Chapter 72

• Pulse rate and quality can help determine the presence of a significant gastrointestinal (GI) bleed.
• Examination of the posterior pharynx in patients with hematemesis may reveal a posterior nosebleed as the cause.
• Cefdinir and Rifampin can cause red stools and be mistaken for a GI bleed.
• The Apt-Downey test can differentiate swallowed maternal blood from neonatal GI bleeding.
• Vascular malformations are a rare but serious cause of both upper and lower GI bleeding.
• The ligament of Treitz is the anatomic separation between upper and lower GI bleeding.
• Melena indicates proximal bleeding, while hematochezia is seen with bleeding from the distal colon and rectum.

Gastrointestinal (GI) bleeding is a common and anxiety-provoking experience for both parents and children. Although the exact incidence of gastrointestinal bleeding in children is unknown, hematemesis and hematochezia are common emergency department complaints. In healthy children, most gastrointestinal bleeding is minor and self-limited, but occasionally the bleeding can be severe and even life-threatening.

As with any chief complaint, initial assessment must focus on rapid assessment and stabilization. Although most children with gastrointestinal bleeding will be clinically stable, rarely a child with a massive gastrointestinal bleed may present critically ill. A child's airway can be jeopardized by profuse bleeding with aspiration of blood, or decreased mental status from blood loss. If the airway is compromised or the child is at risk for aspiration, endotracheal intubation should be quickly performed. A nasogastric tube may be required to keep the stomach decompressed and to minimize vomiting. Assessment of a child's circulation is critical, and if there is any concern about excessive or continued blood loss, two large-bore IVs should be immediately placed. Pulse rate and quality and capillary refill time and blood pressure should be rapidly assessed to determine the need for fluid resuscitation. Fluids should be given as crystalloid boluses, but if blood loss is severe, repletion with blood products including packed red blood cells and fresh frozen plasma may be required.

Once stability of a child's airway, breathing, and circulation has been confirmed, further history and physical examination can be obtained. Asking about the color, timing, and volume of bleeding is essential, although it is often difficult for parents and children to accurately assess the volume of blood loss. Associated symptoms such as abdominal pain, preceding vomiting, fever, and stool patterns are also helpful. Some patients have a history of conditions such as coagulopathy, liver, or bowel disease known to put them at risk for gastrointestinal bleeding. In addition, medications such as NSAIDs, corticosteroids, or anticoagulants are known to increase the risk for bleeding

Although the source of gastrointestinal bleeding is often difficult to visualize, certain physical examination findings can assist in the diagnosis. Vital signs, particularly pulse rate and quality, are essential in determining if a patient has experienced a hemodynamically significant bleed, and other assessments of circulation such as capillary refill and skin color are also helpful adjuncts. Examination of the ...

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