Pediatrics [GI BLEEDS]

Introduction
Presentation of GI bleed can range from positive fecal occult blood test to
frank hematochezia. To sort through pediatric causes, it’s important to
consider age and historical / physical components when searching for a
diagnosis.

1) Necrotizing Enterocolitis (NEC)

If it’s a premature baby and bloody diarrhea the diagnosis can essentially Premature infant + bloody stool = NEC
be assumed. An x-ray / babygram will show pneumatosis intestinalis (air Make NPO and start antibiotics
in the wall of the bowel) to confirm the diagnosis. The baby needs to go
NPO immediately and get started on TPN and IV antibiotics. Hold off
from surgery unless there’s no improvement or conditions worsen.

2) Anal Fissure
This is a tear in the anal mucosa that can be seen on anal exam. They’re Common cause of hematochezia in infants
the most common cause of hematochezia in infants and typically associated Associated with constipation
with constipation. In older children or teenagers, this should give Check for inflammatory bowel disease if older
consideration to inflammatory bowel disease.

3) Intussusception
When part of the bowel telescopes into another the blood supply can be
compromised. This causes an abrupt onset of colicky abdominal pain in
an otherwise healthy baby. It occurs in kids 3 months to 3 years. In children,
~90% don’t have a “lead point” as a cause. In comparison, ~90% of adults
will have a lead point (such as malignancy). Kids will typically assume the
knee-chest position to find relief from the pain. A sausage-shaped mass
can be felt in the abdomen. As the vascular supply is compromised and
bowel begins to die, currant jelly diarrhea can be seen. While a KUB may
show evidence late in the disease (obstruction, perforation), it’s often not
useful in the diagnosis. An ultrasound is exceptionally sensitive for
intussusception and can be used to track resolution. If diagnosed, or there’s
a high index of suspicion, jump straight to an air-contrast barium enema. Acute colicky pain with abrupt onset and resolution
It can both confirm the diagnosis, and, in most cases, serve as the cure for Can diagnose with ultrasound
the disease. If the patient is unstable, or the enema fails surgery is the only Air enema can be diagnostic and therapeutic
option.

4) Meckel’s Diverticulum
Meckel’s diverticulum is a remnant of the omphalomesenteric (Vitelline)
duct which can contain gastric tissue. That can cause acid secretion and
contribute to bleeding by forming ulcers. It presents with either FOBT ,
iron deficiency anemia, or hematochezia in a child (in contrast, an adult
with this presentation would be considered for colon cancer). The bleeding
is painless and may be intermittent. The classic rule of 2s is often pimped,
but rarely tested: <2 years old, 2:1 ♂:♀, 2 inches in length, 2 feet from the
ileocecal valve, 2% of the population. To diagnose, do a Meckel’s scan
(technicium-99 radionucleotide scan). Treat it surgically.

Rule of 2s for Meckel’s

< 2 years old
2x more common in males
2 inches in length
2 feet from ileocecal valve
2% of the population

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 Pediatrics [GI BLEEDS]

5) Inflammatory Bowel Disease (IBD)
Crohn disease and ulcerative colitis can both present with bloody diarrhea. Persistent bloody diarrhea with weight loss = IBD
This diarrhea commonly lasts for > 6 weeks and is associated with Peak #1 = 10-20 years old
significant weight loss. There can be a family history. Usually seen in the Peak #2 = 50-80 years old
10-20 year olds (side note – there’s another peak between 50-80 years old).
A double contrast enema (contrast + air per rectum) and colonoscopy can
be used to help with diagnosis.

6) Infectious Colitis
If a patient has bloody diarrhea plus fever, think of pathogens such as
Shigella, Salmonella, E. coli, Yersinia, etc. There may also be a history of Bloody diarrhea + fever = Infectious
travel or a local outbreak. Obtain stool cultures (and blood cultures if History of travel or outbreak
patient is septic). First line treatment is hydration and electrolyte Care is primarily supportive
management. Antibiotic therapy varies based on the pathogen and severity
of illness. Generally, don’t treat unless patient is septic, there is a suspicion
for Shigella, or immunosuppression is present.

7) Milk-Protein Allergy
Occasionally, children with milk-protein allergy can present with
hematochezia. It’s most common around 6 months of age. Look for the Bloody diarrhea + failure to thrive + infant = Allergy
patient with hematochezia and failure to thrive. There can be IgE- Eliminate offending milk/formula from diet
mediated symptoms, but these aren’t always present. Switching to Switch to hydrolyzed formula
hydrolyzed formula can decrease the bloody diarrhea. It’s typically
outgrown at age 2-3 years.

8) Swallowed Blood
A baby presenting with blood emesis or stool can cause some excitement.
During the peripartum process, babies can swallow maternal blood
which can cause bloody GI outs. The Apt test (alkali denaturation test) in
neonates can determine if the blood is of maternal or fetal origin. Fetal
blood is resistant to denaturation, yield a positive test and require further
investigation. Maternal blood will yield a negative test; it just requires
reassurance that no further testing is needed.

9) “Bleeding” or “Bleeding Not Bleeding”

Not all red emesis is hemoptysis, not all red stool is hematochezia, and not
all black stool is melena. Take a thorough history and perform appropriate
testing to confirm blood is present. Did a child drink a red soft drink and
vomit? Did the child take an antibiotic (cefdinir) or eat a vegetable (beet)
that can cause red stool?

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