Gastrointestinal Bleeding

Marilyn R. Brown

Gastrointestinal (GI) bleeding in children is a common and occasionally life-threatening occurrence. The physician first determines if the child has bled. If the child has bled a significant amount, therapy may need to be instituted before the site of bleeding is determined. The physician attempts to find out whether the bleeding is from the upper (originating above the ligament of Treitz) or lower GI tract. The cause and specific site of bleeding are determined, if possible (Box 346.1). Thirty years ago, a definite cause could be found in only approximately one-half of cases. Current diagnostic techniques, including fiberoptic endoscopy, radiography, scintography, angiography, and video endoscopy, allow
localization of the site of bleeding to be determined in most cases.

BOX 346.1 Causes of Gastrointestinal Bleeding

First 4 weeks

Swallowed maternal blood

Hemorrhagic disease of the newborn

Anal fissure

Hemorrhagic gastritis

Stress ulcers

Infective enterocolitis

Protein-sensitive enterocolitis

Necrotizing enterocolitis

Hirschsprung enterocolitis

Duplication cysts

Midgut volvulus

Vascular malformations

First 6 months

Nonspecific colitis

Anal fissure

Esophagitis

Infective enterocolitis

Protein-sensitive enterocolitis

Intussusception

Lymphonodular hyperplasia

Duplication cysts

Hirschsprung enterocolitis

Vascular malformations

6 months to 5 years

Epistaxis

Esophagitis

Esophageal varices

Gastritis

Infective enterocolitis

Clostridium difficile colitis

Lymphonodular hyperplasia

Intussusception

Meckel diverticulum

Vascular malformations

Henoch-Schönlein purpura

Hemolytic uremic syndrome

Neutropenic typhlitis

Polyps

Anal fissure

5 to 18 years

Same as for 6 months to 5 years plus

Tear in gastric mucosa (Mallory-Weiss syndrome)
Gastritis
Peptic ulcer
Chronic ulcerative colitis
Crohn disease
Hemorrhoids

Some causes of bleeding are more likely to occur at certain ages, and some causes are associated with certain rates of bleeding, varying from slow loss of small amounts to rapid loss of large amounts. Minor bleeding may be caused by esophagitis, infective and allergic enterocolitis, Crohn disease, colonic polyps, and anal fissures. Slow chronic bleeding can result from chronic esophagitis, chronic inflammatory bowel disease, and sometimes colonic polyps. Acute significant losses may be caused by esophageal varices, hemorrhagic gastritis, peptic and stress ulcers, Meckel diverticulum, chronic inflammatory bowel disease, and vascular malformations. The passage of a “currant jelly” stool (mixed blood and mucus, light red) often indicates an acute intestinal obstruction such as intussusception.

ESTABLISHMENT OF BLOOD LOSS

Whether or not blood loss has occurred must be determined first. Many substances ingested by children may be mistaken for blood. Red food coloring, fruit-flavored drinks, fruit juices, and beets may color the vomitus or stool reddish. Stools can acquire a black color from ingested iron, bismuth subsalicylate, grape juice, spinach, and blueberries. The vomitus or gastric aspirate is tested by Gastroccult (pH buffered) and the stool by guaiac, Hemoccult, or Hematest for the presence of blood. If a child presents in the office with anemia that has no clear explanation, several stools should be tested for occult blood.

TYPE OF BLEEDING

A description of the color, location, and amount of blood usually is helpful. Did the child cough up blood (hemoptysis) or vomit up blood (hematemesis) after epistaxis? Gastric acid turns the blood a brown color. Small amounts of bright red blood (hematochezia) or blood streaking in the stool most often is caused by polyps, proctitis, constipation with anal fissures, or hemorrhoids. Bright red blood on the outside of the stool accompanied by pain on passage of the stool usually is from an anal fissure. Bright red blood mixed with mucus in a loose stool is typical of chronic ulcerative colitis. The classic currant jelly stool occurs from ileocolic intussusception (prolapse of the ileum through the ileocecal valve into the colon) and may occur with midgut volvulus. Melena (black or dark maroon stool) suggests a lesion proximal to the right colon, such as a Meckel diverticulum, or an upper GI bleed. A bleeding duodenal ulcer can present with red bloody stools instead of melena because of rapid transit through the GI tract.

If the patient enters the emergency department with melena or hematochezia with evidence of anemia and tachycardia or hypotension, an aspiration of gastric contents must be obtained to look for evidence of upper GI bleeding.

The magnitude of the blood loss is important in formulating the therapeutic and diagnostic plan, as is the age of the patient. Severe life-threatening hemorrhage is a rare occurrence in children, but the cause usually is found; however, the cause of chronic slow blood loss sometimes is difficult to determine.

AGE-INDEPENDENT ETIOLOGIES

Certain causes of GI bleeding are seen more commonly in specific age groups, but considerable overlap exists. At all ages, stress (burns, central nervous system trauma) and ingestion of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) may lead to gastric or duodenal stress erosions and ulcerations. Thrombocytopenia and coagulopathies must be considered. Intestinal bleeding is not an uncommon occurrence in children with cancer who develop thrombocytopenia secondary to chemotherapy. Chemotherapy may be followed by esophagitis, gastritis, and enterocolitis. Although primary tumors of the GI tract are rare findings, they must be considered in the differential diagnosis at any age. Blood in the stool rarely accompanies giardiasis, whereas it is a common finding in amebiasis.

AGE-ASSOCIATED ETIOLOGIES

First 4 Weeks

In the first few days to months of life, a long list of causes of gastrointestinal bleeding include swallowed maternal blood, hemorrhagic disease of the newborn, irritation from a nasogastric tube, anal fissure, hemorrhagic gastritis, gastric or duodenal stress ulcers, necrotizing enterocolitis, Hirschsprung enterocolitis, and midgut volvulus. In the first few days of life, hematemesis or the passage of bloody stools in a healthy newborn most likely is caused by swallowed maternal blood, which can be differentiated from fetal hemoglobin by the Apt alkali denaturation test. If the red blood denatures with alkali to a brown color, the hemoglobin is of adult origin. Hemorrhagic disease of the newborn with prolongation of the prothrombin time must be considered when vitamin K has not been administered. Breast-fed infants are particularly susceptible to this complication. An anal fissure is a common cause of bleeding, usually initiated by the passage of a firm stool that makes a small tear along the anal canal. Significant bleeding in the neonate, particularly in the stressed newborn and premature infant, may occur from hemorrhagic gastritis, gastric erosions, or gastric stress ulcers. Necrotizing enterocolitis (ischemic damage to the bowel wall) may begin with mild diarrhea, which is positive for reducing substances, and with increased gastric residuals after feeding, followed by blood in the stool and the appearance of abdominal distension and pneumatosis intestinalis. Hirschsprung enterocolitis, midgut volvulus, and intestinal duplication cysts also may present with bleeding and must be kept in mind. Irritation from nasogastric tube feedings is a common cause of small amounts of blood in the gastric aspirate or stool.

First 6 Months

A little bit older infant may have protein-induced colitis, gastroesophageal reflux esophagitis, allergic gastritis, bacterial colitis, or malabsorption of vitamin K in cystic fibrosis. Nonspecific colitis and protein-induced colitis are frequent causes of hematochezia in infants younger than 6 months old. Gastroesophageal reflux is a very common occurrence in infants and occasionally will cause reflux esophagitis with blood loss.

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