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Key Features

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Essentials of Diagnosis
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  • A systolic blood pressure below 100 mm Hg and a pulse rate above 100 beats/min in an older child suggest at least a 20% reduction of blood volume

  • A pulse rate increase of 20 beats/min or a drop in systolic blood pressure > 10 mm Hg when the patient sits up is also a sensitive index of volume depletion

  • Tachycardia may be the initial indication of persistent bleeding

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General Considerations
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  • Emergency department visits for GI bleeding in children has increased across the United States over the past several years, now above 94 per 100,000

  • The largest increase in that time has been for lower GI bleeding, rising by more than 31% over a 5-year period

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Clinical Findings

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History
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  • A careful history of the specifics surrounding the bleeding should be ascertained, including

    • Site, volume, and color of blood

    • History of NSAID use

    • Use of other medications

  • Inquiry about associated dysphagia, epigastric pain, or retrosternal pain should be made and, if present, suggest gastroesophageal reflux (GER) or a peptic cause of bleeding

  • Other important aspects of the history include

    • Foreign body/caustic ingestion

    • History of chronic illnesses (especially liver/biliary disease)

    • Personal or family history of food allergy/atopy

    • Associated symptoms (pain, vomiting, diarrhea, fever, weight loss)

    • Family history of GI disorders (inflammatory bowel disease [IBD], celiac disease, liver disease, bleeding/coagulation disorder)

  • In the presence of massive upper GI bleeding in the toddler, a high index of suspicion for button battery injury must be maintained despite the lack of any known history of ingestion

  • In the ICU setting, mechanical ventilation has been found to be the single largest risk factor for stress-induced GI bleeding

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Physical Examination
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  • The first step is to determine whether the child is acutely or chronically ill and initiate supportive measures as needed

  • Physical signs of portal hypertension, intestinal obstruction, or coagulopathy are particularly important

  • Nasal passages should be inspected for signs of recent epistaxis, the vagina for menstrual blood, and the anus for fissures and hemorrhoids

  • Skin examination should assess for hemangiomas, eczema, petechiae, or purpura

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Diagnosis

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Laboratory Findings
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  • At minimum, initial laboratory tests should include

    • Complete blood count

    • Prothrombin time

    • Partial thromboplastin time

  • In specific cases it may be prudent to add

    • Liver profile (with suspected variceal bleeding)

    • Erythrocyte sedimentation rate/C-reactive protein (with possible IBD)

    • Blood urea nitrogen/creatinine (for possible hemolytic uremic syndrome)

    • Stool culture/Clostridium difficile toxin assay (for acute bloody diarrhea suggestive of infectious colitis)

  • Low mean corpuscular volume (MCV) in association with anemia

    • Suggests chronic GI losses

    • May warrant addition of iron studies

  • Serial determination of hematocrit is essential to assess ongoing bleeding

  • Presence of blood should be confirmed with guaiac testing

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Imaging
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  • Multiple-view abdominal radiographs are helpful in ...

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