Bleeding, Gastrointestinal

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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

Clinical Findings

History

• 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

Physical Examination

• 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

Diagnosis

Laboratory Findings

• 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

Imaging