++
Gastrointestinal (GI) bleeding occurs rarely in children; severity
varies from the insidious bleed, 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 bleed. 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 such as 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 is identified by hemoccult examination.1
+++
Clinical Features
and Differential Diagnosis
++
Disorders causing upper gastrointestinal (GI) bleeding occur
with varying frequency depending on the age of presentation (Table 387-1).2 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 such as may be seen
in pyloric stenosis or midgut volvulus may present with GI bleeding.
++
++
GI bleeding in the infant may occur from disorders similar to
those in the newborn. Recurrent vomiting from other etiologies may
result in physical tearing, leading to a Mallory-Weiss tear or traumatic
(prolapse) gastropathy. Infants may also develop GI bleeding
associated with congenital conditions that are delayed in clinical
presentation, such as vascular anomalies, GI duplications, webs,
or midgut volvulus associated with malrotation. Variceal hemorrhage
may occur in infancy as the presenting sign of liver or portal vascular
disease; a history of umbilical catheterization may be seen in cases
of cavernous transformation of the portal vein.
++
Children and adolescents may present with GI bleeding associated
with peptic disease, Mallory-Weiss tears, and varices. A Dieulafoy
lesion may result in vigorous hemorrhage. Variceal hemorrhages occur
with liver disease. Foreign body ingestions may result in bleeding
associated with mucosal erosion, particularly from esophageal impaction
of coins or other foreign bodies. Similarly, caustic ingestions
may present with GI bleeding. Vasculitis may result in GI bleeding.
Hemobilia from biliary disease or endoscopic retrograde cholangiopancreatography (ERCP)
may result in hemorrhage into the descending duodenum with either
an upper or lower GI presentation. Inflammatory bowel disease may
result in upper GI bleeding with Crohn disease or immunodeficiency-related
inflammation.
++
Disorders causing lower GI bleeding also vary in frequency depending
on the age of presentation (Table 387-2).2 Large-volume
upper intestinal hemorrhage may present with lower GI bleeding, particularly
in infants, so it is important to consider causes of upper GI bleeding
in the differential diagnosis. Hematochezia or melena in newborns
should prompt concerns for necrotizing enterocolitis, particularly
in premature or critically ill newborns. Bowel obstruction, such
as with midgut volvulus, should also be considered. Eosinophilic proctocolitis
may result from dietary protein intolerance and may present with
painless hematochezia in otherwise healthy-appearing newborns. A
history of constipation in an infant presenting with bloody diarrhea may
suggest a diagnosis of enterocolitis associated with Hirschsprung
disease. Hemorrhagic disease of the newborn should be considered
in newborns not receiving vitamin K at birth.
++
++
Older infants may also develop lower GI bleeding from bowel obstruction,
enterocolitis (possibly Hirschsprung-related), or dietary protein
intolerance. Intussusception may present with currant-jelly stools
and a palpable abdominal mass. Bleeding that is apparently painful may
be associated with anal fissures, infectious colitis, or immunodeficiency-related
colitis. Painless bleeding may be seen with a Meckel diverticulum,
intestinal duplication, or lymphonodular hyperplasia.
++
Painful bleeding in children and adolescents may be associated
with an anal fissure or infectious colitis. Constipation may result
in rectal mucosal tears. Hemolytic-uremic syndrome may result from
Shiga toxin–producing bacteria, including Escherichia
coli 0157-H7. Inflammatory bowel disease (proctitis, ulcerative
colitis, or Crohn disease) may be diagnosed in young children but
typically presents later in childhood or adolescence. Intestinal
inflammation from Henoch-Schönlein purpura may be seen
in children and adolescents. Painless bleeding suggests a Meckel
diverticulum or polyp; the latter are typically nonmalignant hamartomas.
+++
Diagnostic Evaluation
and Treatment
+++
Initial Assessment
and Management
++
A systematic approach, including assessment of hemodynamic parameters,
history, physical examination, diagnosis, and treatment of the source,
is required. The care of pediatric patients with GI bleeding is
summarized in Figures 387-1 and 387-2 and
begins with a clinical assessment of hemodynamic status. An initial
survey of the patient’s alertness should rapidly screen
for those who are lethargic and may merit aggressive resuscitation.
Tachycardia suggests hypovolemia. Hypotension is worrisome, as it
may be a late sign of impending hypovolemic shock (see Chapter 103). Patients with the acute onset of GI bleeding often require
hospitalization for monitoring. If hemodynamically unstable, volume
resuscitation with crystalloid is a priority, followed by replacement
of blood. Medical management of upper GI bleeding may include administration
of intravenous proton-pump inhibitors.3 A patient
who remains hemodynamically unstable after crystalloid resuscitation
and transfusion of up to 85 mL/kg of packed red blood cells
should be considered for immediate endoscopy and/or surgical exploration
without delay in order to make an extensive evaluation.
++
++
++
The history is initially focused on assessment of the severity
of bleeding, but it may provide clues regarding the underlying cause
of bleeding if the patient has a condition known to predispose to bleeding,
such as hepatic cirrhosis, a disorder associated with vascular malformations,
a bleeding disorder, or use of medications such as nonsteroidal
anti-inflammatory drugs.4,5 Bleeding associated with
a history of pain is more likely associated with an inflammatory
lesion or ischemia, whereas painless bleeding is more likely associated
with a vascular lesion or bleeding from a Meckel diverticulum. However,
the history generally is inadequate to determine the cause of GI
bleeding.
++
Physical examination should assure hemodynamic stability with
vital signs within normal parameters for the child’s age.
Attention should focus on signs of chronic liver disease that may
present with esophageal variceal hemorrhage; such signs include
ascites, hepatosplenomegaly, and spider telangiectasias. Vascular
malformations of the skin suggest the possibility of similar internal
(GI, pulmonary, or airway) lesions. Cutaneous purpura suggests clotting
or vascular dysfunction that may also affect the GI tract. Nasal
and oropharyngeal examination may reveal mucosal or gingival sources
that result in hematemesis of swallowed blood.
++
A laboratory assessment should include a complete blood count
with a reticulocyte count that may help differentiate acute from chronic
conditions. Coagulation indices (prothrombin, partial prothrombin
times, international normalized ratio) will help identify a bleeding
disorder. Elevation of serum aminotransferases may indicate liver
disease.6 Serum albumin may be decreased in both liver
and inflammatory bowel disease. Blood urea nitrogen and creatinine
will indicate renal disease and may also be elevated due to resorption
of blood from the GI tract. Blood should be typed and crossmatched
for transfusion.
++
Apparent blood seen in the emesis, gastric aspirate, or stool
may be rapidly tested for blood using cards impregnated with guaiac,
a colorless resin that is oxidized in the presence of both peroxidase
(test reagent) and peroxidase activity from hemoglobin. False-positive
results may arise from nonhuman hemoglobin peroxidase activity from
red meat, melons, grapes, radishes, turnips, cauliflower, and broccoli.
Iron supplements may result in a dark color but do not cause false-positive reactions.
Heme-positive gastric aspirates may indicate a gastric or esophageal source
or swallowed blood from the lungs or airway. A negative aspirate
does not rule out duodenal bleeding. In the assessment of GI bleeding
from neonates, the Apt-Downey test can help identify swallowed maternal
blood via the differential denaturation of maternal and fetal blood
exposed to alkali.
+++
Gastrointestinal
Endoscopy
++
GI endoscopy is the most valuable initial test for patients with
GI bleeding because it may be both diagnostic and therapeutic.7 It
may be safely performed in children of all ages. It should always
be performed in hemodynamically stable patients and only emergently
in dire circumstances. Esophagogastroduodenoscopy can assess the
upper GI mucosa through the proximal jejunum. Esophageal, gastric, duodenal,
and biliary sources of bleeding should be readily apparent, although
with acute bleeding, the mucosa may be obscured by large, adherent
blood clots. The entire length of the small bowel can be visualized
via wireless capsule video endoscopy. This new technology is licensed
in the United States for use in children 10 years of age and older
but has been successfully performed in very young children.8 The
device may be swallowed or may require endoscopic placement in young
children or those who cannot swallow the device. Colonoscopy can
evaluate the colonic and distal ileal mucosa in children of all
ages. With the exception of capsule endoscopy that is limited to
visualization, endoscopy allows therapeutic control of mucosal bleeding
via cauterization of lesions, injection of peptic lesions with epinephrine
or saline tamponade, sclerotherapy or banding of varices, clipping
of tears, or polypectomy. Single- or double-balloon enteroscopy
is a new technique that allows endoscopic access to the small bowel
for therapeutic treatment. It is now available in some pediatric
centers.9
+++
Radiographic
Evaluation of GI Bleeding
++
Plain radiographs may be useful in the identification of foreign
bodies, GI obstruction (as occurs in volvulus), or GI perforation.
Intramural air may be detected in newborns with necrotizing enterocolitis
or children with neutropenic colitis (typhlitis). Contrast studies
are helpful in the identification of obstruction. Radiographic contrast
may occlude mucosa and may be damaging to endoscopic equipment,
so contrast fluoroscopy (particularly with barium) should be performed
only when subsequent endoscopy is not required. Angiography is sensitive
with hemorrhages of at least 0.5 mL/min and may also allow embolization
of vascular lesions by interventional radiologists; computed tomography angiography
allows detection of vascular lesions with minimal risk, and CT enteroclysis may
also aid in identification of lesions causing occult GI bleeding.10 Scintigraphy
studies such as red blood cell scans are sensitive for hemorrhages
with flows as small as 0.1 mL/min and provide some guidance
on the likely site of bleeding. Meckel scans can identify ectopic
gastric mucosa in a bleeding Meckel diverticulum with a sensitivity
of only 85% following preparation by administration of
an H2-receptor blocking agent.11
+++
Prognosis and
Outcomes
++
Gastrointestinal (GI) bleeding in children may occur at different
ages from various etiologies. Given that GI bleeding can at times
be life threatening, a high index of suspicion for hypovolemic shock
or critical anemia must be maintained. Fortunately, such emergent
presentations are rare. The prognosis and outcome varies depending
on the underlying cause of bleeding. In the vast majority of cases,
if appropriately managed, GI bleeding in childhood resolves following
appropriate medical, endoscopic, interventional radiographic, or
surgical intervention.