool age (2–5 years):
  • Anorectal fissure
  • Enteric infections
  • Polyps
  • Parasites
  • Meckel diverticulum
  • Intussusception
  • Lymphonodular hyperplasia
  • Inflammatory bowel disease
  • Enterocolitis with Hirschsprung disease
  • Hemolytic uremic syndrome
  • Henoch-Schönlein purpura
  • Vascular malformation
  • Child abuse
  • Perianal streptococcal cellulitis
• School age (5–13 years):
  • Anorectal fissure
  • Enteric infections
  • Inflammatory bowel disease
  • Intussusception
  • Meckel diverticulum
  • Polyps
  • Henoch-Schönlein purpura
  • Hemolytic uremic syndrome
  • Parasites
  • Child abuse
  • Vascular malformations
  • Perianal streptococcal cellulitis
• Adolescent (>13 years):
  • Anorectal fissure
  • Enteric infections
  • Inflammatory bowel disease
  • Hemolytic uremic syndrome
  • Intussusception
  • Midgut volvulus
  • Polyps
  • Vascular malformations
  • Lymphonodular hyperplasia
  • Parasites
  • Hemorrhoids

Lower GI Bleeding - DIAGNOSIS

• General goals: Determine location of bleeding and the cause, and begin stabilization and treatment.
  • Phase 1: Determine if there is blood or other cause of red or black stools.
  • Phase 2: Assess patient to determine etiology; follow history, physical, and laboratory.
  • Phase 3: Stabilize patient, decide if emergency treatment or referral is needed. (See “Emergency Care” under “Treatment.”)
• Hints for screening problem:
  • The more rapid the rate, the larger the volume of lower GI bleeding, and greater the drop in hemoglobin and change in pulse and BP.
  • Any significant blood loss will lead to pallor, tachycardia, orthostasis, poor capillary refill, CNS changes (restlessness, confusion), and hypotension.
  • Hypotension may not be seen even in the face of significant blood loss, because vasoconstriction will occur to maintain BP until decompensation.
  • Initial hemoglobin values may be unreliable, because a delay in hemodilution may falsely result in near-normal values.
  • In newborn, determine if this is swallowed maternal blood by the Apt-Downey test.

Lower GI Bleeding - signs & symptoms

Lower GI Bleeding - history

• Obtain a detailed history and note if any recently ingested foods resemble blood.
• Color of blood:
  • If bright red, then site of bleeding is probably in left colon, rectosigmoid, or anal canal
  • If darker red, then from right colon
  • If melena or tarry, then bleeding is proximal to ileocecal valve
• Location of blood in relation to the stool:
  • In colitis, the blood will be mixed with stool
  • With a fissure, it will be in streaks on the outer aspect of the stool.
• Consistency of the stool:
  • If diarrhea, more likely to be colitis
  • If hard, then more likely to be a fissure
• Painful stools suggest anal fissure, local proctitis, or ischemic bowel.
• Painless rectal bleeding is associated with polyps, Meckel diverticulum, or vascular anomaly.
• Abdominal pain can be seen with colitis, inflammatory bowel disease, or surgical abdomen.
• Any underlying known GI disease, previous GI surgery: Past history of colitis, Hirschsprung disease, necrotizing enterocolitis
• Any history of jaundice, hepatitis, liver disease, neonatal history: Suggestive of portal vein thrombosis (sepsis, shock, exchange transfusion, omphalitis, IV catheters), portal hypertension, and variceal bleeding
• Any familial history of bleeding diathesis: von Willebrand disease, hemophilia
• Medications: Heparin, warfarin
• Associated symptoms:
  • Mouth ulcers
  • Weight loss
  • Joint pains as in inflammatory bowel disease
  • Petechiae
  • Renal insufficiency
  • History of ingestion of uncooked meat as in hemolytic uremic syndrome
  • Purpuric rash as in Henoch-Schönlein purpura
  • Severe abdominal pain and vomiting as in a surgical abdomen

Lower GI Bleeding - physical exam

• Skin:
  • Petechiae or purpura
  • Ecchymosis
  • Hemangiomas
  • Evidence of chronic liver disease (spider angiomata, palmar erythema)
  • Jaundice
• HEENT:
  • Freckles on buccal mucosa: Peutz-Jeghers syndrome
  • Mouth ulcers: Crohn disease
• Abdomen:
  • Hepatosplenomegaly, ascites: Portal hypertension
  • Isolated splenomegaly: Cavernous transformation of the portal vein
• Rectal examination:
  • Evidence of any perianal disease
  • Inflammatory bowel disease: Bright red blood in the perianal area
  • Polyps: Bright red blood in stool
  • Hemorrhoids: Portal hypertension

Lower GI Bleeding - tests

Lower GI Bleeding - lab

• CBC: Iron-deficiency anemia:
  • Leukopenia, anemia, and thrombocytopenia: Consider chronic liver disease and portal hypertension
  • Anemia with normal RBC indices: Truly an acute cause for bleeding
  • RBC indices indicate iron-deficiency anemia: Consider varices or a mucosal lesion, i.e., chronic blood loss
  • Thrombocytopenia: Consider hemolytic uremic syndrome.
• Coagulation profile:
  • If PT and PTT are abnormal, consider liver disease or disseminated intravascular coagulation with sepsis.
• Liver function tests: Abnormal in chronic liver disease
• Renal function tests (BUN, creatinine, urine analysis): Abnormal in hemolytic uremic syndrome, Henoch-Schönlein purpura
• ESR or C-reactive protein (CRP): Abnormal in inflammatory disorders or infectious colitis
• Stool tests:
  • Stool culture (Salmonella, Shigella, Campylobacter, Yersinia, Aeromonas, Escherichia coli)
  • Stool for Clostridium difficile toxin A and B
  • 3 stool samples for ova and parasites (amebae)
  • Stool smears for WBCs (not always positive in colitis) and eosinophils (not always positive in allergic colitis)

Lower GI Bleeding - imaging

• Abdominal x-ray helpful in surgical abdomen (dilated bowel, air–fluid levels, perforation), constipation (presence of excessive stool), colitis (edematous bowel, thumb-printing) and toxic megacolon
• Ultrasound can show bowel wall thickening and Meckel diverticulum and is diagnostic of intussusception.

Lower GI Bleeding - diag proced-surgery

• Lower and upper endoscopy:
  • Full colonoscopy to the terminal ileum helpful in diagnosing inflammatory bowel disease
  • Upper endoscopy diagnostic in massive upper GI bleeds presenting with hematochezia
  • Enteroscopy involves the passage of a special endoscope further in the small bowel, identifying rare lesions in the proximal 60–120 cm of the jejunum.
• Barium tests:
  • Air-contrast enema is diagnostic and therapeutic in intussusception and diagnostic in mucosal lesions (polyps).
  • Upper GI series with small-bowel follow-through is helpful in evaluating anatomy and Crohn disease and its complications (fistula, sometimes ulcer may be identified).
  • Enteroclysis or small bowel enema provides good mucosal detail.
• Meckel scan:
  • Diagnostic for Meckel diverticulum that secretes acid
  • There may be false negatives if the Meckel diverticulum has different tissue expression.
• Bleeding scan:
  • Useful when endoscopy is not diagnostic
  • Technetium sulfur colloids versus tagged RBC scan: The former detects rapid bleeding but can miss small bleeds, especially if the patient is not bleeding during the scan. The latter can detect small bleeds, especially if intermittent.
• Angiography:
  • Useful in detecting vascular causes for GI bleeding >0.5 mL/min
  • Can also be therapeutic
• Video capsule endoscopy:
  • Useful in detecting distal small bowel hemorrhage
  • Approved for ages >10 years

Lower GI Bleeding - differencial diagnosis

• The majority of patients with lower GI bleeding have a fissure or infection.
• Mucosal lesions are more likely to be associated with antecedent occult bleeding.
• In most, the bleeding stops spontaneously.
• Pitfalls:
  • Make sure red substance in stool is really blood and not food coloring.
  • Initial hemoglobin, if normal, may be misleading.

Lower GI Bleeding - TREATMENT

Emergency care:

• If patient is critical, stabilize with IV fluids and blood products.
• Order laboratory tests: CBC, PT/PTT, disseminated intravascular coagulation screen, liver function tests, blood type, and cross-match
• Insert a nasogastric tube and lavage with saline if it is unclear whether the patient is having hematochezia due to massive bleeding from the upper GI tract.
• Monitor patient’s vital signs and hemoglobin.
• Make appropriate diagnosis and institute appropriate therapy, i.e., abdominal x-ray, colonoscopy, bleeding scans.

Lower GI Bleeding - general measures

Clinical pearls:

• Anal fissure: Treat the underlying constipation (mineral oil, lactulose, high-fiber diet). Local therapy consists of sitz baths, local emollient creams, and steroid suppositories.
• Polyp: Colonoscopy and polypectomy
• Intussusception: Ultrasound is diagnostic. Air-contrast enema permits confirmation and hydrostatic reduction.
• Parasites: Antiparasitic drugs

Lower GI Bleeding - diet

Introduce hydrolyzed protein formula in infants with cow’s milk protein allergy.

Lower GI Bleeding - surgery

In cases of massive or persistent bleeding with no identifiable site, exploratory laparotomy with intraoperative endoscopic evaluation of the entire bowel to identify mucosal lesions may be required.

Lower GI Bleeding - FOLLOW UP

Lower GI Bleeding - disposition

Lower GI Bleeding - issues for referral

Refer the following patients to a specialist:

• Any patient with significant acute lower GI bleeding after initial stabilization
• Patients with less acute bleeding for whom an easily identifiable cause has not been found or patients with chronic or recurrent lower GI bleeding

Lower GI Bleeding - bibliography

1. Cave D. Technology insight: Current status on video capsule endoscopy. Nat Clin Pract Gastroenterol Hepatol. 2006;3:158–164.
2. Chaibou M, Tucci M, Dugas MA, et al. Clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit. Pediatrics. 1998;102(4 pt 1):933–938.
3. Fox V. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29:37–66.
4. Guritzky RP, Rudnitsky G. Bloody neonatal diaper. Ann Emerg Med. 1996;27:662–664.
5. Lawrence WW, Wright JL. Causes of rectal bleeding in children. Pediatr Rev. 2001;22:394–395.
6. Leung AK, Wong AL. Lower gastrointestinal bleeding in children. Pediatr Emerg Care. 2002;18:319–323.
7. Squires RH. Gastrointestinal bleeding. Pediatr Rev. 1999;20:95–101.
Turk D, Michaud L. Lower gastrointestinal bleeding. In: Kleinman B, Goulet O-J, Mieli-Vergani G, et al. Walker’s Pediatric Gastrointestinal Disease, 4th ed. Philadelphia: BC Decker; 2004:266–280.

Lower GI Bleeding - CODES

Lower GI Bleeding - icd9

578.9 Gastroenteric hemorrhage

Lower GI Bleeding - FAQ

• Q: What is the most common cause of lower GI bleeding?
• A: In all age groups, fissures are the leading cause, followed by infections. However, in infancy, the most common cause is a fissure; in toddlers and young children, polyps; and in older children, inflammatory bowel disease.
• Q: What common foods cause stools to be red? Black?
• A: Red: Raspberries, cranberries, artificial coloring in cereal. Black: Bismuth, licorice.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Gastrointestinal bleeding

Read excerpts from these other book chapters related to Gastrointestinal bleeding:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Gastrointestinal bleeding

• Back to symptom: Gastrointestinal bleeding: Introduction (review 199 causes)
• Next Book Extract About Gastrointestinal bleeding: Upper Gastrointestinal Bleeding (The 5-Minute Pediatric Consult)
• All Book Extracts: All Online Book Extracts for Gastrointestinal bleeding

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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