Paediatric GI haemorrhage

Haematemesis DDx

• Swallowed blood
• Epistaxis/pharyngitis/breastfeeding/dental/tonsillectomy
• Vitamin K deficiency in neonate
• Erosive oesophagitis
• Mallory-Weiss tear
• Haemorrhagic gastritis
• SIRS
• Reactive gastritis
• NSAID’s, alcoholic, cocaine
• Caustic ingestion or rodenticides containing warfarin
• Mechanical trauma

• Crohn’s
• Vasculitis/HSP
• Bezoar
• Hiatal hernia, prolapse of gastro-oesophageal junction
• Peptic ulcer
• Varical bleeding
• Submucosal masses
• Vascular malformation
• Angiodysplasia, haemangioma, Dieulafoy lesion
• Haemobilia

Haematochezia/melaena DDx

• Ischaemic bowel
• Intussusception
• Mid-gut volvulus
• Incarcerated hernia
• Mesenteric thrombosis
• Meckel diverticulum
• Upper source (see haematemesis)
• Vasculitis
• HSP
• Sloughed polyp
• Ulcer
• NSAID gastropathy
• Crohn’s disease/Ulcerative colitis
• Vascular malformation

Colitis DDx

• Differentiated by bloody diarrheoa and tenesmus
• Infectious colitis
  • Salmonella, Campylobacter (in developing countries)
  • Shigella, Yersinia, Vibrio parahaemolyticus, E. coli 0157:H7
  • Entamoeba histolytica
• Haemolytic-uraemic syndrome
• Necrotising enterocolitis
• Eosinophilic proctocolitis
• IBD

Rectal bleeding with normal stools

• Juvenile polyp
• Nodular lymphoid hyperplasia
• Eosinophilic colitis
• IBD
• Vascular malformation

Bright red blood coating normal stool

• Anal fissure
• Beta-haemolytic streptococcal cryptitis
• Ulcerative proctitis
• Rectal prolapse
• Solitary rectal ulcer
• Internal haemorrhoids

Occult GI blood loss DDx

• Oesophagitis
• Reactive gastritis
• Eosinophilic gastroenteritis/colitis
• Coeliac disease
• IBD
• Polyposis
• Meckel’s diverticulum
• Vascular malformation

Neonatal

• Serious cause until proven otherwise
• Well appearing
  • Check for anal fissure
  • Evalute for swallowed blood (can be during birth process alslo)- check nipples and perform Apt test
    • Take specimen of bloody stool, mix with 3-5mL of tap water (supernatant must be pink), to 5 parts supernatant liquid add 1 part 1% NaOH
    • Pink colour persisting over 2 minutes indicates fetal Hb
    • Adult Hb turns yellow/brown within 2 minutes indicating denaturation
  • Consider allergic proctocolitis: Counsel mother on diet modification if breastfed and if formula fed, continue and primary care physician can decide on changing formulas if necessary
    • Cow’s milk protein intolerance usual cause in this case
  • If unclear, FBC and d/w paediatrics

• Ill-appearing
  • NEC, malrotation with volvulus and inherited coagulopathy MUST be considered
  • 15% of NEC occurs in full-term babies
• Pitfalls
  • Haematuria
  • Uric acid crystals: Pink stain without blood clot in nappy

Infants and toddlers

• Well-appearing: Infectious colitis and gastritis are common
• Ill-appearing: Meckel’s, intussusception, cryptogenic liver disease, oesophageal bleeding
  • Check skin for HSP rash
• Pitfalls
  • Epistaxis
  • Artificial food colouring
  • Red medications (amoxicillin)

Older child and adolescent

• Well-appearing
  • Mallory-Weiss after forceful vomiting
  • Trivial haemoptysis after viral symptoms
  • Pill oesophagitis if new to tablets
  • Foreign body ingestion
• Ill-appearing
  • Cryptogenic liver disease
  • Haemorrhagic gastritis
  • Vascular malformation (Dieulafoy lesion – tortuous artery ends just beneath mucosa)
  • IBD

Meckel’s diverticulum

• Most common congenital malformation of GI tract
• Rule of 2’s
  • 2ft from ileocaecal valve
  • 50% symptomatic by age 2
  • 2cm long
  • 2% of population
  • 2 types of mucosa
• Not actively bleeding: Tm-99 pertechnate schintigram (Meckel’s scan)
• Actively bleeding: Radio-labelled red blood cell scan

Inflammatory bowel disease

• 25% will present before age 20
• Classical: Abdominal pain, weight loss, bloody diarrhoea
• Isolated findings: poor growth, anaemia, delayed puberty
• Extra-intestinal symptoms: Oral ulcers, clubbing, erythema nodosum, jaundice, hepatomegaly
• Three cardinal presentations
  • Fatigue, anaemia and bloody diarrhoea
  • Chronic diarrhoea, abdominal pain and poor weight gain/weight loss
  • Fulminant severe abdominal pain, bloody stools, tenesmus, fever leukocytosis and hypoalbuminaemia

• Examination
  • Glossitis (B12 deficiency)
  • Hair loss and brittle nails (protein loss)
  • Purpura (Vitamin C and K deficiency)
  • Episcleritis/uveitis
  • Pericardial rubs
  • Hepatomegaly
  • Perianal skin tags
• Investigations
  • FBC – Microcytic anaemia suggests chronic blood loss
  • Coag profile and platelet count if suspicious for bleeding diathesis or chronic liver disease
  • Stool samples – If bacterial enterocolitis suspected (unwell, bloody/mucoid diarrhoea, not improved by 7 days, immunocompromised or suspect septicaemia

Endoscopy

• If actively bleeding– ASAP
• Belgian guidelines
  • If not actively bleeding, may have endoscopy within first 24 hours of admission
  • 90% effective at controlling source of upper GI bleeding

Medications

• NO evidence in children and bleeding gastric ulcers very uncommon
• IV somatostatin or octreotide has been shown to be effective for uncontrolled variceal bleeding, however, most ceases spontaneously
• Hydrolysed formula if cow’s milk protein intolerance is suspected
  • Mother’s of breatfed infants can eliminate dairy products
• Stool softeners can be helpful for anal fissures

Antibiotics

• Empiric antibiotics if suspected infectious colitis and systemically unwell
• Parenteral preferred if:
  • Toxic appearance
  • Immunodeficient
  • Febrile infant <3mo
• There is evidence that antibiotic therapy for E. coli O157:H7 actually increases risk of HUS
• Ciprofloxacin is a reasonable first-line agent

Disposition

• Most children will have self-limiting/benign causes and thus can be managed as outpatients
• If significant co-morbidities or instability – admit +- ICU
• If recurrent GIT bleeding – D/w paediatric gatroenterology regarding need for and timing of endoscopy
• If infectious colitis
  • <7 days and <6 stools/day – Stool sent off and OPD f/u
  • If unwell, >6 stools/day or abdominal complications – Admit
  • If >7 days duration – consider alternative diagnosis

Last Updated on November 20, 2021 by Andrew Crofton