Introduction
Digestive system Hemorrhage
Inflammatory adhesions
Episodes of intra-abdominal inflammation, including, but not limited to ovarian torsion, ventriculoperitoneal shunt infection, Crohn's disease, acquired immunodeficiency syndrome, and pelvic inflammatory disease, can lead to adhesion formation and subsequent intestinal obstruction in the absence of previous surgical procedures.
Gastrointestinal bleeding accounts for at least 3 of every 1,000 pediatric emergency room visits.
Gastrointestinal bleeding is usually classified based on the anatomic relationship between the suspected site of bleeding and the ligament of Treitz. Bleeding from sites proximal to the ligament of Treitz is considered upper gastrointestinal bleeding and bleeding from sites distal to the ligament of Treitz is considered lower gastrointestinal bleeding.
Occult gastrointestinal bleeding refers to an initial presentation with a positive fecal occult blood test or iron deficiency anemia without visible evidence of blood loss. Patients with upper gastrointestinal bleeding typically present with melena, hematemesis, or blood clots mixed with emesis. Patients with lower gastrointestinal bleeding sometimes report bloody diarrhea, hematochezia, blood seen on toilet paper or blood streaks or clots mixed with stool. Patients with occult gastrointestinal bleeding sometimes present with non-specific signs and symptoms including fatigue, pallor, or anemia.
Certain types of gastrointestinal bleeding occur in children of any age; however, many etiologies are age-specific and warrant additional distinction (Tables 4.1 and 4.2).
The patient's age and clinical presentation are the most useful pieces of information in determining the likely cause of bleeding and for directing the diagnostic and treatment algorithm.
The approach to any patient with gastrointestinal bleeding should begin with an assessment of hemodynamic stability and overall clinical status followed by resuscitation, diagnosis, and therapy.
After resuscitation, the level of bleeding must be established and a list of potential diagnoses generated based on the child's age and clinical presentation.
A nasogastric tube lavage helps to confirm or exclude an upper GI source of bleeding (proximal to the ligament of treitz) and to remove particulate matter and clots from the stomach to facilitate endoscopy. For patients with a suspected upper GI bleed, EGD helps identify the bleeding source, permits treatment of the identified bleeding lesions, and allows for stratification of the risk for rebleeding.
For patients with a suspected lower GI bleed, the diagnostic workup depends on the suspected diagnosis based on the patient's age and presentation.
Adjunct treatments for upper gastrointestinal bleeding may include intravenous proton pump inhibitors or octreotide.
Table 4.1
Age-based differential diagnosis of gastrointestinal bleeding (by Jay L. Grosfeld, 2006).
Age | Upper gastrointestinal bleeding | Lower gastrointestinal bleeding |
Newborn (<1 month) | · Hemorrhagic disease of the newborn · Swallowed maternal blood · Stress gastritis · Coagulopathy · Septicemia · Vascular malformations | · Anal fissure · Necrotizing enterocolitis · Malrotation with volvulus · Hirschsprung's disease with enterocolitis |
Infancy (1 month- 2 years) | · Gastritis · Esophagitis · Hypertrophic pyloric stenosis · Trauma secondary to gastrostomy tube · Foreign body · NSAIDs | · Anal fissure · Milk protein allergy (allergic proctocolitis) · Intussusception · Lymphonodular hyperplasia · Intestinal duplication · Gangrenous bowel · Infectious diarrhea · Eosinophilic gastroenteropathy · Acquired thrombocytopenia |
Child (>2 years) | · Peptic ulcer · Esophageal varices · Gastric varices · Gastritis · Esophagitis · Mallory-Weiss tear · Trauma secondary to gastrostomy tube · Eosinophilic gastroenteropathy · Munchausen syndrome by proxy · NSAIDS · Foreign body · Chemotherapy | · Polyps · Lymphonodular hyperplasia · Meckel's diverticulum · Hemolytic uremic syndrome · Henoch-Schonlein purpura · Infectious colitis · Anal fissure · Eosinophilic gastroenteropathy · Inflammatory bowel disease · Vascular lesions |
Table 4.2
Common presentation and workup of specific causes of gastrointestinal bleeding (by Peter Mattei, 2011)
Diagnoses | Suggestive history/physical findings | Age groups | Diagnostic test |
Upper gastrointestinal bleeding | |||
Esophagitis, gastritis or gastroduodenal ulcers | Vomiting, GERD, epigastric pain, dysphagia, indwelling NGT or gastrostomy tube, critical illness, NSAIDs, alcohol, caustic ingestion | All age groups | EGD |
Mallory-Weiss tear | Hematemesis after forceful vomiting | All age groups | EGD |
Varices | Hematemesis with hepatomegaly, splenomegaly, jaundice or ascites | Infancy and older | EGD |
Lower gastrointestinal bleeding | |||
Anorectal fissure | Painful defecation with streaks of red blood on stool | All age groups | Physical exam |
Allergic colitis | Blood stained vomiting or diarrhea within 48 h of introducing formula | Neonates and infants | History |
Necrotizing enterocolitis | Non-specific systemic signs of toxicity with abdominal distention, tenderness, vomiting, thrombocytopenia, or diarrhea with enteral feeding | Neonates (especially preterm) | KUB |
Malrotation with midgut volvulus | Melena with abdominal distention and bilious emesis | Neonates | Upper GI series |
Hirschsprung disease | Delayed meconium passage (>48 h) or progressive constipation with abdominal distention | Neonates | Contrast enema and suction rectal biopsy |
Intussusception | Sudden onset, severe, colicky pain with vomiting and bloody mucoid stool; possible abdominal mass | Infants, preschool | Contrast enema or ultrasound |
Meckel's diverticulum | Well child with large volume painless bleed | Infants, preschool | Meckel's scan |
Lymphonodular hyperplasia | Painless bleeding after viral illness or allergic colitis | Infants, preschool | Colonoscopy |
Juvenile polyp | Painless rectal bleeding with blood on top of the stool | Preschool, school age (up to 8 years old) | Colonoscopy |
Infectious diarrhea | Bloody diarrhea with fever, pain, or tenesmus | Preschool, school age | History, stool cultures |
Inflammatory bowel disease | Chronic bloody diarrhea with weight loss, anorexia, arthralgia or erythema nodusum | School age | Colonoscopy |