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Upper GI (UGI) bleeding is bleeding proximal to the ligament of Treitz, whereas lower GI (LGI) bleeding originates distal to this ligament. 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 profuse bright red blood from the rectum (hematochezia). Occult bleeding may result in unexplained pallor, fatigue, and anemia. The severity is assessed by vital signs, the 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, and advances in endoscopy, radiology, and newer therapeutic modalities have helped identify the causes of bleeding more accurately and have provided more treatment options.

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.

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 treatments?1

Is the Patient Stable or Unstable?

The presence of tachycardia, pallor, tachypnea, prolonged capillary refill time, altered mental status, or metabolic acidosis indicate significant GI bleeding.

Tachycardia and tachypnea are the first clinical signs followed by delayed capillary refill, decreased urine output, altered mental status, metabolic acidosis, and pallor. Any signs of hemorrhagic shock require simultaneous resuscitation, diagnosis, and treatment. Maintain the airway, monitor oxygen saturation and provide oxygen, place two large-bore IVs (20 gauge or larger) and administer boluses of crystalloid and, possibly, blood products.

Is This Really Blood?

Determine whether or not the vomit or stool really contains blood. Beets, food coloring, and fruit juices can look like blood. Black and tarry stools can result from vitamins with iron, Pepto-Bismol, spinach, cranberries, blueberries, or licorice. Urinary crystals in the neonatal diaper are often orange in color and may be interpreted by a caregiver as blood. The Gastroccult®/Hemoccult® card (Beckman Coulter, Brea, CA) can be used to document the presence of blood in stool or gastric contents. False negative tests can occur in the setting of small amounts of blood originating from the UGI ...

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