Gastrointestinal Bleeding in Children: Causes and Management
Anal fissure is the most common cause of gastrointestinal bleeding in children, while bleeding is not the most common presentation of intussusception, clear nasogastric aspirate does not rule out upper gastrointestinal bleeding, and Meckel's diverticulum can cause massive bleeding. 1
Common Causes of Gastrointestinal Bleeding by Age
Infants and Toddlers
- Mucosal bleeding (gastritis and stress ulcers) is a common cause in this age group 2
- Anal fissures are the leading cause of lower gastrointestinal bleeding in young children 1
- Allergic colitis is unique to infants and can present with blood-streaked stools 3
Children Above 2 Years
- In developing countries, variceal bleeding due to Extra-Hepatic Portal Venous Obstruction (EHPVO) is the most common cause of significant upper GI bleeding 2
- In developed countries, peptic ulcer disease is more common 2
- Meckel's diverticulum, though less common, can cause massive bleeding and should not be dismissed 1
Diagnostic Approach
Initial Assessment
- Determine severity of bleeding - hemodynamic stability is key to management decisions 1
- Digital rectal examination is essential to confirm blood in stool and may identify up to 40% of rectal carcinomas 1
- Presence of orthostatic hypotension indicates significant blood loss requiring intensive care monitoring 1
Laboratory Evaluation
- Check for coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL), which require correction with fresh frozen plasma or platelets 1
- Hemoglobin threshold for transfusion is generally 7 g/dL 4
Endoscopic Evaluation
- Upper gastrointestinal endoscopy is the most accurate diagnostic tool for upper GI bleeding 2
- Colonoscopy is the first-line diagnostic procedure for lower GI bleeding 5
- A clear nasogastric aspirate does NOT rule out upper gastrointestinal bleeding, contrary to option (b) 1, 6
Small Bowel Evaluation
- For patients with negative upper endoscopy and colonoscopy, small bowel evaluation is indicated 1
- Video capsule endoscopy identifies bleeding sources in 55-65% of cases 1
- A radionuclide scan for Meckel's diverticulum is appropriate in young patients with unexplained lower GI bleeding 1
Management Strategies
Resuscitation and Stabilization
- Immediate resuscitation with fluid and blood products for hemodynamically unstable patients 6
- Protect airway in severe bleeding cases 4
- Correct coagulopathy with fresh frozen plasma and vitamin K 1
Pharmacological Management
- Administer parenteral vitamin K (infants: 1-2 mg/dose; children: 5-10 mg) empirically for major GI bleeding 2
- Start proton pump inhibitors (PPIs) or histamine-2 receptor antagonists for non-variceal bleeding 2, 6
- For suspected variceal bleeding, initiate octreotide infusion 2
Endoscopic Intervention
- Perform endoscopy once the child is hemodynamically stable 6
- For active bleeding lesions, use combination therapy: epinephrine injection plus either cautery, hemoclips, or hemospray 4
- For variceal bleeding, therapeutic emergency endoscopy is the treatment of choice after initial stabilization 5
Surgical Intervention
- Surgery is indicated when hemodynamic instability persists despite aggressive resuscitation 1
- Continued bleeding requiring >6 units of blood transfusion despite other interventions 1
- Sengstaken-Blakemore tube placement can be life-saving if pharmacologic/endoscopic methods fail to control variceal bleeding 2
Special Considerations
Intussusception
- Contrary to option (d), bleeding is NOT the most common presentation of intussusception 1
- Intussusception typically presents with intermittent abdominal pain, vomiting, and sometimes a palpable abdominal mass 1
- "Currant jelly" stools occur in only a minority of cases and represent a late finding 3
Meckel's Diverticulum
- Contrary to option (c), Meckel's diverticulum CAN cause massive bleeding 1
- It is an important cause of significant lower GI bleeding in children 1
- A radionuclide scan is appropriate for diagnosis in young patients with unexplained GI bleeding 1