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Lower GI Bleeding, Pediatric

Basics

Description

- Other diagnostic clues: - Painful stools: may be consistent with anal fissure, local proctitis, or ischemic bowel - Painless rectal bleeding: associated with polyps, Meckel diverticulum, nodular lymphoid hyperplasia of colon, intestinal duplication, intestinal submucosal mass (GIST), or vascular anomaly - Abdominal pain: inflammatory bowel disease, other causes of colitis, or a surgical abdomen

- Hemodynamic stability should be assessed immediately. - Heart rate: Tachycardia may be an early sign of intravascular volume depletion. - Blood pressure: Hypotension is a late sign and may not be present even with significant blood loss because vasoconstriction maintains BP until decompensation occurs. - In the setting of normal blood pressure, obtain orthostatic BP. - Capillary refill: Delayed capillary refill suggests intravascular volume depletion. - Oxygen saturation: may be decreased due to decreased oxygen carrying capacity - Evaluate for signs of shock: - Vitals signs listed earlier - Cool clammy extremities - Poor mentation

- Skin - Petechiae or purpura: HSP or coagulopathy - Ecchymosis: coagulopathy - Hemangiomas: vascular anomaly - Spider angioma: liver disease or portal hypertension - Caput medusa: liver disease or portal hypertension - Palmar erythema: liver disease or portal hypertension - Jaundice: liver disease or portal hypertension

- HEENT - Freckles on buccal mucosa: Peutz " “Jeghers syndrome - Telangiectasias on buccal mucosa: (Osler-Weber-Rendu syndrome). - Mouth ulcers: Crohn disease - Icteric sclera: portal hypertension

- Abdomen - Hepatosplenomegaly, ascites: liver disease or portal hypertension - Isolated splenomegaly: cavernous transformation of the portal vein

- Enteroscopy - Involves the passage of a special endoscope (either by push, single balloon or double balloon) to evaluate the small intestine - May be indicated if a lesion is seen on capsule endoscopy that may be amenable to endoscopic therapy

- Polyp: colonoscopy with polypectomy - Intussusception: air-contrast enema for confirmation and hydrostatic reduction - Parasites: antiparasitic medications - Inflammatory bowel disease: referral to pediatric gastroenterologist for therapy

  • Lower gastrointestinal bleeding (LGIB) is defined as bleeding that occurs distal to the ligament of Treitz.
  • Melena and maroon-colored stools can be seen with small bowel bleeding, whereas hematochezia is classically seen with colonic bleeding.
  • It is important to recognize that hematochezia can also be a presentation of severe upper gastrointestinal bleeding (UGIB).

Epidemiology

  • In a population study of 40,000 admissions to a tertiary care pediatric emergency department, LGIB accounted for 0.3% of all admissions.
  • 4.2% of patients with LGIB met criteria for severe life-threatening bleeding.

Etiology

Causes of LGIB vary by age: ‚

  • Neonatal period (birth to 1 month)Allergic colitisAnorectal fissureNecrotizing enterocolitisEnteric infectionsUpper GI sourceDuplication cystHirschsprung disease enterocolitisMeckel diverticulumMalrotation with volvulusHemorrhagic disease of the newborn
  • Infancy (1 month to 2 years)Allergic colitisAnorectal fissureEnteric infectionsIntussusceptionMeckel diverticulumMalrotation with volvulusLymphonodular hyperplasiaUpper GI sourceDuplication cystEnterocolitis with Hirschsprung diseaseVascular malformation
  • Preschool age (2 " “5 years)Anorectal fissureEnteric infectionsPolypsParasitesMeckel diverticulumIntussusceptionLymphonodular hyperplasiaInflammatory bowel diseaseHirschsprung disease enterocolitisHemolytic uremic syndromeHenoch-Sch ƒ ¶nlein purpura (HSP)Vascular malformationVolvulusRectal prolapse/rectal ulcerChild abusePerianal streptococcal cellulitis
  • School age (5 " “13 years)Anorectal fissureEnteric infectionsInflammatory bowel diseaseIntussusceptionMeckel diverticulumPolypsHSPHemolytic uremic syndromeIntestinal ischemiaNeutropenic colitis (typhlitis)ParasitesChild abuseVascular malformationsPerianal streptococcal cellulitis
  • Adolescent (>13 years)Anorectal fissureEnteric infectionsInflammatory bowel diseaseHemolytic uremic syndromeIntussusceptionMidgut volvulusIntestinal ischemiaNeutropenic colitis (typhlitis)PolypsVascular malformationsLymphonodular hyperplasiaParasitesHemorrhoids

Diagnosis

Approach to the Patient

General goals of initial evaluation of patient with LGIB: Determine if patient is actively bleeding, an approximate location of the bleeding and cause, as well as presence or absence of hemodynamic instability, which may indicate need for urgent/emergent clinical resuscitation: ‚

  • Phase 1: Determine if there is blood or other cause of bright red or black stools.
  • Phase 2: Assess patient to determine etiology; follow history, physical, and laboratory.
  • Phase 3: Assess and stabilize patient, decide if emergency treatment is needed or if outpatient referral is required.

History

  • Obtain a detailed history and note if any recently ingested foods resemble blood.
  • Evaluate the color of blood:Bright red: Site of bleeding is probably in left colon, rectosigmoid, or anal canal.Darker red stool: right colonMelena or maroon: Bleeding is likely proximal to ileocecal valve.
  • Location of blood in the stool:Colitis: Blood will be mixed with stool.Anal fissure/constipation: Blood streaks will be seen on the outer aspect of the stool.
  • Consistency of the stool:Diarrhea: suggests colitisHard stool: may be indicative of fissure and constipation
  • Other diagnostic clues:Painful stools: may be consistent with anal fissure, local proctitis, or ischemic bowelPainless rectal bleeding: associated with polyps, Meckel diverticulum, nodular lymphoid hyperplasia of colon, intestinal duplication, intestinal submucosal mass (GIST), or vascular anomalyAbdominal pain: inflammatory bowel disease, other causes of colitis, or a surgical abdomen
  • Obtain past medical history for any underlying or known GI disease (i.e., previous GI surgery, past history of colitis, Hirschsprung disease, necrotizing enterocolitis).
  • Evaluate for history of jaundice, hepatitis, liver disease, neonatal history: suggestive of portal vein thrombosis (sepsis, shock, exchange transfusion, omphalitis, and IV catheters), portal hypertension, and variceal bleeding.
  • Familial historyInflammatory bowel disease, intestinal polyps, and bleeding diathesis (e.g., von Willebrand disease, hemophilia)
  • Personal medications: in particular, nonsteroidal anti-inflammatory medications, heparin or warfarin. In addition, a history of medications in the house should also be obtained due to possible accidental ingestion in younger children.
  • Associated symptoms:Mouth ulcersWeight lossJoint painsFeversRashPetechiaeRenal insufficiencyHistory of ingestion of uncooked meat (hemolytic uremic syndrome [HUS])Purpuric rash (HSP)

Physical Exam

  • Hemodynamic stability should be assessed immediately.Heart rate: Tachycardia may be an early sign of intravascular volume depletion.Blood pressure: Hypotension is a late sign and may not be present even with significant blood loss because vasoconstriction maintains BP until decompensation occurs.In the setting of normal blood pressure, obtain orthostatic BP.Capillary refill: Delayed capillary refill suggests intravascular volume depletion.Oxygen saturation: may be decreased due to decreased oxygen carrying capacityEvaluate for signs of shock:Vitals signs listed earlierCool clammy extremitiesPoor mentation
  • SkinPetechiae or purpura: HSP or coagulopathyEcchymosis: coagulopathyHemangiomas: vascular anomalySpider angioma: liver disease or portal hypertensionCaput medusa: liver disease or portal hypertensionPalmar erythema: liver disease or portal hypertensionJaundice: liver disease or portal hypertension
  • HEENTFreckles on buccal mucosa: Peutz " “Jeghers syndromeTelangiectasias on buccal mucosa: (Osler-Weber-Rendu syndrome).Mouth ulcers: Crohn diseaseIcteric sclera: portal hypertension
  • AbdomenHepatosplenomegaly, ascites: liver disease or portal hypertensionIsolated splenomegaly: cavernous transformation of the portal vein
  • Rectal examinationEvidence of perianal disease: inflammatory bowel diseasePolyps: Rectal polyps may be detected on digital exam.Hemorrhoids: chronic constipation, portal hypertension

Diagnostic Tests & Interpretation

  • NG tube lavageNo longer recommended in patients with suspected upper or lower GI bleeding for diagnosis, prognosis, visualization, or therapeutic effect
  • Stool guaiacMay help to distinguish blood in stool from other blood colored substances (i.e., food coloring)

Lab

  • CBC should be measured serially.Initial hemoglobin values may be unreliable because a delay in hemodilution may falsely produce near-normal values.
  • Iron deficiency anemia: may indicate anemia of chronic diseaseLeukopenia, anemia, and thrombocytopenia: Consider chronic liver disease and portal hypertension.Anemia with normal RBC indices: truly an acute cause for bleedingRBC indices indicate iron deficiency anemia: Consider mucosal lesion, that is, chronic blood loss.Thrombocytopenia: Consider hemolytic uremic syndrome.
  • Coagulation profileIf PT and PTT are abnormal, consider liver disease or disseminated intravascular coagulation with sepsis.
  • Liver function tests: abnormal in chronic liver disease
  • Renal function tests (BUN, creatinine, urine analysis): abnormal in hemolytic uremic syndrome, HSP, acute bleed
  • ESR or C-reactive protein (CRP): abnormal in inflammatory disorders or infectious colitis
  • Stool tests:Stool culture (Salmonella, Shigella, Campylobacter, Yersinia, Aeromonas, Escherichia coli, Klebsiella)Stool for Clostridium difficile toxin A and BOva and parasites (Amebae)Stool smears for WBCs (not always positive in colitis) and eosinophils (not always positive in allergic colitis)Stool CMV: Consider in immunocompromised patients.

Imaging

  • Abdominal x-rayCan be helpful in evaluating surgical abdomen (dilated bowel, air " “fluid levels, and perforation), constipation (presence of excessive stool), colitis (edematous bowel, thumb-printing), pneumatosis intestinalis, and toxic megacolon
  • UltrasoundCan show bowel wall thickening consistent with inflammatory bowel disease, Meckel diverticulum, intussusception
  • Barium tests:Air-contrast enema is diagnostic and therapeutic in intussusception and diagnostic in mucosal lesions (polyps).Upper GI series with small bowel follow-through is helpful in evaluating anatomy and inflammatory bowel disease.CT scan can show evidence of intestinal inflammation and evidence of bowel obstruction.
  • Nuclear medicineMeckel scan: Technetium-99m pertechnetate can detect a Meckel diverticulum when it contains gastric mucosa.Bleeding scan: useful in a patient with significant bleeding that precludes endoscopy or in whom endoscopy is nondiagnostic. Technetium-99m " “tagged erythrocyte scan detects rapid bleeding at a rate of 0.1 " “0.5 mL/min; can be performed at 30-minute intervals for up to 24 hours.

Diagnostic Procedures

  • EndoscopyUpper endoscopy and colonoscopy is the prime diagnostic and therapeutic tool for upper and lower GI bleeding.Endoscopy can be used to accurately delineate the bleeding site and/or to determine specific cause. It is 90 " “95% sensitive at locating bleeding site.Upper endoscopy diagnostic in massive UGIB presenting with hematochezia or melenaUpper endoscopy and colonoscopy should be performed when the suspicion is high for inflammatory bowel disease.Colonoscopy should be performed when there is a suspicion for polyps.
  • Video capsule endoscopyCapsule endoscopy has become 1st-line treatment in adults and children to diagnose obscure causes of GI bleeding in the small intestine.Capsule endoscopy may be limited by ability of the patient to swallow the capsule.The capsule can be placed endoscopically into the small intestine in younger children.
  • EnteroscopyInvolves the passage of a special endoscope (either by push, single balloon or double balloon) to evaluate the small intestineMay be indicated if a lesion is seen on capsule endoscopy that may be amenable to endoscopic therapy
  • AngiographyUseful in detecting vascular causes of UGIB; can also be therapeutic (i.e., injection of coils into a vascular malformation may occlude it); requires bleeding rate of 0.5 " “1 mL/min

Treatment

General Measures

  • Initial managementMake patient NPO.Secure stable vascular access (i.e., intravenous line).Obtain blood type, and cross-match RBCs.Stabilize the patient with IV fluids and blood products if necessary (target hemoglobin ≥7 g/dL).Target INR <2.5Consult specialists (pediatric surgery and/or pediatric gastroenterologist).
  • Disease-specific therapyAnal fissureTreat the underlying constipation (mineral oil, lactulose, MiraLax, high-fiber diet, increased water intake).Local therapy consists of sitz baths, local emollient creams, and steroid suppositories.Polyp: colonoscopy with polypectomyIntussusception: air-contrast enema for confirmation and hydrostatic reductionParasites: antiparasitic medicationsInflammatory bowel disease: referral to pediatric gastroenterologist for therapy

Issues for Referral

Refer the following patients to a specialist: ‚

  • Any patient with significant acute lower GI bleeding after initial stabilization
  • Patients with less acute bleeding for whom an easily identifiable cause has not been found or patients with chronic or recurrent lower GI bleeding

Surgery/Other Procedures

In cases of massive or persistent bleeding with no identifiable site, exploratory laparotomy with intraoperative endoscopic evaluation of the entire bowel to identify mucosal lesions may be required. ‚

Hospitalized Patients

Initial Stabilization

Emergency care ‚

  • If patient is critical, stabilize with IV fluids and blood products.
  • Order laboratory tests: CBC, PT/PTT, disseminated intravascular coagulation screen, liver function tests, blood type, and cross-match
  • Monitor patient 's vital signs and hemoglobin.
  • Make appropriate diagnosis and institute appropriate therapy.

Ongoing Care

Patient Monitoring

  • Monitor hemoglobin in the hospital until patient 's condition is stable.
  • Send stool studies.
  • Refer patients with LGIB that is chronic in nature and hemodynamically stable to specialist for further workup.

Diet

  • Consider recommendation of an exclusion diet that restricts (milk and/or soy, egg, wheat, other foods) in breastfeeding mothers of infants consuming breast milk with evidence of allergic colitis.
  • Introduce hydrolyzed protein formula in formula-fed infants with suspected cow 's milk protein allergy.

Additional Reading

  • Boyle ‚ JT. Gastrointestinal bleeding in infants and children. Pediatric Rev. 2008;29(2):39 " “52. ‚ [View Abstract]
  • Cohen ‚ SA, Klevens ‚ AI. Use of capsule endoscopy in diagnosis and management of pediatric patients, based on meta-analysis. Clin Gastroenterol Hepatol. 2011;9(6):490 " “496. ‚ [View Abstract]
  • Fox ‚ V. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29(1):37 " “66. ‚ [View Abstract]
  • Leung ‚ AK, Wong ‚ AL. Lower gastrointestinal bleeding in children. Pediatric Emerg Care. 2002;18(4):319 " “323. ‚ [View Abstract]
  • Liu ‚ K, Kaffes ‚ AJ. Review article: the diagnosis and investigation of obscure gastrointestinal bleeding. Aliment Pharmacol Ther. 2011;34(4):416 " “423. ‚ [View Abstract]

Codes

ICD09

  • 578.9 Hemorrhage of gastrointestinal tract, unspecified
  • 578.1 Blood in stool
  • 558.3 Allergic gastroenteritis and colitis

ICD10

  • K92.2 Gastrointestinal hemorrhage, unspecified
  • K92.1 Melena
  • K52.2 Allergic and dietetic gastroenteritis and colitis

SNOMED

  • 87763006 lower gastrointestinal hemorrhage (disorder)
  • 2901004 Melena (disorder)
  • 30304000 Allergic colitis
  • 405729008 Hematochezia (finding)

FAQ

  • Q: What is the most common cause of lower GI bleeding?
  • A: In all age groups, fissures are the leading cause, followed by infections.
  • Q: What is the most common cause of blood mixed in the stool of an infant?
  • A: Allergic colitis. This is an indication to recommend a hypoallergenic diet (exclusion diet in mothers of infants who are breastfeeding, extensively hydrolyzed protein formulas in infants receiving formula).
  • Q: What common foods cause stools to be red? Black?
  • A: Red: raspberries, cranberries, Kool-Aid, artificial coloring in cereal. Black: bismuth, spinach, blueberries, licorice.