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Gastrointestinal (GI) bleeding can be occult (not readily visible) or overt. This chapter will focus on overt GI bleeding that is acute or subacute. Separate chapters (e.g., Chapters 13 and 16) will cover aspects of chronic or occult GI blood loss in more detail. The source of visible blood in stool or vomit may be from the upper GI (UGI) tract, lower GI (LGI) tract, extraintestinal (e.g., swallowed blood from a nosebleed), or an exogenous substance (e.g., red-colored foods). Regardless of the source, obvious blood from the GI tract tends to be a very distressing problem for patients and their families that quickly bring them to medical attention. GI bleeding can be serious and life threatening. Thankfully, serious GI bleeding is uncommon in the pediatric age group and the problem often resolves without specific intervention. The key to approaching a patient with GI bleeding is a rapid assessment of the severity of bleeding and hemodynamic status of the child. Given the nature of the content, this chapter will focus on differential diagnosis, diagnostic approach, and treatment based on clinical presentation: hematemesis or coffee ground emesis, hematochezia, and melena.

UGI bleeding is defined as a source proximal to the ligament of Treitz (where the duodenum meets the jejunum). LGI bleeding is from a source distal to the ligament of Treitz (see Figure 6–1).


Position of ligament of Treitz. Bleeding above this point is considered upper GI and below is lower GI.

Hematemesis refers to vomiting bright red blood, usually indicating fairly brisk bleeding. Coffee ground emesis usually occurs with slower bleeding and coagulation of blood after exposure to gastric acid. Melena refers to stools that are jet black and tarry, and often have a distinctive foul odor. Melena occurs when intestinal bacteria have time to oxidize heme to hematin, usually indicating a relatively slow bleed proximal to the cecum. Hematochezia refers to bright red or maroon blood in stools, usually from a colonic bleed but can occur with high-volume UGI bleeding with rapid transit time. Bleeding, if severe, can also become symptomatic (dizziness, syncope, pallor, tachycardia, and hypotension) before the passage of a bloody stool.

The pathogenesis of true GI bleeding varies greatly by etiology. A few broad categories of pathology underlie most causes of bleeding. Vascular anomalies (e.g., arteriovenous malformations or hemangiomas), collateral vessel formation (e.g., esophageal varices), or erosion of the intestinal mucosa (e.g., inflammation, ulceration, sloughing, and perforation) bring blood vessels in close proximity to the intestinal lumen and may make them prone to rupture. Acute or chronic vascular congestion, thrombosis, and/or ischemia may also lead to bleeding. Any illness (most often viral gastroenteritis) that causes persistent retching and vomiting can cause bleeding from mucosal tears in the lower esophagus and upper stomach (Mallory–Weiss tears) and/or broken capillaries in the gastric mucosa (emetogenic gastropathy).

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