Chapter 131: Gastrointestinal Bleeding in Infants and Children

INTRODUCTION AND EPIDEMIOLOGY

GI bleeding varies in its epidemiology and presentation depending on whether it originates from the upper or lower GI tract. Upper GI (UGI) bleeding is bleeding proximal to the ligament of Treitz, whereas lower GI (LGI) bleeding originates distal to this ligament. UGI bleeding is a relatively uncommon presentation in pediatrics, with one population-based survey reporting an incidence of 1 to 2 per 10,000 children/year.¹ LGI bleeding is more common, but most cases are benign and self-limited.² In one study, LGI bleeding constituted the chief complaint of 0.3% of children presenting to a pediatric ED, but only 4.2% of these patients had bleeding considered to be life-threatening.³

The signs and symptoms of GI bleeding in children vary: bright red blood in small strands or clots in emesis or bowel movements, vomiting of gross blood (hematemesis), black tarry stools (melena), or the passage of bright red or maroon-colored blood from the rectum (hematochezia). Occult bleeding may result in unexplained pallor, fatigue, and anemia. Severity is assessed by vital signs, physical appearance, and the hemodynamic status of the patient, all of which lead to an estimation of the volume of blood loss. Worrisome symptoms and signs include pallor, diaphoresis, lethargy, abdominal pain, tachycardia, hypotension, and altered mental status. GI bleeding can be life threatening. Advances in endoscopy, radiology, and newer therapeutic modalities have helped identify the causes of bleeding more accurately and have provided more treatment options.

CLINICAL APPROACH

Assess bleeding and institute resuscitation if the child has signs of hemorrhagic shock. Next, obtain a history and perform a physical examination, and try to establish the level of bleeding as UGI or LGI, because the subsequent diagnostic and treatment steps differ. Then, narrow the differential diagnosis based on history, physical examination, laboratory studies, and the categorization of age-related causes of UGI and LGI bleeding. The presence of any one of melena, hematochezia, unwell appearance, or moderate to large volume of fresh blood in the vomitus was associated with a clinically significant UGI bleed (defined as a hemoglobin drop of >20 g/L, need for blood transfusion, need for emergent endoscopy, or need for surgical procedure).⁴

ASSESS BLEEDING AND BEGIN RESUSCITATION

There are several important questions to consider. Is the patient stable or unstable? Is this really blood, and is it coming from the GI tract? Is it a small amount of blood or a large volume? Has the child had prior episodes of bleeding, and if so, do the parents know the cause and prior treatment?⁵

IS THE PATIENT STABLE OR UNSTABLE?

The presence of tachycardia, pallor, tachypnea, prolonged capillary refill time, altered mental status, metabolic acidosis, and/or hypotension indicates significant GI bleeding. Tachycardia and tachypnea are the first clinical signs, followed by delayed capillary refill, decreased urine output, altered mental status, metabolic acidosis, ...