REVIEW Gastrointestinal bleeding 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 blood, the further man- Michigan State University, overt. Occult bleeding presents with fatigue, agement is decided. Early consultation with a Providence Hospital, iron-deficiency anemia, 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 abdominal pain or vomiting. 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 (hematemesis), tion to melena; a drop of hematocrit by more or per rectum, as passage of either bright red gross than 10%; or tachycardia, diaphoresis, orthostatic blood, dark red blood (hematochezia) or black changes or any suggestion of portal hypertension tarry stools (melena). The bleeding is considered or liver 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 medications 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 diarrhea, 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 hemoglobin. 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 diverticulum [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 fetal hemoglobin is alkali resistant [3]. bleeding suggests mid-gut volvulus from malrota- In patients who present with hematemesis, a tion. A child who presents with diarrhea and rectal history of heartburn, chest pain, epigastric pain bleeding may have colitis of infectious etiology, or or frequent regurgitation may suggest erosive as a result of inflammatory bowel disease. Rectal esophagitis or peptic ulcer disease. A history of bleeding is a frequent presentation of allergic colitis liver disease, such as biliary atresia, could point from milk-protein intolerance in infancy [1]. towards variceal bleeding. A history of forceful retching 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 gastritis 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 rash 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 rectal bleeding 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 antibiotic 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 review of systems 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. dizziness or orthostatic changes in heart rate or • Swallowed blood: especially in newborns, swallowed maternal blood blood pressure, 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]. • Esophageal varices The physical examination (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 Helicobacter pylori 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 gastroenteritis defined as an increase of 20 beats per min of • Peptic ulcer disease heart rate, or decrease of 20 mmHg of systolic • Vasculitis; Henoch–Schonlein purpura blood pressure or 10 mmHg of diastolic blood • Variceal bleeding from gastric varices pressure on changing from a supine to upright • Vascular malformations or sitting position [6]. The presence of jaundice, • Coagulation disorders; platelet dysfunction ascites or hepatosplenomegaly could point • Trauma, including nasogastric tube suctioning towards chronic liver disease [1]. In a child with • Gastrointestinal stromal tumors chronic diarrhea, weight loss or growth failure, • Hemobilia the bleeding could indicate inflammatory • Upper gastrointestinal tract duplication bowel disease. 466 Therapy (2008) 5(4) futurefuture sciencescience