Gastrointestinal bleeding

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7.2 Gastrointestinal bleeding

Elizabeth M. Cotterell

Essentials

1 The causes of gastrointestinal (GI) bleeding in infants and children fall into age-specific diagnostic categories
2 The majority of GI bleeding ceases spontaneously, requiring no treatment or treatment on the basis of a presumptive diagnosis.
3 A good history is important in determining the likely site of GI bleeding, the significance and acuity of the bleed and guides appropriate investigations.
4 Initial assessment is for signs of haemodynamic compromise due to the blood loss, followed by identification of underlying disease.

Introduction

Gastrointestinal (GI) bleeding in infants and children is an uncommon cause of presentations to an emergency department (ED) but nonetheless is an alarming symptom that concerns parents greatly. Fortunately, in the majority of infants and children, the cause is benign or relatively uncomplicated, and not associated with significant morbidity or mortality. There are, however, some less common conditions that occur in infancy and childhood that may be a cause of potentially life-threatening blood loss and require rapid assessment and resuscitation.

The epidemiology of GI bleeding in children is very limited. The reported incidence of GI bleeding of 6.4% in paediatric ICU patients1 and the most frequent diagnoses confirmed endoscopically2 (duodenal and gastric ulcers, oesophagitis, gastritis, and varices) represent selected populations and are not representative of the ambulatory paediatric population.

Definitions

Haematemesis is the vomiting of blood that may be either fresh (bright red) or altered by gastric acidity and described as ‘coffee grounds’.

Melaena is the passage of black, tarry stool. This is caused by bacterial degradation of haemoglobin and implies that the bleeding has occurred over a period of hours.

Haematochezia is the passage of bright red blood per rectum. Haematemesis and melaena are usually indicative of an upper GI bleeding source. The passage of fresh blood per rectum usually indicates a source of blood from the lower GI tract. It can, however, derive from an upper GI source, especially in infants less than six months, due to rapid colonic transit times. Streaks of blood may be mixed with the stool, usually indicative of colitis, as compared to blood coating a hard or normal stool which may be due to an anal fissure.

Aetiology

The aetiology of GI bleeding is best considered within defined age groups, with some overlap between groups, and the likely location of the bleed, as guided by history and examination (see Tables 7.2.1 and 7.2.2).

Table 7.2.1 Causes of upper GI bleeding (causes listed most common to rare)

Neonates (<1 month) Infants (1 month to 1 year) Toddlers and school age Ingested maternal blood Ingested blood Ingested blood Gastritis Reflux oesophagitis Reflux oesophagitis Vascular malformations Gastritis Gastritis Bleeding disorders Mallory–Weiss tear Mallory–Weiss tear   Peptic ulceration Oesophageal varices   Vascular malformation Peptic ulceration   Bleeding disorders Bleeding disorders
Table 7.2.2 Causes of lower GI bleeding
Neonates Infants Toddlers and school age
Ingested maternal blood Anal fissure Anal fissure
Necrotising enterocolitis Protein sensitive enterocolitis Juvenile colonic polyps
Protein-sensitive enterocolitis Hirschsprung’s enterocolitis Infectious gastroenteritis
Hirschsprung’s enterocolitis Ischaemic enterocolitis Meckel’s diverticulum
Ischaemic enterocolitis Infectious gastroenteritis Intussusception
Infectious gastroenteritis Meckel’s diverticulum Ischaemic enterocolitis
Congenital bleeding disorders Intussusception Haemolytic uraemic syndrome
  Haemolytic–uraemic syndrome Henoch–Schönlein purpura
  Bleeding disorders Inflammatory bowel disease
  Vascular malformation Vascular malformation
  Inflammatory bowel disease Bleeding disorders

The term newborn infant who is breast fed and has GI bleeding is most likely to have ingested maternal blood either at the timeof delivery or from breast feeding from cracked nipples. Premature infants are at an increased risk of necrotising enterocolitis, although it can occur in term neonates with birth asphyxia or cyanotic heart disease. Any sick newborn, compromised by hypoxia or hypotension is at risk of GI bleeding from stress ulcers. An infant who has not received parenteral vitamin K after birth, or has interference with vitamin K absorption, is at risk of haemorrhagic disease of the newborn. Formula fed infants may develop cow’s milk protein intolerance within the first few weeks to months.

The bowel habit of the infant or child prior to onset of GI bleeding is important to note. Constipation associated with pain when straining at stool would make an anal fissure a probable diagnosis. The older infant or child with cerebral palsy may have severe gastro-oesophageal reflux and therefore most likely has an oesophagitis-related source of upper GI bleeding.

The key factor in identifying the cause of GI bleeding in toddlers and older children is the presence of associated symptoms. Crampy abdominal pain and diarrhoea with mucus and fresh blood may be caused by infectious gastroenteritis due to Campylobacter, Shigella, Salmonella and Yersinia. Intermittent colicky abdominal pain with episodes of lethargy occurring in intussusceptions may manifest with blood in the stools as a late sign. Henoch–Schönlein purpura will manifest with the typical palpable purpura on extremities as well as abdominal pain. Certain diagnoses also have a recognised age pattern; juvenile polyps have a peak incidence of 1 to 6 years of age, intussusception peaks at 5 to 18 months, and inflammatory bowel disease more commonly presents in adolescence, although can occur at any age.

History

Details of the timing of the blood appearing in the vomitus or bowel motions, in relation to other events, may give a clue to alternative sources of the blood. For example, the ingestion of substances such as iron or food colourings, onset of epistaxis or recent oral or ENT surgery, indicate a source of bleeding other than from the GI tract (Table 7.2.3).

Table 7.2.3 Chart for guided history taking for GI bleeding

Is it blood? Consider haemoccult(r) test on stool samples and gastroccult(r) on vomit or NG aspirates
History of ingestion of food colouring or iron supplements Is it from the GI tract? Consider other sources for the blood
Ingestion of maternal blood at delivery or breast feeding
History of epistaxis, post ENT or oral surgery or pharyngitis Where in the GI tract is it from? Upper GI tract – haematemesis, melaena or haematochezia for profuse bleed
Lower GI tract – haematochezia, redcurrant jelly stools Is it a significant amount? Estimate acuity of bleed by history and assess clinical signs
Resuscitate immediately if haemodynamic compromise Are there other concerning symptoms or signs? Paroxysmal abdominal pain and/or lethargy – intussusception
Bilious vomiting – volvulus
History of chronic liver disease – oesphageal varices
Renal or haemotological abnormalities

A history of recurrent retching or vomiting prior to the appearance of blood in the vomit suggests a Mallory–Weiss tear, but may occur in the absence of these symptoms. Symptoms of epigastric pain and nausea may be elicited with gastritis. Crampy abdominal pain with a passage of loose stools, with blood and mucus mixed throughout, suggest infectious or inflammatory colitis. Fresh blood coating the stool implies a lesion in the lower rectum or anus, such as a polyp or fissure.

A positive family history may be helpful, particularly with the less common causes, such as polyps, inflammatory bowel disease, coagulation disorders, haemorrhagic telangiectasia and Hirschsprung’s disease. A medication history, including use of non-steroidal anti-inflammatory drugs (NSAIDs), salicylates and anticoagulants may provide further clues. Inadvertent ingestion of caustic agents and rodenticides containing warfarin-type agents should be considered in preschool-age children.

Examination

Initial assessment is for the presence or absence of any haemodynamic compromise due to the blood loss. This is uncommon in children but, if present, clinical assessment proceeds while resuscitation is commenced.

Specific findings in the physical examination of the GI tract may establish potential causes for the GI bleeding. The abdomen should be assessed for any localised tenderness or peritoneal signs. Children with minor bleeding in the setting of gastroenteritis will have a benign abdomen. The finding of hepatosplenomegaly with stigmata of chronic liver disease may suggest oesophageal varices as the cause. Palpation of a tender abdominal mass may support a diagnosis of intussusception. Visualisation of an anal fissure is important to confirm the source of blood on stools when the history is suggestive with the defect in the rectal mucosa usually superficial and posteriorly located. Consider beta haemolytic streptococcal infection if there is marked perianal erythema. Skin and mucus membrane examination may reveal signs of a bleeding tendency due to a coagulation or platelet disorder. Clinical signs of anaemia are more suggestive of a chronic picture of GI bleeding. Examination of the nose and throat may show a nasopharyngeal source for ingested blood.

In addition, parents may often provide evidence of the symptoms that they have reported, such as a cloth with blood-streaked vomitus or a nappy with bloody streaks in the faeces. In the event of a fresh sample of stool or vomit being provided, testing for occult blood will verify if GI bleeding has occurred.

Investigations

The appropriate investigation of GI bleeding needs to be tailored to the most likely cause on the basis of history and examination findings.

Blood tests

Blood tests for haemoglobin level and red cell indices may indicate a hypochromic microcytic anaemia and point to a chronic source of bleeding. Haematocrit changes in the acute setting are unreliable indicators of acute bleeding. Coagulation profile and platelet count should be checked if the history and examination findings suggest a bleeding diathesis or chronic liver disease.

If the GI bleeding has occurred in a breast-feeding infant, most commonly as streaks of fresh blood in the vomitus, then it may be possible to distinguish if the blood is maternal (ingested) rather than from the infant’s gut by performing an Apt test. By diluting the blood from the sample with water (1:5), adding 1 mL of sodium hydroxide to the centrifuged mixture, foetal haemoglobin is resistant to denaturisation by alkali, as opposed to the brown–yellow colour that occurs in the presence of adult haemoglobin.

Stool testing

Stool samples for microscopy, looking for red and white cells, as well as for bacterial culture, should be sent if bacterial enterocolitis is suspected.

Endoscopy

The role of endoscopy for investigating GI bleeding in the acute setting in children is limited. It can, however, serve both a diagnostic and therapeutic role, especially in the case of oesophageal varices. Consultation with a paediatric gastroenterologist or surgeon is helpful in determining those patients most likely to benefit from this investigation.

Imaging

Nuclear medicine studies such as technetium pertechnetate scan for ectopic gastric mucosa in a Meckel’s diverticulum may have a role in investigating the cause of GI bleeding. However, the Meckel scan has a relatively low negative predictive value and may not obviate the need for operative evaluation despite a negative scan, where clinical suspicion is high.3 Other imaging techniques such as ultrasound and contrast air enema for intussusception should be considered in children under the age of 2 years with abdominal pain, GI bleeding and lethargy.

Treatment

Initial assessment and stabilisation

In the event of significant GI bleeding, the child or infant will develop signs of haemodynamic compromise. Cool peripheries, delayed capillary refill and tachycardia will be the first detectable signs. Hypotension occurs as a late sign of hypovolaemia in children.

Resuscitation should include the administration of high-flow oxygen, insertion of two large-bore cannulae and titrated 20 mL kg–1 fluid boluses with crystalloid. Children with significant GI bleeding require ongoing monitoring of heart rate, blood pressure, and urine output in the ED. These observations combined with frequent clinical assessment, help guide ongoing fluid therapy. Transfusion of cross-matched blood is indicated for ongoing or recurrent bleeding with haemodynamic instability unresponsive to initial fluid boluses. Correction of identified coagulopathy with fresh frozen plasma, activated factor VII or platelet infusions may be needed to control the GI bleeding.

Pharmacological treatment

Studies addressing the use of H2 antagonists and proton pump inhibitors (PPIs) for acute upper GI bleeding are restricted to the adult population. PPIs have been shown in systematic reviews to reduce the risk of further bleeding and need for surgery for peptic ulcers.4 However, the routine use of H2 antagonists or PPIs in children with acute GI bleeding cannot be recommended as bleeding gastric ulcers are very uncommon.

Intravenous somatostatin or octreotide have been shown to be effective for uncontrolled bleeding oesophageal varices by decreasing splanchnic blood flow; however, most variceal bleeding ceases spontaneously.

Bacterial enterocolitis is usually self limiting and does not require empiric antibiotic treatment.Children with gastroduodenal ulceration shown to be associated with Helicobacter pylori infection may benefit from antibiotic eradication treatment.

Infants with a presumptive diagnosis of cow’s milk protein intolerance should be changed to a hydrolysed protein formula with expected improvement within days. Mothers of breastfed infants can be advised to eliminate all dairy products from their diet if this diagnosis is considered for their infant.5

Children with bleeding from an anal fissure may require laxatives to ensure regular soft stools so that the fissure will heal.

Surgery

Laparoscopy or laparotomy for investigation of lower GI bleeding may be both a diagnostic and therapeutic tool in children with GI bleeding of obscure origin. A study of 17 children with GI bleeding and no identifiable source after upper endoscopy and colonoscopy found that eight patients had Meckel’s diverticulum at laparoscopy, five patients had other GI pathology that accounted for symptoms and four patients had normal findings.6 Laparotomy may be necessary for acute abdominal emergencies such as intussusception unsuccessfully reduced at air enema, midgut volvulus or for management of continuous or recurrent active GI bleeding with haemodynamic compromise.

Endoscopic sclerotherapy

Injection sclerotherapy for oesophageal varices in children is well established with a reported efficacy of controlling active bleeding and eradication of varices exceeding 90%.7 Complications can occur, including oesophageal ulceration leading to stricture formation. Variceal band ligation may be limited by size in infants and small children.

Dispositon

The decision to admit or discharge the infant or child with GI bleeding from the ED is very much influenced by the presumptive diagnosis. Given that the majority are self-limiting or respond readily to treatment, most patients can be managed on an out-patient basis. Those infants and children suitable for discharge will have no haemodynamic instability or significant co-morbidities at presentation to ED. High-risk patients with significant GI blood loss will need to be managed in an intensive care or high dependency unit. Children who present with recurrent GIT bleeding of unclear cause should be discussed with a paediatric gastroenterologist regarding the need for and timing of endoscopy.

Controversies

The lack of evidence of benefit from the use of H2 antagonists and PPIs for acute gastrointestinal bleeding in children has not prevented their frequent use.
There is debate about the use of nasogastric aspiration as a diagnostic tool to establish an upper GI tract source of bleeding as it has low specificity for active bleeding.

References

1 Lacroix J., Nadeau D., Laberge S., et al. Frequency of upper gastrointestinal bleeding in a paediatric intensive care unit. Crit Care Med. 1992;20:35-42.

2 Cox K., Ament M.E. Upper gastrointestinal bleeding in children and adolescents. Paediatrics. 1979;63:408-413.

3 Swaniker F., Soldes O., Hirschl R.B. The utility of technetium-99m pertechnetate scintigraphy in the evaluation of patients with Meckel’s diverticulum. J Pediatr Surg. 1999;34:760-764.

4 Leontiadadis G.I., Sreedharan A., Dorwrad S., et al. Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess. 2007;11:iii-iiv. 1–164

5 Maloney J., Nowak-Wegrzyn A. Educational clinical case series for pediatric allergy and immunology: Allergic proctocolitis, food protein-induced enterocolitis syndrome and allergic eosinophilic gastroenteritis with protein losing enteropathy as manifestations of non-IgE-mediated cow’s mild allergy. Pediatr Allergy Immunol. 2007;18:360-367.

6 Lee K.H., Yeung C.K., Tam Y.H., Ng W.T., Yip K.F. Laparoscopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children. J Pediatr Surg. 2000;35:1291-1293.

7 Fox V.L. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29:37-66.

Futher reading

Boyle J.T. Gastrointestinal bleeding in infants and children. Pediatr Rev, 29. 2008:39-52. http://pedsreview.aappublications/org/cgi/content/full/29/2/3

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