Pediatric emergency medicine trisk 0698 0698
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Preschool Period (2 to 5 Years)
The most common conditions to cause bleeding in children 2 to 5 years of age are anal
fissures, juvenile polyps (benign hamartomas), and infectious enterocolitis. Polyps in
childhood are most often multiple and inflammatory in nature without significant
malignant potential. Polyps typically present with painless rectal bleeding in this age
group, and significant bleeding is unusual. In children older than 3 years with
intussusception, a lead point (polyp, Meckel diverticulum, or hypertrophied lymphoid
patch) is more often found than in younger children. Infectious causes of colitis are
similar to those discussed in younger age groups.
Hematochezia may be a manifestation of systemic diseases such as hemolytic uremic
syndrome (HUS) and Henoch–Schönlein purpura (HSP). HUS is the most prevalent of
these conditions reported in infants and children up to 3 years of age. Bloody diarrhea
due to Escherichia coli O157:H7 may precede the development of renal and
hematologic abnormalities in HUS. GI manifestations of HSP occur in 50% of patients
and include colicky abdominal pain, melena, and bloody diarrhea. These symptoms
precede the characteristic rash in 20% of patients. GI complications among patients with
HSP include hemorrhage (5%), intussusception (3%), and rarely, intestinal perforation.
Angiodysplasia is a rare cause of GI bleeding but can be associated with massive
hemorrhage. Vascular lesions of the GI tract may have a congenital basis. Several
recognized syndromes, including Rendu–Osler–Weber syndrome and Turner syndrome,
may be associated with intestinal telangiectasia.
School Age Through Adolescence Period
For the most part, the diagnostic considerations relevant to the preschool child apply to
school-age children and adolescents. In this age group, colorectal polyps become more
frequent, with a prevalence of 12% in children with lower GI bleeding undergoing
colonoscopy. Solitary juvenile polyps are the most common type, but up to 26% of
patients may have multiple juvenile or adenomatous polyps. Inflammatory bowel disease
(IBD) is also unique to the age group, and is rare before the age of 10 years. Rectal
bleeding is a common presentation of both ulcerative colitis and Crohn disease. Massive
lower GI bleeding occurs in 2% to 5% of children with Crohn disease. Fulminant colitis
and toxic megacolon are life-threatening presentations of both ulcerative colitis and
Crohn disease.
Evaluation and Decision: Lower Gastrointestinal Bleeding
History and Physical Examination
As noted above, after ruling out hemorrhagic shock (see Chapter 10 Shock ), ask
historical questions about GI bleed imitators, bleeding onset and amount, upper versus
lower GI bleeding distinguishers, and associated symptoms. Symptoms of an acute
abdominal process with bowel obstruction, including abdominal pain, distention, and
vomiting, should be elicited. Cases of NEC present with nonspecific signs of sepsis
