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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
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Clinical Features
and Differential Diagnosis
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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.
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GI bleeding in the infant may ...