1. Gastrointestinal Hemorrhage
Carolyn A. Sullivan, MD
Pediatric Gastroenterology

2. Objectives
Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding
Review the most common etiologies for GI bleeding in pediatric patients in various age groups

3. Definitions
Melena: passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve
Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding
Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz

4. History Present illness source, magnitude, duration of bleeding
associated GI symptoms (vomiting, diarrhea, pain)
associated systemic symptoms (fever, rash, joint pains)
Review of systems
GI disorders, liver disease, bleeding diatheses
Anesthesia reactions
medications (NSAID’s, warfarin)
Family history

5. Physical examination Vital signs, including orthostatics
Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill
HEENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding
Abdomen: organomegaly, tenderness, ascites, caput medusa
Perineum: fissure, fistula, induration
Rectum: gross blood, melena, tenderness

6. Further assessment Is it really blood? Apt-Downey test in neonates
Hemoccult stool, gastroccult emesis
Apt-Downey test in neonates
Nasogastric aspiration and lavage
Clear lavage makes bleeding proximal to ligament of Treitz unlikely
Coffee grounds that clear suggest bleeding stopped
Coffee grounds and fresh blood mean an active upper GI tract source

7. Substances that deceive
Red discoloration
candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin
Black discoloration
bismuth, activated charcoal, iron, spinach, blueberries, licorice

8. Laboratory studies CBC, ESR; BUN, Cr; PT, PTT in all cases
Others as indicated:
Type and crossmatch
AST, ALT, GGTP, bilirubin
Albumin, total protein
Stool for culture, ova and parasite examination, Clostridium difficile toxin assay

9. Imaging studies and indications
Upper GI series: dysphagia, odynophagia, drooling
Barium enema: intussusception, stricture
Abdominal US: portal hypertension
Meckel’s scan: Meckel’s diverticulum
Sulfur colloid scan, labeled RBC scan, angiography : obscure GI bleeding

10. Endoscopy: indications
EGD: hematemesis, melena
Flexible sigmoidoscopy: hematochezia
Colonoscopy: hematochezia
Enteroscopy: obscure GI blood loss

11. DDx: neonates Upper GI bleeding Lower GI bleeding
swallowed maternal blood
stress ulcers, gastritis
duplication cyst
vascular malformations
vitamin K deficiency
hemophilia
maternal ITP
maternal NSAID use
Lower GI bleeding
swallowed maternal blood
dietary protein intolerance
infectious colitis
necrotizing enterocolitis
Hirschsprung’s enterocolitis
duplication cyst
coagulopathy
vascular malformations

12. Neonatal stress ulcers or gastritis
Causes
Shock
Sepsis
Dehydration
Traumatic delivery
Severe respiratory distress
Hypoglycemia
Cardiac condition

13. DDx: infants Hematemesis, melena Hematochezia Esophagitis Gastritis
Duodenitis
Hematochezia
Anal fissures
Intussusception
Infectious colitis
Dietary protein intol.
Meckel’s diverticulum
Duplication cyst
Vascular malformation

14. DDx: children Upper GI bleeding Lower GI bleeding Esophagitis
Gastritis
Peptic ulcer disease
Mallory-Weiss tears
Esophageal varices
Pill ulcers
Lower GI bleeding
Anal fissures
Infectious colitis
Polyps
Lymphoid nodular hyperplasia
IBD
HSP
Intussusception
Meckel’s diverticulum
HUS

15. Esophageal varices

16. Erosive esophagitis

17. DDx: adolescents Hematemesis, melena Hematochezia Esophagitis
Gastritis
Peptic ulcer disease
Mallory-Weiss tears
Esophageal varices
Pill ulcers
Hematochezia
Infectious colitis
Inflammatory bowel disease
Anal fissures
Polyps

18. NSAID induced ulcers

19. Peptic Ulcer

20. Mallory-Weiss Tear

21. Risk of rebleeding of ulcer
Stigmata of recent hemorrhage
Visible vessel
Clot
Spot
Clean base
Rate of rebleed
40-50%
25-30%
10%
2-4%

22. Ulcer with red spot

23. Therapy Supportive care: begin promptly
IV fluids, blood products, pressors
Specific care
Barrier agents (sucralfate)
H2 receptor antagonists (cimetidine, ranitidine, etc.)
Proton pump inhibitors (omeprazole, lansoprazole)
Vasoconstrictors (somatostatin analogue, vasopressin)
Endoscopic therapy: stabilize and prepare patient first
Coagulation (injection, cautery, heater probe, laser)
Variceal injection or band ligation
Polypectomy

24. Bleeding Ulcer