Basics
Description
- 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 colitis
- Anorectal fissure
- Necrotizing enterocolitis
- Enteric infections
- Upper GI source
- Duplication cyst
- Hirschsprung disease enterocolitis
- Meckel diverticulum
- Malrotation with volvulus
- Hemorrhagic disease of the newborn
- Infancy (1 month to 2 years)
- Allergic colitis
- Anorectal fissure
- Enteric infections
- Intussusception
- Meckel diverticulum
- Malrotation with volvulus
- Lymphonodular hyperplasia
- Upper GI source
- Duplication cyst
- Enterocolitis with Hirschsprung disease
- Vascular malformation
- Preschool age (2 " “5 years)
- Anorectal fissure
- Enteric infections
- Polyps
- Parasites
- Meckel diverticulum
- Intussusception
- Lymphonodular hyperplasia
- Inflammatory bowel disease
- Hirschsprung disease enterocolitis
- Hemolytic uremic syndrome
- Henoch-Sch ƒ ¶nlein purpura (HSP)
- Vascular malformation
- Volvulus
- Rectal prolapse/rectal ulcer
- Child abuse
- Perianal streptococcal cellulitis
- School age (5 " “13 years)
- Anorectal fissure
- Enteric infections
- Inflammatory bowel disease
- Intussusception
- Meckel diverticulum
- Polyps
- HSP
- Hemolytic uremic syndrome
- Intestinal ischemia
- Neutropenic colitis (typhlitis)
- Parasites
- Child abuse
- Vascular malformations
- Perianal streptococcal cellulitis
- Adolescent (>13 years)
- Anorectal fissure
- Enteric infections
- Inflammatory bowel disease
- Hemolytic uremic syndrome
- Intussusception
- Midgut volvulus
- Intestinal ischemia
- Neutropenic colitis (typhlitis)
- Polyps
- Vascular malformations
- Lymphonodular hyperplasia
- Parasites
- Hemorrhoids
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 colon
- Melena 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 colitis
- Hard stool: may be indicative of fissure and constipation
- 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
- 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 history
- Inflammatory 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 ulcers
- Weight loss
- Joint pains
- Fevers
- Rash
- Petechiae
- Renal insufficiency
- History 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 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
- Rectal examination
- Evidence of perianal disease: inflammatory bowel disease
- Polyps: Rectal polyps may be detected on digital exam.
- Hemorrhoids: chronic constipation, portal hypertension
Diagnostic Tests & Interpretation
- NG tube lavage
- No longer recommended in patients with suspected upper or lower GI bleeding for diagnosis, prognosis, visualization, or therapeutic effect
- Stool guaiac
- May 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 disease
- Leukopenia, anemia, and thrombocytopenia: Consider chronic liver disease and portal hypertension.
- Anemia with normal RBC indices: truly an acute cause for bleeding
- RBC indices indicate iron deficiency anemia: Consider mucosal lesion, that is, chronic blood loss.
- Thrombocytopenia: Consider hemolytic uremic syndrome.
- Coagulation profile
- If 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 B
- Ova 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-ray
- Can 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
- Ultrasound
- Can 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 medicine
- Meckel 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
- Endoscopy
- Upper 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 melena
- Upper 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 endoscopy
- Capsule 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.
- 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
- Angiography
- Useful 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 management
- Make 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 <2.5
- Consult specialists (pediatric surgery and/or pediatric gastroenterologist).
- Disease-specific therapy
- Anal fissure
- Treat 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 polypectomy
- Intussusception: air-contrast enema for confirmation and hydrostatic reduction
- Parasites: antiparasitic medications
- Inflammatory 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.