Gastrointestinal Bleeding

After completing this article, readers should be able to:An 11-year-old boy is seen in the emergency department after fainting at home. He has a 2-day history of headache and dizziness. Epigastric pain has been present during the past 2 days. His pulse is 150 beats per minute, and his blood pressure is 90/50 mm Hg. An intravenous bolus of normal saline is administered; his hemoglobin level is 8.1 g/dl (81 g/L). He passes a melanotic stool. He is admitted to the pediatric intensive care unit and prescribed intravenous esomeprazole. He receives a transfusion of packed red blood cells, which increases his hemoglobin level to 8.5 g/dl (85 g/L). Esophagogastroduodenoscopy (EGD) reveals nodularity in the antrum of the stomach and a large ulceration with a visible, actively bleeding vessel in the duodenum. The ulcer is coagulated with an argon plasma coagulation (APC) laser. Biopsy specimens taken during the procedure reveal Helicobacter pylori, and the patient is treated by continuing esomeprazole therapy and initiating amoxicillin and clarithromycin therapy. No further bleeding occurs, and he is discharged 4 days later. Gastrointestinal (GI) bleeding is a relatively common and potentially serious problem in pediatrics. It is important for practitioners taking care of children to be familiar with the causes, evaluation, and treatment of GI bleeding. In this article, the etiology of bleeding at different ages and the modalities of evaluation and treatment are discussed. Newer technologies for diagnosis are also addressed.The spectrum of causes of GI bleeding in children ranges from a small amount of bleeding as seen in an infant with an anal fissure to severe bleeding that may be present in a child with varices from underlying chronic liver disease. It is important for the clinician to quickly evaluate the patient with GI bleeding and to differentiate the extent and severity of the bleeding.GI bleeding in children presents in a number of different ways. Upper GI tract bleeding may present as hematemesis, melena, or hematochezia from rapid transit of blood through the intestinal tract due to acute bleeding. The most common causes of bleeding when investigated by endoscopy in the upper GI tract include gastric and duodenal ulcers, gastritis, esophagitis, varices, prolapse gastropathy, and Mallory-Weiss tears.Lower GI tract bleeding may present as either melena or hematochezia. The most common causes of lower GI tract bleeding include fissures, allergic colitis, enteric infections, and juvenile polyps. Severe bleeding may be seen with Meckel diverticulum, inflammatory bowel disease, vascular anomalies, and intussusception.The initial evaluation of a child after presenting with GI bleeding should focus on stabilizing the patient and determining the severity of the bleed. Vital signs should be measured and reviewed. A focused history should be quickly obtained when feasible because it may provide clues to the cause of bleeding. Signs of a significant bleeding episode may include symptoms of hypovolemia, such as tachycardia and hypotension. Orthostatic changes may also be present. Capillary refill may be prolonged. Children with signs and symptoms of significant bleeding and children with active blood loss should be hospitalized in a pediatric intensive care unit if possible. Stabilizing the patient should generally take precedence over evaluation and therapeutic considerations. Large bore venous access should be instituted and fluid resuscitation initiated with Ringer’s lactate or normal saline. Transfusion with packed red blood cells may be indicated, and coagulation factors or platelets may need to be administered in specific cases.The presence of coffee ground emesis or melena generally implies a slower rate of bleeding when compared with emesis or passage per rectum of bright red blood.Guaiac of stool or emesis is helpful in defining whether blood is present. Red emesis or stool may reflect ingested red-colored food or other material. Newer guaiac methods using buffered and stabilized hydrogen peroxide are preferred because they have lower false-positive and false-negative detection.An initial focused physical examination may be helpful in determining the cause of the bleeding. The presence of hepatomegaly and splenomegaly may point to variceal bleeding from liver disease. Scleral icterus, palmer erythema, and spider telangiectasias may be noted with chronic liver disease. Perianal disease may point to the presence of Crohn disease. Careful nasal examination may determine epistaxis as the cause of bleeding. Skin lesions may be seen with Peutz-Jeghers, Cronkhite-Canada (a rare syndrome of multiple intestinal polyps), Osler-Weber-Rendu, and other syndromes, and the presence of multiple skin hemangiomas may be associated with visceral hemangiomas as a cause of GI bleeding.Laboratory studies should be performed to help elicit the cause and define the extent of bleeding. A complete blood cell count documents the hemoglobin level and hematocrit to help determine the extent of bleeding and whether platelet numbers are adequate. A low mean corpuscular volume may point to chronic loss of blood and the presence of iron-deficiency anemia. Abnormal coagulation study results may point to underlying liver disease or malabsorption. Measurement of alanine aminotransferase, aspartate aminotransferase, and bilirubin may point to the presence of liver disease. Blood urea nitrogen and creatinine may help determine fluid status and the presence of renal insufficiency. A low serum albumin level suggests hypoproteinemia, which may herald significant liver disease or protein-losing enteropathy, such as inflammatory bowel disease. With any sign of significant bleeding, blood should generally be obtained for type and cross-match.Many clinicians favor placing a nasogastric tube for lavage in a patient with suspected GI bleeding. Presence of blood from lavage indicates bleeding in the upper GI tract proximal to the ligament of Treitz. Sources in the small bowel, including the duodenum, may or may not lead to blood being present in the stomach, which can be noted when lavage is performed. Lavage should be performed with warmed normal saline to reduce the risk of hyponatremia and hypothermia. In the past, lavage was often performed using cold or iced saline. This is no longer recommended because it may be associated with hypothermia. Clearing of blood from returned lavage fluid indicates that active bleeding may have ceased.Hematochezia generally indicates a colonic source of bleeding, although hematochezia may be seen with upper GI tract bleeding sites, such as bleeding ulcers when brisk bleeding causes rapid transit of blood through the intestine. Melena is more commonly seen from bleeding proximal to the ligament of Treitz and from more proximal colonic sites due to slow loss of blood.Abdominal radiography may be performed for evaluation of possible obstruction or bowel perforation. In the past, barium studies were performed to evaluate for ulcer disease and other causes of bleeding, but now endoscopy is preferable because this method is more sensitive and specific and can provide therapeutic intervention. On occasion, ultrasonography may be useful to identify portal hypertension or an intussusception. A Meckel scan should be considered in children with painless rectal bleeding.EGD and colonoscopy are helpful in the evaluation of the child with bleeding. Endoscopy is generally the favored method for evaluating the cause of bleeding and may provide a method of therapy as well. In general, these procedures are performed once the patient is stabilized, although this procedure may be necessary to control bleeding in an unstable patient. Administration of an intravenous proton pump inhibitor is helpful before endoscopy for upper GI tract bleeding to aid in control of bleeding and in reducing the chance of additional bleeding. Some practitioners administer a prokinetic agent, such as metoclopramide or erythromycin, before the procedure in an attempt to empty material from the stomach and better visualize the mucosal lining. EGD and colonoscopy are performed with the child asleep under either conscious sedation or anesthesia. Endoscopy allows the direct visualization of the mucosal lining and identification of any visible bleeding lesions. With active bleeding or when therapeutic measures are being considered, general anesthesia with endotracheal intubation is generally preferred to best protect the child’s airway.Complications of endoscopy have been reported in approximately 2% of cases. The most frequent complications include hypoxia or bleeding during the procedure, although both are relatively uncommon. Perforation of the intestinal tract may occur but is infrequent.Control of bleeding from gastric or duodenal ulcers may be accomplished with cautery or an APC laser. Figure 1 shows a large duodenal ulcer with a cherry red bleeding spot, indicating a bleeding vessel. Coagulation with cautery by heater probes or electrocautery is accomplished by application of electrical current through a probe to or around the bleeding lesion. Epinephrine may be injected locally via the scope before cautery to decrease the risk of rebleeding. The bleeding lesion may then be compressed and coagulated. Laser coagulation using ACP lasers is an alternative procedure. With this technique, argon gas is passed through a probe introduced through the endoscope. The gas is electrically activated to an ionized state, causing tissue coagulation. Figure 2 shows the ulcer in Figure 1 after use of the APC laser. Endoscopically placed clips are also useful to control bleeding from ulcers that have a visibly bleeding vessel. Preloaded clips are attached to the end of an endoscope and deployed over vessels believed to be at high risk of bleeding. All these techniques have been reported to be effective. Technique preference varies, depending on the endoscopist’s experience and institution resources. On occasion, these techniques can cause bleeding, which may require surgical intervention to correct.Variceal bleeding may be controlled with sclerotherapy or elastic band ligation. Sclerotherapy is performed by varices with a of causing of the include the of variceal may also be accomplished by the of small elastic with an endoscope. An to small to a is attached to the end of an endoscope. is through the of the the the and placing a band around the vessel. In general, is preferred by most pediatric because it has a lower risk of may generally be using cautery via an current is passed through a deployed through an endoscope. The is as the current is The may then be and to the for are when EGD and colonoscopy may not be able to determine the source of bleeding. In these a number of other modalities may be with red blood cells may point to a source of bleeding and are of bleeding at a rate these may not the source of bleeding because false-positive and false-negative scan results Blood may in such as the when the source is in the intestinal may be more helpful in bleeding sites when the rate of bleeding is as as 1 to 2 endoscopy has been to identify bleeding sites in the small in that are by upper and lower Endoscopy a that can take per are to a attached to the patient. are at a after of the study to determine whether bleeding lesions are present. A to using endoscopy is that the a bleeding lesion and specimens or therapeutic The is either or placed if the child is to A of endoscopy is of the by a due to intestinal or other causes, a that may require to reduce the chance of a often an study of the small to as small intestinal with or with is an alternative a may be with an obtained to that the has the small The if it in the small that the study in The of the the use of this in children 2 of bleeding in may require small intestinal a using longer that have or attached to the end of the may help identify bleeding in the small bowel in by and may therapeutic such as control of bleeding and is more commonly performed in has been performed in should be considered when other measures identify a bleeding include have a Meckel diverticulum, bowel or other bleeding not on the common causes of GI bleeding, depending on at 1 common and common important causes of GI bleeding for different blood is a common cause of in a Blood may be ingested during and may also occur from blood during The is helpful in defining the source of blood as being This the that hemoglobin to a in have ingested A generally the need for further evaluation of causes of from is relatively common cause of bleeding in this from underlying may lead to and bleeding. The amount of blood seen from is generally relatively in hospitalized may also present with are more common duodenal ulcers in this as to children duodenal causes are more The amount of bleeding may be may for a number of in It is seen with from severe and may also be seen with infections, including from disease of the may be seen if has not been due to may occur and should be considered in this as well. as the infant may also be seen in children with underlying due to or liver although relatively may present with GI bleeding and should be in the diagnosis at this may cause bleeding in may be associated with a Melena or hematochezia may also be signs of this Blood in the stool is generally the presenting and is seen most commonly in the of Children are may also to a relatively common and are the most commonly associated with to are to to studies may reveal and is with and may be depending on the severity of the may and on is generally not for is the most common cause of bleeding in this with anal being more may for to after of the is a serious common cause of GI bleeding. The of should evaluation for a or other serious cause of intestinal can also present with with such a suggests bowel and is a surgical may an for further additional studies or surgical treatment is surgical to be considered in the as a cause of bleeding. may present as blood in the stool. may reveal bowel commonly in have after 2 to of is with the use of and of intervention is often to bowel or due to disease presents with to have a bowel in the 2 days of severe or symptoms of A if the diagnosis has been may present with an also after surgical of disease and should be considered in any child with a history of disease presents with or Children with may and and are often Blood loss may be should be considered in an infant and has treatment bowel intravenous fluid and that include for Careful rectal with normal saline is often performed as well. is a significant problem that in the past was associated with a high rate and should be treated are the most common cause of rectal bleeding in this are most commonly seen in the and present with of blood on the of the stool. A examination of the rectal is an important of the physical examination of a child with blood in the stool. anal are associated with the passage of that cause bleeding may be seen with with passage of stool is often present. therapy with stool is is of cause of GI bleeding in The presence of is a relatively of bowel presents with pain with may intestinal and the diagnosis may be with a of the the of the may be accomplished by or by A pediatric should be during in bowel during the procedure. intervention is if the be by or common causes of bleeding in this include intestinal and vascular lesions. lesions may include venous and lesions are rare causes of bleeding at any of the causes of bleeding in such as esophagitis, also occur in may from of ingested may be severe after from are more common in this and may be at can occur in the lower and the or in the of the stomach the gastropathy, in which or the proximal stomach the and bleeding and also presents with Blood loss may be significant after Mallory-Weiss may be treated during in children may be by and as in at this may also occur after of In and may have of is now in may cause bleeding from and may also be associated with bleeding from gastric or duodenal the gastric antrum is noted to be as seen in Figure from the and for and initial diagnosis from EGD on and results or of the may be on stool or urea The stool is to sensitive and The urea is performed by urea and The is in the and This is to sensitive and stool urea is recommended if the patient has been taking proton pump or in the 2 are but useful in children because they are not as as the and are not recommended for have more commonly in and both duodenal and gastric ulcers may present with hematemesis, melena, and hematochezia from rapid transit through the intestine. are often at The of ulcers is in children with due to severe or and are source of GI bleeding. can from underlying liver or portal can be a of venous during the hypertension causes of vessels that can lead to severe bleeding. liver disease can also lead to due to of blood factors and to seen in due to portal and the risk of GI are a frequent cause of and bleeding. including and other can cause and with is stool for these should be may also be obtained to for of and other such as and may cause on is now commonly seen use of and may also present with melena or hematochezia. of the stool for is the preferred method for presence of this can be of normal bowel to 1 of and causes symptoms in this Figure 4 shows the of the colonic in a patient with due to commonly presents with painless rectal bleeding, which is often of the is by from the gastric of the Meckel Meckel are often 2 from the and 2 in are commonly present in children 2 and occur in 2% of the Meckel may also cause around an associated of the or present as in a to is on a Meckel scan using which is taken by gastric This scan that gastric with or proton pump can the of the Meckel is by surgical may present in this as most commonly by a lead point of tissue due to a the presence of a lead such as a or can also lead to an may also cause GI bleeding. can cause significant bleeding and is also associated with an risk of intussusception. a on the lower and GI bleeding. often after a with can occur in for syndrome is also associated with GI bleeding by from most commonly from including renal and may also be associated with this disease. is by the of and generally to days if syndrome Children have been as should be for the of is cause of lower GI tract bleeding in colonoscopy reveals small of may occur after and also from is more common in children with and also with can present as small of red blood in the stool or as is a common during colonoscopy in most is not associated with may that can bleed. are the most common in seen during the most commonly 1 and of are of the most common causes of bleeding in this Children with juvenile have painless rectal a through the juvenile are associated with are 1 to in and generally attached to the via a of the can occur with rectal bleeding, which may be from of the mucosal lining of the Figure shows the of a juvenile during are and not reveals and an inflammatory in the is to the and to evaluate for additional of juvenile are in the rectum or are but multiple may occur in to of may occur in of children with a juvenile but colonoscopy is not recommended symptoms if or more are the child may have juvenile and should have performed with juvenile syndrome most commonly have or more noted at In approximately of juvenile is with juvenile are at risk of which may occur in to of with this A number of have been in this including and which are in approximately of may also in the small in juvenile is no of colonoscopy has been recommended 1 to 2 in for small intestinal also to be considered using including small intestinal may also occur from and syndrome are rare with in the syndrome is by the GI tract with in the Children with this syndrome may present with intestinal obstruction due to in the small with a history of may be is a in which to of and in which is a high risk of over to in and to intestinal may include of the and and lesions. are often present. In to are at risk for and gastric Children are also at risk for of may be performed if a has an after with the child and in the APC are for and may be in to of occur in to of cases. colonoscopy should be performed at ages to for and of and should also be GI tract bleeding may be seen with may in with by this associated with relatively often the use of prolapse may cause blood in the stool. reveals a rectal ulcer due to from of prolapse is often with a history of and may but are a common cause of bleeding in A can cause a that can lead to blood in the stool. This can present with to severe of the rectum and with is most common causes of bleeding in this include esophagitis, gastritis, and ulcers, which have been in the bleeding is and due to use may cause GI bleeding. may also cause and should be considered as a cause of in The of ingested to be or for to use is also associated with prolapse and from are more common in this In enteric infections, in the are a common cause of hematochezia in this present with and blood and in the stool. may be present with of the infections, from On occasion, and other may also cause significant disease and may present with melena or hematochezia. bleeding is it may from that are guaiac to due to or that have blood bleeding is more common in and Crohn with small intestinal Crohn disease. significant bleeding can occur from vessels in the small with Crohn disease. blood loss is common with both pain is often but not present. blood loss may be by the presence of a low mean corpuscular is more common in Crohn disease. studies are useful for Figure shows from the small obtained during endoscopy in a patient with chronic blood loss and from Crohn disease. Crohn disease and to the need to specimens during may have associated gastritis, which may also to are other causes of GI bleeding in causes and of the common causes of GI bleeding in children at ages are in GI tract bleeding to may be controlled by that and proton pump may both be With acute bleeding of significant proton pump are generally because they are more effective. A bolus by of esomeprazole or may be After significant bleeding, the chance for bleeding is in the and use of intravenous proton pump is during this After control of the bleeding, the patient may be to an for 2 the of these may be useful for and disease. This is as a and to the mucosal lining of a that the from and the lesion It also increases also with and is in both and are in including and may be useful in upper GI tract bleeding. has been for variceal bleeding because it causes complications include such as and renal and has a on vascular and portal blood with this is in but it may be helpful in is helpful in variceal bleeding. may also be helpful in other causes of upper GI tract bleeding, in are not able to endoscopy or in endoscopy has been to determine or the cause of bleeding. include and with it has complications compared with is as a bolus by The is after bleeding has been are in in with endoscopy are at in GI bleeding. such measures are has been reported to control GI bleeding due to vascular may be when bleeding be controlled by or With portal may be for children should be familiar with the diagnosis and treatment of bleeding. The initial are to the extent and severity of the bleeding when indicated, to and the patient as quickly as possible. stabilized, with a of modalities is to the cause of bleeding. studies are often to help determine the of bleeding and for therapeutic intervention in specific cases. Newer such as endoscopy and small intestinal may be useful when bleeding sites are to be should be familiar with the common and of the common causes of GI bleeding in children and should also be familiar with for these

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