GI

Lower GI Bleeding

Although gastrointestinal bleeding is worrisome for parents, unlike adult medicine, it is rarely associated with malignancies in pediatrics. 

 

Confirming the Presence of Blood in the Stool

1. Hemoccult or Hematest. This test material contains a peroxide which interacts with peroxidates in hemoglobin and causes a visible color change.
            a. False negatives can be caused by large amounts of absorbic acid in the diet or if intestinal bacterial degrade hemoglobin to porphyrin. 
            b. False positives can be caused by large amounts of rare red meat and certain vegetables: broccoli, cauliflower, turnips, radishes, and cantaloupe. 
            c. Foods and Medicines that can make stool appear bloody include red licorice, red pop, koolaid, jello, beets, iron and Pepto Bismol. 

 

Upper vs. Lower Intestinal Tract Bleeding

An important part of the work-up of GI bleeding involves differentiating upper from lower GI tract bleeding. 

  1. If there is blood on the surface of the stool this is usually of anal-rectal origin
  2. Bright red blood mixed in with stool usually is from below the ligament of Treitz but could be from above if bleed is brisk and large
  3. Melana or tarry stools are usually above the ligament of Treitz

 

Evaluation of Bleeding

  1. History
    1. Amount of blood and appearance of stool. (Bright red blood vs. tarry stools)
    2. How long has there been bleeding?
    3. Associated symptoms of fever, weight loss, diarrhea, vomiting, constipation, pain, change of appetite, 
    4. Diet
    5. Travel 
    6. Family History
    7. Growth
  2. Physical Exam
    1. Pallor
    2. Rashes, petechiae, purpura, hemangiomas, jaundice, telangiectasias 
    3. Mouth lesions
    4. Abdominal exam for masses, tenderness
    5. Rectal exam
    6. Vital signs
    7. jaundice(hepatic failure) or cutaneous bruising

 

 Commom Etiologies of Rectal Bleeding

  1. Neonatal
    1. Necrotizing enterocolitis- usually in preterm 
    2. Hirchsprung's disease associated with enterocolitis
    3. Malrotation and associated volvulus
    4. Swallowed blood- Do anApt test to differentiate fetal from adult hemoglobin
    5. Coagulaopathy
  2. One month to 2 years
    1. Anal or rectal fissures- (most common in <1 year olds) may be associated with painful bowel movements
    2. Formula intolerance
    3. Meckel's diverticulum - disease of 2's (2 inches long, 2 feet from the ileocecal valve, 2% of the population, most common diagnosied in the first 2 years of life, 2 types of tisuue present) 
    4. Hirschsprung's disease
    5. Intussusception- most common in the ileocecal area
    6. Lymphonodular hyperplasia
    7. Infectious diarrhea
    8. HUS
    9. HSP
  3. Two to 5 years old
    1. Polyps- may have large amount of bleeding and often pass spontaneously
    2. Infectious diarrhea- either viral or bacterial
  4. Five years to adolescence
    1. Similar to younger with the addition of Inflammatory Bowel Disease

 

Evaluation

  1. The evaluation of the infant or child with blood in their stools is dependent on the history, general condition of the child, growth and development, amount of blood in the stool, the condition of the child including heart rate, blood pressure, amount of discomfort, and degree of anemia, if any. If necessary, the child should be stabilized.
  2. After a thorough history and physical exam, a CBC, reticulocyte count, smear, and platelet count should be performed. If the child is ill appearing, a type and cross match should be done. If the child is not ill and massive bleeding is not suspected, an outpatient evaluation may be performed.

 

Reference

  1. Silber, Gary. Lower Gastrointestinal Bleeding. Pediatrics in Review. September 1990.
  2. Boyle, John T. Gastrointestinal bleeding in infants and children. Pediatrics in Review 29.2 (2008): 39-52.
  3. Causes of Rectal Bleeding.  Pediatrics in Review. November 2001
  4. Lake A. Food-Induced Eosinophilic Ptroctocolitis.  Journal of Pediatric Gastroenterolgy and Nutrition.  Jan 2000
  5. Arain, Zahid, and Thomas M. Rossi. Gastrointestinal bleeding in children: an overview of conditions requiring nonoperative management. Seminars in pediatric surgery. Vol. 8. No. 4. Philadelphia, PA: WB Saunders Co., c1992-, 1999.