What is the emergency department management of pediatric rectal bleeding?

Emergency Department Management of Pediatric Rectal Bleeding

The emergency department management of pediatric rectal bleeding requires immediate assessment of hemodynamic stability, followed by targeted diagnostic evaluation to identify the bleeding source, with colonoscopy being the investigation of choice for prolonged rectal bleeding in children. 1

Initial Assessment and Stabilization

• Hemodynamic Assessment:

  • Immediately check vital signs (heart rate, blood pressure)
  • Calculate shock index (heart rate/systolic BP) - value >1 indicates instability 2
  • Assess for orthostatic changes and signs of ongoing bleeding
  • Evaluate for signs of shock (pulse >100 beats/min and systolic BP <100 mmHg)

• Resuscitation Priorities:

  • Rapid volume resuscitation with crystalloids for hemodynamically unstable patients 2
  • For severe bleeding:
    • Maintain hemoglobin level >7 g/dL
    • Maintain mean arterial pressure >65 mmHg
    • Avoid fluid overload which may exacerbate bleeding 3
  • Blood transfusion if necessary (hemoglobin <7 g/dL)
  • Correction of coagulopathy if present 3

Diagnostic Evaluation

• For Hemodynamically Unstable Patients:

  • CT Angiography (CTA) should be first-line investigation for actively bleeding, unstable patients
  • High sensitivity (80-90%) for detecting bleeding at rates of 0.3-1.0 mL/min 2

• For Stable Patients:

  • Colonoscopy is the investigation of choice for prolonged rectal bleeding 1
  • Complete colonoscopy rather than limited sigmoidoscopy is recommended as 22% of polyps would be missed with sigmoidoscopy alone 1
  • Consider adding upper endoscopy (EGD) if accompanying symptoms like abdominal pain or diarrhea are present 1

• Additional Diagnostic Considerations:

  • If upper GI source is suspected and CTA is negative, proceed to urgent upper endoscopy 2
  • Video capsule endoscopy if small bowel source is suspected (highest yield within 48 hours of bleeding) 2
  • Nuclear medicine studies (tagged RBC scintigraphy) if source remains unidentified 2

Common Etiologies in Pediatric Patients

• Benign and Self-Limiting Conditions (most common):

  • Anal fissures
  • Infections
  • Allergies (cow's milk allergy in 18% of infants with rectal bleeding) 4

• More Serious Conditions (less common):

  • Inflammatory bowel disease
  • Polyps (common finding requiring complete colonoscopy) 1
  • Necrotizing enterocolitis (in neonates)
  • Very early onset inflammatory bowel diseases
  • Vascular malformations 5

Management Approach

• For Mild Bleeding:

  • Intravenous fluid replacement if needed
  • Correction of coagulopathy if present
  • Consider outpatient management (80% of pediatric rectal bleeding cases can be managed as outpatients) 4

• For Severe Bleeding:

  • Endoscopic treatment for high-risk stigmata (active bleeding, visible vessel, adherent clot)
  • Options include band ligation, sclerotherapy, or hemostatic clips 2
  • Consider endorectal placement of a compression tube as a bridging maneuver for stabilization 3
  • Angiographic embolization for ongoing bleeding not amenable to endoscopic treatment 2, 6

• Medication Management:

  • High-dose proton pump inhibitor therapy while awaiting definitive diagnosis 2
  • Discontinue NSAIDs if applicable 2
  • Manage antiplatelet/anticoagulant therapy in consultation with specialists 2

Special Considerations

• Cow's Milk Allergy:

  • Present in approximately 18% of infants with rectal bleeding 4
  • Elimination diet alone does not affect the duration of rectal bleeding 4
  • Proper diagnosis requires elimination and provocation testing 4

• Gut Microbiota:

  • Lower bifidobacteria and lactobacilli counts have been observed in infants with rectal bleeding 4
  • Common pathogens like Salmonella, Shigella, and Yersinia are rarely found in pediatric rectal bleeding 4

• Clinical Course:

  • Rectal bleeding in infants is generally a benign and self-limiting disorder
  • Bloody stools typically occur irregularly for only a few days during the following months 4
  • Most infants with rectal bleeding have normal growth patterns 4

Follow-up Recommendations

• Schedule follow-up visit within one month
• Consider age-appropriate cancer screening for persistent cases 2
• For patients discharged with anemia, provide iron supplementation 2
• For diagnosed cow's milk allergy, continue monitoring as some patients (18%) may develop multiple food allergies 4