Gastrointestinal (GI) bleeding occurs rarely in children; severity varies from the insidious bleeding, with only iron-deficiency anemia suggestive of occult hemorrhage, to dramatic hemorrhage with rapidly evolving, life-threatening hypovolemic shock. Upper GI bleeding is bleeding from a source proximal to the ligament of Treitz (duodenojejunal junction). Hematemesis is the vomiting of frank blood and suggests a rapidly bleeding lesion. Coffee-ground emesis describes the appearance of vomited blood that has been coagulated by gastric acid. Hematochezia is blood passed with stool from the anus. Blood limited to the outside of otherwise unremarkable stool suggests a rectal origin; blood mixed throughout the stool suggests a colonic source. Melena is black, tarry stool produced by the oxidation of heme by intestinal flora; as little as 50 mL of blood may result in melena, and it may persist for 3 to 5 days following resolution of the bleeding. Maroon-colored stool is associated with rapidly bleeding small bowel lesions in which the transit of blood is too fast for complete oxidation. Currant-jelly stool is associated with ischemic small bowel or proximal colonic lesions and may be seen in intussusception. Occult GI bleeding is bleeding that occurs in the absence of overt bleeding and is usually suspected due to chronic iron-deficiency anemia or identification by stool guaiac examination.
Disorders causing upper GI bleeding occur with varying frequency depending on the age of presentation (Table 382-1). In the newborn, several unique disorders not usually considered in the differential diagnosis of older infants and adults must be considered. Swallowed maternal blood, either from parturition or from feeding from a fissured nipple, may cause what appears to be GI bleeding. Hemorrhagic disease of the newborn may occur when neonatal vitamin K is not administered at birth, and it should be considered in newborns born outside of traditional medical settings or who required acute resuscitation at birth such that routine administration was neglected. Peptic disease may occur in newborns and result in gastritis or ulceration. Dietary protein intolerance (often cow milk) may result in mucosal inflammation and hemorrhage. GI obstruction, as seen in pyloric stenosis or midgut volvulus, may present with GI bleeding.
TABLE 382-1ETIOLOGY OF UPPER GASTROINTESTINAL BLEEDING BY PEDIATRIC AGEa ||Download (.pdf) TABLE 382-1ETIOLOGY OF UPPER GASTROINTESTINAL BLEEDING BY PEDIATRIC AGEa
|Newborn ||Infant ||Child/Adolescent |
|Swallowed maternal blood ||Mallory-Weiss tear ||Peptic ulcer disease |
|Vitamin K deficiency ||Prolapse gastropathy ||Erosive gastritis |
|Peptic ulcer disease ||Vascular malformation ||Mallory-Weiss tear |
|Vascular malformation ||Anatomic duplication ||Variceal bleed |
|Coagulopathy ||Bowel obstruction ||Caustic ingestion |
|Dietary protein intolerance ||Mucosal webs ||Vasculitis |
| ||Foreign body ||Inflammatory bowel disease |
| || ||Bowel obstruction |
| || ||Hemobilia |
| || ||Vascular ectasias |
| || ||Foreign body |