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  • Examination of the posterior pharynx in patients with hematemesis may reveal posterior epistaxis as the cause.

  • 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.

  • Melena typically indicates proximal bleeding, while hematochezia is usually seen with bleeding from the distal colon and rectum.


Although the exact incidence of gastrointestinal (GI) bleeding in children is unknown, hematemesis, hematochezia, and melena are common and often anxiety-provoking medical conditions for parents, children, and emergency department (ED) providers. In healthy children, most GI bleeding is minor and self-limited, but occasionally can be life-threatening.

Although most children will be clinically stable, a child with massive GI bleeding may present critically ill and hemodynamically unstable, requiring rapid stabilization. The Pediatric Assessment Triangle facilitates a quick bedside assessment.1

Once stability of a child’s airway, breathing, and circulation has been confirmed, obtain further history and a more complete physical examination to direct secondary management. Information regarding the color (red, coffee-ground, black, or tarry), timing, and volume (drops, “spoonful,” “cupful”) of bleeding is essential, although often difficult to accurately assess.2 Associated symptoms such as abdominal pain, vomiting, fever, diarrhea, and stooling patterns may be helpful. A history of certain pre-existing medical conditions known to be associated with GI bleeding, such as coagulopathy, liver or bowel disease, or recent surgical procedures, may further direct care. A thorough medication history including prescription and non-prescription medicines, such as NSAIDs, corticosteroids, and anticoagulants, that are known to increase the risk for bleeding may help identify the cause.3 Also consider inadvertent or accidental ingestion of medications prescribed to close contacts.

The origin of GI bleeding is often difficult to visualize on physical examination. However, beyond the initial assessment, a focused methodical examination can reveal key diagnostic findings. Examine the nose and pharynx for extra-gastrointestinal bleeding sources such as epistaxis, oropharyngeal trauma, or post-tonsillectomy hemorrhage. Look for signs of liver disease, including jaundice, hepatosplenomegaly, and ascites. Bruising or petechiae may indicate an underlying coagulopathy or platelet disorder. In patients with suspected rectal bleeding, carefully examine the perineum, rectum, and anus for anal fissures, hemorrhoids, excoriated skin from diaper rashes, or signs of physical or sexual abuse.

Direct the diagnostic evaluation and treatment according to the child’s level of hemodynamic stability, history, and physical examination. Patients with small and self-limited GI bleeding who are clinically well-appearing require minimal diagnostic testing. If there is any question about the presence of blood, perform a guaiac or gastroccult test.4 Seemingly apparent bloody stool or vomitus may be caused by ingestions of red food dyes, medications (e.g., cefdinir and rifampin), and foods (e.g., beets) rather than true bleeding. Bismuth salicylate, iron supplementation, spinach, licorice, cranberries, and other foods can turn stools very ...

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