Pediatric emergency medicine trisk 0685 0685
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CHAPTER 33 ■ GASTROINTESTINAL BLEEDING
LENORE JARVIS
INTRODUCTION
Gastrointestinal (GI) bleeding is a relatively common problem in pediatrics. Over one
12-month study period at a large urban pediatric emergency department, complaints of
rectal bleeding accounted for 0.3% of all visits. Upon the patient’s arrival, the
emergency physician must first assess the need for cardiovascular resuscitation and
stabilization. However, most children who arrive in the ED with an apparent GI bleed
have an acute, self-limited GI hemorrhage and are hemodynamically stable.
In most cases of upper and lower GI bleeding, the source of the bleeding is inflamed
mucosa (infection, allergy, drug induced, stress related, or idiopathic). The emergency
physician must be vigilant in differentiating inflammatory conditions that are often selflimited from causes that may require emergent surgical or endoscopic intervention, such
as ischemic bowel (intussusception, volvulus), structural abnormalities (Meckel
diverticulum, angiodysplasia), and portal hypertension (esophageal varices). Acute GI
bleeding rarely represents a surgical emergency. In the previously noted study, only
4.2% of 95 patients required a blood transfusion or an operative intervention.
INITIAL ASSESSMENT
The clinician should sequentially assess the patient through the following questions:
1. Is the patient in hemorrhagic shock (see Chapter 10 Shock )?
2. Is the patient really bleeding? Is the bleeding coming from the GI tract? If so, how
severe is the bleeding?
3. Is it upper or lower GI bleeding?
4. What is the age-related differential diagnosis based on pertinent history, physical
examination, and diagnostic tests?
GI Bleed Imitators
Many substances ingested by children may simulate fresh or chemically altered blood.
Red food coloring (found in cereals, antibiotics and cough syrups, Jell-O, and KoolAid), as well as fruit juices and beets, may resemble blood if vomited or passed in the
stool. Medications such as antibiotics (cefdinir—which can cause “brick-red” stools),
iron supplementation, and bismuth (in Pepto-Bismol) may cause the stool to look
melanotic or bloody. Foods such as dark chocolate, spinach, cranberries, blueberries,
grapes, or licorice may also produce dark-colored stools. In these cases, confirmation of
the absence of blood with Gastroccult (vomitus) or Hemoccult (stool) tests will allay
parental anxiety, as well as prevent unnecessary concern and testing.
A careful search for other causes of presumed GI bleeding (recent epistaxis, dental
work, menses, and hematuria) should be sought. Hematemesis (vomiting of blood) also
