What are the common causes and presentations of gastrointestinal bleeding in children?

From the Guidelines

The correct answer is (c) Meckel's diverticulum is seldom the cause of massive bleeding. Regarding gastrointestinal bleeding in children, Meckel's diverticulum rarely causes massive bleeding, though it can cause painless rectal bleeding 1. Anal fissures are common but not the leading cause of GI bleeding in children. A clear nasogastric aspirate does not definitively rule out upper GI bleeding, as intermittent bleeding may be missed. Intussusception typically presents with colicky abdominal pain, vomiting, and lethargy, with the classic "currant jelly" stool occurring in only about 50% of cases, not as the most common presentation. The most common causes of GI bleeding in children vary by age group, with milk protein allergy and gastroenteritis common in infants, infectious causes and inflammatory bowel disease more common in older children, and peptic ulcer disease, gastritis, and esophageal varices seen in adolescents. When evaluating a child with GI bleeding, the clinical approach should include assessment of hemodynamic stability, localization of the bleeding source, and age-appropriate diagnostic testing, such as a Meckel scan for unexplained intermittent GI bleeding in children and adolescents after negative endoscopic evaluation 1.

Some key points to consider in the evaluation of GI bleeding in children include:

• The role of imaging in evaluating GI obstruction and bleeding, including the use of a Meckel scan to identify the cause of unexplained intermittent GI bleeding 1
• The importance of assessing hemodynamic stability and localizing the bleeding source in children with GI bleeding
• The varying causes of GI bleeding in children by age group, including milk protein allergy and gastroenteritis in infants, and infectious causes and inflammatory bowel disease in older children
• The need for age-appropriate diagnostic testing, including endoscopic evaluation and cross-sectional imaging of the small bowel, to evaluate the cause of GI bleeding in children.

In terms of specific diagnostic approaches, a Meckel scan can be considered to identify the cause of unexplained intermittent GI bleeding in children and adolescents after negative endoscopic evaluation, including capsule endoscopy if available, and cross-sectional evaluation of the small bowel 1. Additionally, the clinical evaluation should include a thorough history and physical examination, as well as laboratory tests to evaluate for underlying conditions such as inflammatory bowel disease or infections 1.

Overall, the evaluation and management of GI bleeding in children requires a comprehensive approach that takes into account the varying causes of bleeding by age group, as well as the need for age-appropriate diagnostic testing and treatment. The most important consideration is to prioritize the child's hemodynamic stability and to localize the bleeding source in order to provide appropriate treatment and prevent complications.

From the Research

Gastrointestinal Bleeding in Children

• The causes of gastrointestinal bleeding (GIB) in children are diverse and can originate from either the upper or lower gastrointestinal tract 2.
• The estimated prevalence of GIB in children is 6.4%, with spontaneous resolution in approximately 80% of cases 2.
• A clear nasogastric aspirate does not necessarily rule out upper gastrointestinal bleeding, as the bleeding may be intermittent or the aspirate may not be representative of the entire upper GI tract.
• Meckel's diverticulum can be a cause of gastrointestinal bleeding in children, although it is not the most common cause 3.
• Intussusception is a frequent cause of bowel obstructions and pediatric surgical consults, and it can be associated with a Meckel's diverticulum or other lead points 3.
• Bleeding is not the most common presentation of intussusception, although it can be a symptom in some cases.

Common Causes of Gastrointestinal Bleeding in Children

• Anal fissure is a common cause of lower gastrointestinal bleeding in children, but it is not typically associated with massive bleeding.
• Upper gastrointestinal bleeding in children can be caused by a variety of conditions, including variceal and non-variceal bleeding 4.
• The diagnosis and management of gastrointestinal bleeding in children require a structured, age-specific approach and collaboration with a multidisciplinary team 5.

Diagnostic Approach

• Diagnostic modalities for gastrointestinal bleeding in children may include esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography, computed tomography, and magnetic resonance imaging 2.
• Endoscopy should be performed with the goal of using combinations of therapies to treat a bleeding lesion, generally involving epinephrine injection along with either cautery, hemoclips, or hemospray 4.