Paediatrics: Gastrointestinal haemorrhage

Gastrointestinal haemorrhage

This condition is relatively rare in childhood. Upper GI tract bleeding may present as haematemesis (vomiting of frank blood or ‘coffee grounds’) or melaena (black, tarry, foul-smelling stools). Haematochezia (bright or dark red blood PR) indicates lower GI tract bleeding.

Beware of spurious haemorrhage, e.g. black stools after bismuth/iron ingestion, red vomit after beetroot, urate crystals in nappies, or normal pseudomenstruation in newborns. Use Dipstix test or laboratory testing to confirm blood you are if unsure.

Causes

Neonates

•   Swallowed maternal blood, i.e. not GI haemorrhage.

•   NEC.

•   Dietary protein intolerance.

•   Coagulopathy.

•   Stress ulcers.

•   Gastritis, vascular.

•   Malformations.

•   Duplication cyst.

•   Infectious colitis, including pseudomembranous colitis.

•   Inflammatory colitis.

Infants

Most of the above plus:

•   Oesophagitis.

•   Swallowed blood from upper airway, e.g. epistaxis.

•   Anal fissure.

•   Intussusception.

•   Meckel’s diverticulum (often presents as a massive painless rectal bleed;).

Older children

Most of the above plus:

•   Peptic ulcer disease.

•   Mallory–Weiss tear.

•   Oesophageal varices.

•   Nonsteroidal anti-inflammatory drugs (NSAIDs).

•   Intestinal polyps.

•   IBD.

•   GI infection, e.g. dysentery.

•   HSP.

•   HUS.

Management

·Detailed history: e.g. is there associated abdominal pain?

• Examination: specifically, vital signs; skin (pallor, abnormal blood vessels); hepatic stigmata; ENT examination (e.g. epistaxis); organomegaly; abdominal tenderness; anal inspection (e.g. fissure or fistula); rectal examination. Examine vomit or stool to confirm nature of bleed.

• Supportive treatment: fluids; blood product transfusion; airway protection with NGT or ETT as necessary.

• Drug treatment: somatostatin or vasopressin reduces splanchnic blood flow and, thereby, upper GI bleeding.

• Therapeutic endoscopy: in severe bleeds, e.g. balloon tamponade, electrocautery, bleeding vessel ligation, paravariceal injection.

• Treat underlying cause: e.g. surgical removal of Meckel’s diverticulum.