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Home , Blood in stool, Gastric varices, Hematemesis, Hematochezia, Jaundice, Melena

REVIEW

Gastrointestinal in infants and children

R Bhanu Pillai1† & Gastrointestinal (GI) bleeding in infants and children is an alarming symptom to both the Vasundhara Tolia2 patient and parents. It can present orally and/or rectally. While minor GI bleeding is usually †Author for correspondence a self-limited condition, requiring only minimal intervention, it can certainly be a life- 1Department of Pediatrics, PO Box 250558, threatening condition at times. An initial focused review of the history and physical Medical University of South examination, followed by a detailed history, investigations and management, is necessary Carolina, 135, Rutledge Ave, to identify the etiology of the bleeding and aid in its treatment. This article reviews the Charleston, SC 29425, USA Tel.: +1 843 792 7653 different etiologies, investigation and therapeutic options for management of GI bleeding Fax: +1 843 792 7332 in infants and children. [email protected] 2Department of Pediatrics, Gastrointestinal (GI) bleeding can be occult or been determined that it is , the further man- Michigan State University, overt. Occult bleeding presents with , agement is decided. Early consultation with a Providence Hospital, -deficiency , or is identified when pediatric gastroenterologist, either in the emer- Southfield, MI 48075, USA stool is tested in a child with other symptoms, gency department or after admission to the hospi- such as or . However, tal, should be considered for a child with overt bleeding can be frightening. Overt GI significant bleeding, which is defined as: the pres- bleeding can manifest either as vomiting gross ence of large clots in the emesis or stool, in addi- blood or coffee-ground material (), tion to ; a drop of hematocrit by more or per , as passage of either bright red gross than 10%; or tachycardia, diaphoresis, orthostatic blood, dark red blood () or black changes or any suggestion of portal tarry stools (melena). The bleeding is considered or disease. However, they should also have to be of the upper GI tract in origin if it is prox- carried out a quick assessment of symptoms, such imal to the ligament of Treitz, and lower GI as abdominal pain, weight loss or jaundice, and bleeding if it is distal to it. also be aware of any significant family history, such as inflammatory bowel disease in a hospital- Is it blood or not blood? ized child. Less severe cases of bleeding, including Evaluation by the emergency physician begins suspected polyps, or occult GI bleeding can be with a quick assessment of the patient to decide evaluated in an outpatient setting. the level and urgency of the intervention. An important consideration is to make sure that what Differentiation of upper versus lower appears to be blood, really is blood. Certain foods GI bleeding and can certainly alter the color of In most cases, the clinical presentation helps to the emesis or stool, and even an experienced indi- determine the site of bleeding. In a child present- vidual could mistake this for blood and prompt ing with hematemesis, the source of bleeding is in unnecessary investigations in a child. Substances the upper GI tract, even though it certainly can that may give red color to stool or vomitus represent swallowed blood – as in newborns with include ingested red candies, fruit punch, beets swallowed maternal blood, or swallowed blood in and medications such as rifampin, whereas black a child with epistaxis. In children presenting with color could be from bismuth, iron, charcoal and bright red blood in the stool or bloody , foods such as spinach and blueberries [1]. Hence, the source of bleeding is usually the lower GI it is important to test the emesis or stool for tract, most likely the colon. Rarely, massive upper blood. Stool or vomitus is tested for blood by GI bleeding can present with hematochezia. using the widely available guaiac test, which Keywords: children, changes color in the presence of . The Differential diagnoses gastrointestinal bleeding, ® hematemesis, hematochezia, newer Hemoccult ICT is an immunochemical It would be appropriate to consider the differential infants, melena test that is more specific, with fewer false-positive diagnoses of GI bleeding, depending on the pre- results [101]. Emesis should be tested with a test kit sentation and age of the patient (Boxes 1–4). Differ- part of for gastric fluid (e.g., Gastroccult®), because they ent etiologies cause bleeding at different ages in are more reliable in acidic pH [2,102]. Once it has children, from newborn to adolescents. In a

10.2217/14750708.5.4.465 © 2008 Future Medicine Ltd ISSN 1475-0708 Therapy (2008) 5(4), 465–473 465 REVIEW – Bhanu Pillai & Tolia

healthy-appearing newborn or breast-fed young [1]. In a younger child who presents infant who presents with hematemesis, swallowed with intermittent crying, lethargy and vomiting maternal blood is a strong possibility, and this can with acute hematochezia, it may suggest intussus- be differentiated by the Apt–Downey test, since ception. Vomiting, frequently bilious, with rectal is alkali resistant [3]. bleeding suggests mid-gut from malrota- In patients who present with hematemesis, a tion. A child who presents with diarrhea and rectal history of , chest pain, epigastric pain bleeding may have of infectious etiology, or or frequent regurgitation may suggest erosive as a result of inflammatory bowel disease. Rectal or . A history of bleeding is a frequent presentation of allergic colitis , such as , could point from milk-protein intolerance in infancy [1]. towards variceal bleeding. A history of forceful and vomiting preceding the hemat- Initial evaluation emesis could be due to Mallory–Weiss tear, A rapid assessment of the bleeding child is manda- which is a mucosal laceration at the gastroesoph- tory, and the following questions need to be ageal junction, or gastric cardia. NSAID- answered: induced can be an important cause of • Is the child stable? hematemesis [4] . • Is it significant bleeding? Patients in intensive care units may develop • Is the child actively bleeding now? hematemesis from hemorrhagic stress gastritis or ulcerations from nasogastric (NG) tube suctioning • Is there a known condition that makes this or other trauma. Bleeding associated with severe child susceptible to bleeding? abdominal pain with of the lower extremities History is very essential in the evaluation of a may signal Henoch–Schonlein purpura [5]. bleeding child. The source of bleeding, extent or The differential diagnoses of magnitude of the bleeding, duration of bleeding depend on the character of blood, age of the and associated symptoms should be sought from patient, and other associated symptoms. The the caregiver and the child, if possible, as well as blood from the upper GI tract certainly can from any person who witnessed the event. A his- present as melena or hematochezia depending on tory of bleeding disorders, liver disease, GI dis- the magnitude of bleeding, at times without eases and ingestion of medications, especially hematemesis. The painless, intermittent rectal NSAIDs, alcohol or recent use, would bleeding could be from colonic polyps, but such a be critical in the initial evaluation. In a stable presentation with massive bleeding is more likely child, detailed history and can due to bleeding from an ulcerated Meckel’s be obtained prior to initiating management. In a seriously ill child with evidence of significant bleeding, such as lethargy, pallor, diaphoresis, Box 1. Causes of hematemesis. or orthostatic changes in heart rate or • Swallowed blood: especially in newborns, swallowed maternal blood , immediate attention is given to – Epistaxis, following tonsillectomy, breast feeding stabilizing the child after a quick focused history • Erosive esophagitis: either reflux related or other causes of esophagitis as above [1]. • The (Box 5) of the child • Mallory–Weiss tear can certainly help in the evaluation of the sever- • Prolapse of the gastroesophageal junction ity of the bleeding, as well as in assessment • Gastritis, including gastritis, NSAIDs, caustic ingestion, regarding possible diagnosis. The presence of graft-versus-host disease • Gastric ulcers: patients in intensive care units, severe burns, anemia and orthostatic changes could point to Crohn’s disease significant blood loss. Orthostatic change is • Eosinophilic defined as an increase of 20 beats per min of • Peptic ulcer disease heart rate, or decrease of 20 mmHg of systolic • ; Henoch–Schonlein purpura blood pressure or 10 mmHg of diastolic blood • Variceal bleeding from pressure on changing from a supine to upright • Vascular malformations or sitting position [6]. The presence of jaundice, • Coagulation disorders; platelet dysfunction or could point • Trauma, including nasogastric tube suctioning towards [1]. In a child with • Gastrointestinal stromal tumors chronic diarrhea, weight loss or growth failure, • Hemobilia the bleeding could indicate inflammatory • Upper duplication bowel disease.

466 Therapy (2008) 5(4) futurefuture sciencescience groupgroup Gastrointestinal bleeding in infants & children – REVIEW

Box 2. Causes of hematochezia and melena. GI bleeding, additional studies would be neces- sary, such as abdominal ultrasound with Doppler • Upper gastrointestinal source: see causes of hematemesis flow of hepatic and portal blood flow and subse- • Infectious colitis: Salmonella, Shigella, , Escherichia quent further investigations [1]. The placement of coli O157:H7, Yersinia enterocolitica, Clostridium difficile, Entamoeba a NG tube can be helpful to confirm upper GI histolytica, and other opportunistic infections bleeding, as well as to lavage the so that • , visualization of the upper GI tract would be supe- • Necrotizing • Graft-versus-host disease rior when an is performed [7]. This is • NSAID-induced injury especially useful when the child presents with sig- • Meckel’s diverticulum nificant bleeding presenting as melena, or rectal • Inflammatory bowel diseases bleeding without hematemesis. Presence of fresh • Eosinophilic colitis/eosinophilic gastroenteritis blood in the NG tube aspirate indicates active • Vascular malformations bleeding [1]. Suspicion of esophageal varices is not • Lymphoid nodular hyperplasia a contraindication for placing an NG tube. Sev- • Colonic polyps eral measures can be taken as supportive care, • Intussusception including intravenous fluids (initially normal •Volvulus saline or lactated Ringer’s solution), blood prod- • from vascular insult ucts (packed red blood cells, fresh frozen plasma •Trauma • Solitary rectal ulcer or whole blood) and vasopressors [1,7]. The hema- tocrit should be maintained at approximately 30% [1,2]. Correction of with fresh Management frozen plasma and platelet transfusion to keep Appropriate management should follow the platelets above 50,000 should be attempted [2]; quick initial assessment. In patients with impend- however, these blood products still may not cor- ing or actual circulatory compromise, the resusci- rect the coagulopathy in the presence of advanced tation should be prompt. The patient should liver disease. have vascular access, preferably two wide-bore A child with chronic liver disease is susceptible intravenous lines should be inserted, diagnostic to fluid overload when receiving fluids and blood laboratory tests drawn and crystalloids should be products. Recombinant factor VIIa, along with started as initial fluids. Colloids or blood prod- endoscopic treatment, was associated with ucts would be necessary depending on the sever- improved hemostasis in a recent study in adults ity of the bleeding. Supplemental oxygen is with [8]. Bacterial is a major com- administered through an age-appropriate device plication associated with cirrhosis following an [1,7]. The initial laboratory evaluation includes episode of variceal bleeding, and short-term use complete blood count, , partial of has shown improved survival [9]. thromboplastin time and liver profile, which Specific intervention, such as acid suppression includes , transaminases and [1]. with intravenous histamine 2 receptor antago- The decision to type and screen or cross-match is nists or proton-pump inhibitors, such as omepra- dependent on the extent, as well as cause of the zole, lansoprazole, pantoprazole or esomeprazole, bleeding. In acute bleeding the hemoglobin may could be useful in upper GI bleeding, even look erroneously higher than the actual value, though only limited data are available in and hence should be interpreted with caution [7]. children [6,7,10,11]. These drugs can be used orally In patients with liver disease who presented with in patients awaiting elective endoscopy, especially in suspected peptic ulcer disease or gastroesoph- ageal reflux disease [12]. Vasopressin is an effective Box 3. Causes of occult gastrointestinal agent to decrease the splanchnic blood flow by bleeding. splanchnic arteriolar vasoconstriction, thereby • Esophagitis lowering portal inflow and portal pressure and • Acid peptic disease subsequently decreasing variceal GI bleeding. It •Gastritis has significant side effects in 32–64% of patients • Peptic ulcer disease in different clinical trials [2]. • Inflammatory bowel diseases Somatostatin and its analog, , • Eosinophilic gastroenteritis decrease the portal blood inflow and are useful in •Polyps variceal and nonvariceal bleeding [1,2]. Octreotide • Vascular malformations is administered as 1 µg/kg bolus, followed by

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Box 4. Causes of painless rectal presenting with recurrent hematemesis, hemoc- bleeding. cult-positive stool or evaluation for esophageal varices, an elective endoscopy can be performed. • Colonic polyps Several therapeutic interventions that are possi- • Meckel’s diverticulum ble during an upper endoscopy in a child with • Vascular malformations GI bleeding are discussed later. • Intestinal duplication • Coagulation disorders; platelet dysfunction Variceal bleeding Both endoscopic sclerotherapy (EST) and 1–2 µg/kg/h as a continuous infusion in active endoscopic variceal band ligation (EBL) are bleeding, and has an excellent safety profile [2]. available for treating esophageal varices [17]. Even in patients with esophageal varices, the When injected with a sclerosant, the varices bleeding can certainly be occurring from other become thrombosed, scarred and eventually causes, such as peptic ulcer disease, Mal- obliterated [17]. Various sclerosants are avail- lory–Weiss tears or gastritis, so an endoscopy able, such as 5% sodium morrhuate, absolute would be necessary to identify the etiology and alcohol, 5% ethanolamine oleate, and sodium manage the bleeding [12]. Although more com- tetradecyl sulfate. The sclerosant is injected at monly used for variceal bleeding, octreotide may the time of the endoscopy at the bleeding site, also be considered in nonvariceal bleeding, such starting at the gastroesophageal junction and as peptic ulcer bleeding before the endoscopy or progressing proximally. In adults, the volume of when the endoscopy is unsuccessful or the sclerosant injected at each site is usually contraindicated [13]. 1–2 ml, and a total of 10–15 ml per session [2]. EST may cause several potential complications Upper endoscopy (Box 6). Esophageal ulcers are seen in up to 90% Upper endoscopy is indicated in hematemesis, of patients the day after EST, and in approxi- melena, hematochezia and occult . mately 70% after a week of the EST, and there It is not only diagnostic, but also useful for ther- is a risk of bleeding from these ulcers in up to apeutic interventions. When the child is stable 20% [18,19]. Limited pediatric experience has enough to be sedated, upper endoscopy can be been reported with some of these modalities, as performed. It is better to perform semi-elective described in subsequent sections. An alternative endoscopy rather than an emergent endoscopy, to EST is EBL, in which an elastic band is used as this allows for adequate preparation and stabi- to strangulate the varix, thereby producing lization of the patient [1,14,15]. Emergency endo- , necrosis and sloughing of the scopy is performed when the bleeding continues mucosa, with subsequent healing of the ulcer with continued significant transfusion require- resulting in the obliteration of the varix [20]. ment, in which case the procedure is performed Caution must be taken in individuals who are under general anesthesia with a controlled air- sensitive to latex, since the bands contain natu- way. The upper endoscopy can identify the site, ral rubber latex. Several multiband ligators are as well as the source, of bleeding, for example, commercially available with four, six or ten variceal bleeding, mucosal bleeding or other vas- bands preloaded in a plastic cylinder device [21]. cular problems, such as Dieulafoy lesion. Stig- The cylinder is attached to the tip of the endo- mata of recent bleed can be noted on the varix as scope and the varix is sucked into the cylinder. cherry-red spots, or clots, during the endoscopy. The elastic band is then released by the trigger The presence of residual blood or clots in the wire when a complete ‘red-out’ occurs. The vis- stomach could interfere with the visualization of ibility can be affected due to the plastic cylinder the source of bleeding. with place- at the tip of the scope. Another disadvantage is ment of a NG tube improves the visualization of that the smallest scope that can be used to the bleeding at the time of endoscopy, but attach the banding device is 8.5 mm outer should be removed after evacuating the gastric diameter, and the diameter further increases contents [6,7]. Maintaining the tube for pro- after attaching the device, which may pose a longed periods, especially when suction is problem in infants. Esophageal ulcers develop attached, can cause mucosal injury. Intravenous in up to 90% of these patients in a week after erythromycin of 3 mg/kg over 30 min, the EBL. , chest pain, bleeding from 30–90 min before the endoscopy, could help to the ulcers, esophageal strictures and bacterial clear the gastric contents [7,16]. In stable patients have all been reported at a decreased

468 Therapy (2008) 5(4) futurefuture sciencescience groupgroup Gastrointestinal bleeding in infants & children – REVIEW

Box 5. Physical examination. graphically between hepatic and portal , and serves as a side-to-side portosystemic shunt, General allowing portal decompression [1,22,23]. Severe • Level of consciousness congestive heart failure, severe pulmonary • Diaphoresis hypertension, severe hepatic failure and • Active bleeding? portal thrombosis, active infections, and Weight polycystic liver disease are contraindications for Vital signs TIPS placement. Several complications are also • Heart rate described after the TIPS procedure, including • Respiration (neck and liver) pneumothorax, car- • Blood pressure diac arrhythmia, and puncture of the gall blad- •Orthostatic changes der and extrahepatic portal vein. Other • refill complications of TIPS include stent thrombo- Head, eyes, ears, nose & throat sis, infection, stent migration, occlusion, • Jaundice , and hepatic • Pallor decompensation [2]. Orthotopic liver transplan- • Bleeding from oropharynx tation can achieve hemostasis and prevent rebleeding and ; however, this is rarely available under such circumstances. If the • Tenderness bleeding is occurring from gastric varices, EST • (liver, ) •Ascites or EBL can be attempted to achieve hemostasis, • Abnormal blood vessels but these have a higher incidence of rebleeding from the ulcers (more than 50% after EST). Tissue adhesives, such as acrylate glue, can be • Jaundice injected into the varix [2,17]. Two tissue adhe- • Bleeding sives have been studied: isobutyl-2-cyanoacry- •Circulation late (bucrylate) and N-butyl-2-cyanoacrylate • Pallor •Rash (histoacryl). Hemostasis is achieved in up to • Vascular malformations 90% of cases by using these adhesives, and variceal obliteration is achieved with two ses- sions in 87–100% of patients. Upon exposure • Perianal area: , fissures, hemorrhoids to blood, the material polymerizes into a hard • Gross blood substance and plugs the variceal lumen, result- • Melena ing in hemostasis. However, these agents are not available in the USA owing to potential side incidence with EBL as compared with EST. In a effects, such as thrombotic events and carcino- patient with adequately controlled variceal genicity in rats with cyanoacrylate [24]. Throm- bleeding, repeat sessions of EST or EBL are bin has successfully been used to inject the needed in the subsequent weeks to further gastric varices [25], and TIPS have been used in obliterate the varices [2]. the management of bleeding gastric varices [25], In patients with recurrent or uncontrolled as have surgical shunts. variceal bleeding, additional measures are Following effective hemostasis of variceal needed. Balloon tamponade can be useful in bleeding, nonselective β-blocker therapy is the achieving hemostasis in many patients, but is mainstay of pharmacologic therapy to prevent associated with potential complications, includ- recurrence of variceal bleeding [26,27]. Non- ing airway compromise, pressure necrosis of the selective β-blockers can also be used in the pre- esophageal mucosa and a high incidence of vention of first variceal bleeding [28]. Congestive rebleeding when the balloon is deflated [2]. heart failure, severe asthma and heart block are Repeat endoscopic treatment may be attempted contraindications to β-blocker therapy. Side on an individual basis. Transjugular intrahe- effects, such as fatigue, weakness and sleep distur- patic portosystemic shunts (TIPS) are another bances, can affect compliance with the medica- intervention that could be attempted to attain tion. Addition of spironolactone to the β-blocker hemostasis in variceal bleeding. During TIPS, therapy has been shown to reduce the variceal an artificial communication is created angio- pressure further than with β-blocker alone [29].

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Box 6. Complications of endoscopic also be used, in which case a lower volume is sclerotherapy. used (1–2 ml) per injection site. Solutions that contain 1:10,000 epinephrine can be used at a • Retrosternal chest pain dose of 3 ml per injection site; in either situa- • Dysphagia, both transient and long term tion, 3–4 injections are used around the bleeding •Fever vessel and then at the vessel. Absolute alcohol •Sepsis should be used with caution, since the volume • Bleeding used is very small (0.1–0.2 ml per injection), and • Bleeding from esophageal ulcers • Mediastinitis a tuberculin syringe should be used for the injec- • Esophageal perforation tion. Plasma levels of catecholamines were found •Pericarditis to be elevated following epinephrine injection • Spontaneous bacterial peritonitis for bleeding ulcers [32]. Other adverse effects • Esophageal strictures include increased bleeding, bowel ischemia, • Increased risk of bleeding from perforation and peritonitis. portal gastropathy Thermocoagulation Nonvariceal bleeding Several pieces of equipment can be used to per- There are several therapeutic interventions that form thermocoagulation. A heater probe pro- can be performed during the endoscopy for vides a fixed temperature (250°C) at the tip, and nonvariceal bleeding. This is indicated in high- produces tissue coagulation. Pressure is applied risk stigmata, such as actively bleeding ulcer, with the probe as a tamponade before coagula- oozing from the base of a clot or a vessel that is tion, by applying 30 J for 3–8 s in up to four visible at the base of the ulcer, since they are applications. During the application, the patient associated with a high risk of rebleeding [30,31]. is positioned in such a fashion to allow blood to Effective endoscopic therapy significantly flow away from the lesion. When used in the reduces the incidence of rebleeding. The endo- colon, especially the right colon, a lower setting scopic techniques used to control GI bleeding is used owing to the thin bowel wall [31]. Perfora- are: injection, coagulation/thermal therapy, laser tion (1–3%), as well as bleeding (5%), can occur treatment, ligation devices and hemostatic after heater-probe application. devices. If size permits, a larger therapeutic endoscope can be used, which enables simulta- Electrocoagulation neous suctioning or irrigation through one In monopolar coagulation, the current is con- channel, with therapy being attempted through verted to high-temperature heat at the point of the second channel. The standard pediatric gas- tissue contact and coagulates the tissue. The troduodenoscope permits the needles for the pressure is applied directly over the vessel, if sclerotherapy, but does not allow the passage of small, or around it, if it is a larger vessel, until the a heater probe, multipolar probe or laser. The bleeding stops. Perforation is a potential prob- adult gastroduodenoscope is usually required to lem, as well as delayed bleeding and the tissue use the heater probe, multipolar probe or laser. being adherent to the tip of the electrode [31]. The colonoscopes enable the endoscopists to Bipolar or multipolar probes are more com- perform various therapeutic interventions monly used owing to the above limitations of because of the larger size of the channel. monopolar probes [31]. The maximal tempera- ture achieved with this method is significantly Injection therapy less than that of monopolar coagulation, and The injection of a sclerosing agent around the hence the tissue injury is less. As with the heater bleeding vessel helps to tamponade the vessel, probe, tamponade is applied before coagulating and then directly at the site of the vessel helps to the area. A gold probe is a bipolar electrocau- attain hemostasis by varying the degree of tam- tery catheter with irrigation capability, and also ponade, vasoconstriction and cytochemical has a Hemoglide™ coating to allow easy pas- changes, depending on the agent used [31]. Dif- sage through the endoscope [103]. Universal- ferent agents are used, including epinephrine length disposable bipolar hemostasis probes with normal saline (1:10,000 to 1:20,000), epi- that can be used via any scopes are also avail- nephrine with hypertonic (3.6%) saline, and able. Short (2 s long) multiple pulses are used. absolute alcohol. A combination of 1:1000 epi- Heater probes, as well as multipolar probes, can nephrine (1 ml) with normal saline (9 ml) can achieve hemostasis up to 90% of cases. An

470 Therapy (2008) 5(4) futurefuture sciencescience groupgroup Gastrointestinal bleeding in infants & children – REVIEW

argon plasma coagulator is a noncontact Loops method of delivering high-frequency monopo- For lesions such as large polyps, before snare lar current by delivery of ionized, electrically polypectomy, the loop can be applied at the base conductive argon gas or argon plasma through to prevent bleeding. Preloaded detachable nylon the coagulation probe with the electrode at the loops are applied through the endoscope and the tip [31,33]. Ionization of the gas results in con- base ligated: When they are correctly applied duction of the spark to the nearest point, and they show color change. Care must be taken to this results in coagulation. Multiple-site treat- avoid the entanglement of the loop in the ment is possible. The argon plasma should be snare [31]. Combination therapy with more than aspirated frequently to avoid overdistension of one intervention produces more effective hemo- the bowel. argon plasma coagulator can be used stasis, such as application of hemostatic clips fol- to treat vascular ectasias, angiectasias, radiation- lowed by injection therapy, or injection therapy induced proctopathy, bleeding ulcers and resid- with thermocoagulation or heater probes, and ual adenomatous tissue. One pediatric series decreases the need for [36,37]. Such emer- reported minor complications in 17% of cases, gencies are not common in pediatrics, so it is success with hemostasis in 66% with one ses- important to have a network with adult gastro- sion and recurrence of bleeding in 25% [34]. enterology colleagues who can help by providing Several complications, such as pneumatosis the necessary equipment and expertise to deliver intestinalis, ulcerations at the site, pneumo- many of these therapeutic interventions. , bleeding, stricture, perforation and death, are reported. Colonoscopy is performed in children who Hot biopsy present with hematochezia and occult blood-posi- Hot biopsy forceps have the advantage of tive stool when the upper endoscopy fails to reveal obtaining the tissue for examination and simul- the cause. Although usually performed in a semi- taneously attaining hemostasis by electrocoagu- elective or elective manner, urgent colonoscopy lating the base [31]. Small lesions, such as polyps may occasionally be needed. In the absence of up to 5 mm in size, can be removed by hot proper bowel preparation, it is a difficult but feasi- biopsy and small vascular ectasias can be ble endeavor after rapid intestinal lavage with treated. Perforations, precipitation of bleeding polyethylene glycol solutions [38]. A NG tube may and delayed bleeding are known complications. be necessary in most children, owing to the large volume needed to adequately prepare the colon. Laser photocoagulation Inflammatory bowel disease can be diagnosed by Laser has been used in hemostasis in GI biopsies from the GI tract during upper endo- bleeding [31]. However, there are potential com- scopy, as well as colonoscopy. Polyps can be plications, including: precipitation of bleeding, removed by electrocautery using hot biopsy for- perforation, laser burns, and injury to the user ceps or bipolar snares, depending on the size. The and assistants, in addition to difficulties with endoscopic interventions discussed earlier can also cost and decreased portability. The neody- be performed, as appropriate, during colonoscopy mium:yttrium–aluminum garnet (ND:Yag) laser to achieve hemostasis. is predominantly used in . Other investigations, such as CT angiography with embolization of the bleeding vessel, may be Hemostatic clips necessary in lesions that are not amenable Stainless steel two- or three-pronged clips are through the endoscopes [39]. A Meckel’s scan can available as ready-to-use packages [35]. Newer identify a Meckel’s diverticulum, and thus enable versions can rotate inside the endoscope to a surgical intervention to proceed [40]. The achieve optimal positioning, and can open and (99m)Tc scan is useful in identify- close multiple times before being applied. Unlike ing the location of GI bleeding not visualized by the injection therapy, clips are applied directly at upper or lower endoscopy. The location of a the bleeding vessel first. Hemostasis can be lesion as indicated by a positive scan within 2 h is achieved in 84–100% with clips, and can be fol- helpful for guiding surgical intervention and lowed by other modalities, such as injection ther- angiography, although a definitive diagnosis usu- apy [36]. Most clips will pass within 2–4 weeks. ally requires additional methods, particularly Perforation has been reported. [41,42].

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Double-balloon endoscopy of the small bowel of a training simulator would be essential in has opened new dimensions in the management achieving such skills. This is a situation similar to that were of obscure GI bleeding by identifying liver transplant centers. However, close coopera- lesions previously not accessible. This has been tion with adult gastroenterologists, surgeons and successfully used in children [43]. Wireless cap- intensivists can help with management locally, sule endoscopy is being increasingly used to rather than requiring transfer to specialized cen- identify the source of obscure GI bleeding; this ters. Multicenter studies are needed to provide can guide in planning the intervention, depend- data on the etiology, intervention and outcomes ing on the pathology and its location [44,45]. of such patients. With the advent of liver trans- Surgical colleagues should be consulted in any plantation, the incidence of variceal bleeding from child if the bleeding is not amenable to endo- chronic liver disease is decreasing, so competence scopic intervention or to medical therapy, such at such procedures for trainees is important. as in nonresponding fulminant colitis, or if the Emergence and widespread availability of new bleeding is from a surgically curable condition, methods, such as wireless and such as Meckel’s diverticulum. Elective surgical double-balloon endoscopy, will help in the visual- consultation is necessary in patients with familial ization of the site of the bleeding and in adenomatous polyposis. A team of emergency optimizing the outcome. room physicians, pediatric gastroenterologists, surgeons, interventional radiologists and inten- Financial & competing interests disclosure sivists is necessary for delivering optimal care of a Dr Tolia receives grant support from Astra, JNJ, Wyeth and patient with significant GI bleeding. Glaxo, is on the speaker’s bureau for TAP and Nutricia, and is a consultant for Astra and JNJ. The authors have no other Future perspective relevant affiliations or financial involvement with any orga- Since GI pathology is different in children than in nization or entity with a financial interest in or financial adults, such life-threatening situations arise less conflict with the subject matter or materials discussed in the frequently in pediatrics. Specialized pediatric manuscript apart from those disclosed. endoscopy centers can provide training in thera- No writing assistance was utilized in the production of peutic intervention techniques, and even then, use this manuscript.

Executive summary

• Although gastrointestinal (GI) bleeding in children can present a challenge to the caregiver, as well as to the physician, it can be effectively managed.

• A focused initial review of the patient and stabilization, followed by in-depth evaluation and management, is necessary for appropriate management of the patient.

• Variceal bleeding can be best managed by supportive care and pharmacological and therapeutic intervention, such as variceal banding, even though such procedures can be challenging in younger patients owing to their small size.

• Bleeding nonvariceal lesions may be best managed by combination therapy, such as injection therapy with a heater probe, or clip devices with injection therapy.

• Double-balloon endoscopy can be a useful, but not easily available, test.

• Wireless capsule endoscopy and enteroscopy can be a useful alternative to aid in the evaluation of GI bleeding not identified by upper and lower endoscopy.

• The use of colonoscopy with or without the use of some of the therapeutic modalities can aid in the management of lower GI bleeding.

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