Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding can present in several ways, with the presentation often providing clues about the location and etiology of the bleed. Common presentations and definitions are listed below.

Causes of GI Bleeding

Although the etiologies of GI bleeding overlap among different age groups, some causes are more common in younger individuals, particularly neonates. The causes of GI bleeding are stratified by age group in the following tables.

Note: One of the most common causes of apparent hematemesis is swallowed maternal blood. Maternal blood can be distinguished from fetal blood by the Apt test performed on vomitus or stool. The test relies on the fact that fetal hemoglobin resists alkali denaturation. To perform the test, 1% sodium hydroxide is added to the supernatant of centrifuged sample of blood mixed with water. A positive test (sample turns yellow-brown) indicates the presence of maternal blood. In contrast, fetal hemoglobin resists the alkali denaturation and remains pinkish or red.

Evaluation of GI Bleeding

Initial evaluation should focus on the identification of ill-appearing patients and subsequent stabilization, with fluid and blood product resuscitation taking precedence over the below diagnostic workup.

Guaiac test of stool or emesis can be performed to confirm the presence of blood. Mimickers of blood include food coloring, gelatin, sports drinks, red candy, beets, tomatoes, antibiotic syrups, iron, and licorice.

Physical exam: A targeted physical exam should be completed to identify clues about the etiology of the bleeding such as:

• Head, eyes, ears, nose, and throat: scleral icterus, mucosal/lip pallor, trauma

• cardiovascular: murmur, perfusion

• abdominal: focal tenderness, ascites, hepatosplenomegaly

• rectal: anal fissures, hemorrhoids, fistulae

• skin: pallor, jaundice, vascular malformations

Basic laboratory workup should include complete blood count (CBC), blood urea nitrogen (BUN), creatinine, coagulation profile, liver transaminases, and type and cross. Other laboratory studies should be considered based on patient presentation (e.g., infectious stool studies if concern for infection, inflammatory markers if concern for inflammatory bowel disease).

Nasogastric (NG) lavage can be considered in situations of diagnostic uncertainty. The presence of blood in the lavage indicates an upper GI bleed (which could originate from the stomach or duodenum). Clearing of blood with lavage suggests that the bleeding has stopped.

Imaging: The following imaging modalities may be considered, depending on the patient’s presentation and symptoms.

• abdominal x-ray: consider for suspicion of intestinal obstruction, pneumatosis intestinalis, or foreign body

• ultrasound: for suspicion of intussusception or portal hypertension

• Meckel scan: for suspicion of Meckel diverticulum

• radioisotope-tagged red blood cell (RBC) scan: requires active bleeding; may be used for partial localization of an obscure bleed

• angiography: requires active bleeding; may be used for brisk bleeds after other diagnostic modalities (e.g., endoscopy) have failed to identify a source; interventional angiography can offer therapy for patients who are poor surgical candidates or who have obscure GI bleeding

• CT angiography: an emerging modality for bleed localization; does not allow option for therapeutic intervention (unlike regular angiography)

• capsule endoscopy: may be used to identify bleeding in the small intestine not reachable by endoscopy

Endoscopy: Typically involves both esophagogastroduodenoscopy (EGD) and colonoscopy; allows for diagnosis of many etiologies of GI bleeding and also treatment of pathology in some cases:

• Emergent endoscopy is reserved for life-threatening bleeding.

• In stable patients with GI bleeding of unclear etiology, endoscopy typically is performed within 1 to 2 days of presentation (see endoscopic treatment of GI bleeding below).

Management of GI Bleeding

In all patients with GI bleeding, management starts with stabilization of the patient’s hemodynamic status (intravenous [IV] resuscitation with crystalloid or blood products) and correction of coagulation or platelet abnormalities. Signs of significant bleeding in children include tachycardia, hypotension, orthostasis, and prolonged capillary refill.

Pharmacologic Management

Acid suppression with either proton pump inhibitors (PPIs) or H₂-receptor antagonists is commonly utilized when upper GI bleeding is suspected. In the case of severe bleeds, acid suppression classically is given as an IV bolus followed by a continuous infusion. This regimen is based on research in adults, with few studies in children investigating pharmacologic treatment of GI bleeding. In one study in adults, intermittent dosing of PPIs was noninferior to continuous dosing, suggesting that continuous PPI therapy may be unnecessary.

Octreotide is commonly used for variceal bleeding with an initial IV bolus followed by a continuous infusion. This therapy also is not widely studied in pediatrics; however, it is used in clinical practice. Read a review on the usage of octreotide in children here.

Endoscopic Treatment

• Definitive treatment for many causes of GI bleeding can be achieved through endoscopic hemostasis. For mucosal lesions (e.g., ulcers), options include:

  • injection therapy with (epinephrine) usually only has temporary effect but allows for other more definitive therapies

  • contact thermal coagulation (e.g., argon plasma coagulation or bipolar cautery)

  • clip placement

  • topical hemostatic agents

• For acute variceal bleeding, options include:

  • injection sclerotherapy

  • variceal band ligation therapy

• For colonic lesion (e.g., polyps), treatment involves endoscopic polypectomy.

The Sheffield Scoring System can be used to predict the need for endoscopic therapy.