Definitions

• 1.
  

  Melena is the passage of dark, black, tar-like colored stool usually associated with esophageal, gastric, or upper small bowel gastrointestinal hemorrhage.

  
  
• 2.
  

  Hematochezia is the passage of bright red blood or maroon colored material from the rectum usually associated with distal small bowel, or colonic gastrointestinal bleeding.

  
  
• 3.
  

  Hematemesis is the passage of bloody or dark brown (“coffee ground”) appearing material from the mouth usually associated with bleeding in the gastrointestinal tract proximal to the ligament of Treitz.

Initial Presentation and Assessment

The child or adolescent with gastrointestinal (GI) bleeding may present to medical attention in a wide variety of ways and locations including a local emergency room, a pediatrician’s office, a phone call from a parent, or an inpatient hospital ward. Regardless of the location, by asking several brief and pointed questions, the medical provider will be able to assess the need for immediate intervention and subsequently establish a specific diagnosis. These include ( Box 13-1 ):

• 1.
  

  Describe the location, duration, quantity, and appearance of the bleeding.

  
  
• 2.
  

  What is the physical appearance and vital signs of the patient, if available?

  
  
• 3.
  

  What other medical conditions does the child have?

  
  
• 4.
  

  What medication is the child on?

Based on the answers to these questions one could approximate the severity of bleeding, where the patient needs to be sent, and what services need to be readied for therapy. For example, large volume bleeding, history of portal hypertension or coagulopathy, ill appearance, or unstable vital signs would prompt emergent care with rapid medical transport. On the other hand, if the answers do not suggest a need for emergent care or if the care plan has already started, further questions will help assess a possible cause. Specific areas that should be addressed include:

• 1.
  

  History:

  
  
  
  
  • a.
    

    Description of onset, location, and duration of bleeding

    
    
  • b.
    

    Exposure to other individuals with similar symptoms or development of similar symptoms in contact

    
    
  • c.
    

    History of travel

    
    
  • d.
    

    Exposure to toxins, animals, or potentially contaminated food or water source

    
    
  • e.
    

    Foreign body ingestion

    
    
  • f.
    

    Ingestion of specific foods or medications

    
    
  • g.
    

    Other associated symptoms (mouth sores, abdominal pain, rashes, vomiting, swelling, headaches, neck pain, chest pain, diarrhea, fevers, bruising).

  
  

Each of the answers to the above questions must be taken in appropriate context with the understanding that in times of emergency parents and children may overestimate the amount of blood, duration of the event, or frequency. A good estimate of the amount of blood is the appearance of blood in the toilet. If the water is opacified (not transparent), it is likely significant. If the child is old enough to provide a reliable history, additional questions should be asked of him/her and if needed without parental presence. One should also remember that having one positive historical event does not forgo the possibility of another one that could be more serious. For example, a child who ingests blueberries that cause a melenic type stool could also have a bleeding duodenal ulcer that could cause melena.

Along with a directed history of the current events, a directed social and family history should be performed. These may direct the physician to specific conditions that could be presenting for the first time. Additionally, various foods and medications can cause stool or vomitus to falsely appear to contain blood ( Box 13-2 ).

Foods and medications that may cause abnormal color of stool: Red: candy, fruit punch, beets, laxatives, phenytoin, rifampin Black: bismuth, activated charcoal, iron, spinach, blueberry, licorice

Physical Exam and Laboratory Evaluation: ( Box13-3 and Box 13-4 )

Once the practitioner takes an appropriate history he/she should be able to place the child into one of two pathways: emergent and nonemergent. This should subsequently be substantiated by a physical exam and laboratory evaluation. The physical exam should also be similarly focused to direct the possible sick patient to appropriate care quickly. It should primarily assess a directed ABC approach of General A ssessment for Well or Ill, Evidence of Brisk B leeding (blood in the oral cavity or on rectal exam), and vital signs directed at C irculatory adequacy (heart rate, orthostatic vital signs, pulse pressure, blood pressure, urine output). The balance of the physical exam will analyze possible causes of bleeding such as splenomegaly for portal hypertension, lip and buccal hyperpigmentation for Peutz Jeghers syndrome, emaciation and perianal disease for Crohn’s disease, or abdominal distention and ill appearance for intussusception. A directed physical exam with appropriate areas of interest is outlined below.

Once the physical exam is complete, a targeted set of diagnostic laboratory studies should be requested. Similar to the history with a primary and secondary assessment, the laboratory studies should be ordered in a proper sequence. Unless the bleeding is obvious, testing for the presence of blood should usually be confirmed with the appropriate test kit. Except in cases where upper GI bleeding appears to be minor, consideration should be given to investigation with nasogastric lavage to assess the volume and for evidence of continued bleeding. This is performed with a double lumen vented pediatric-sized nasogastric tube. The tube is placed after adequate lubrication and topical anesthesia nasally and advanced into the stomach. Placement confirmation may differ from institution to institution, but commonly used methods include pH testing or air bubble technique. After the placement, the tube is irrigated with 50 cc aliquots of room temperature sterile water until the irrigant is clear. If one is unable to lavage, the tube might be positioned against the stomach wall or clogged by the presence of a clot or gastric contents. Repositioning of the tube and/or flushing it should resolve this. The lavage is usually reported as amount of fluid necessary until the tube aspirate is clear. Confirmation of the material as blood should be performed with appropriate gastric testing equipment. Presence of dark (“coffee-ground”) material suggests blood that has been exposed to oxygen for some time and indicates that the acute bleeding may have ceased, while bright red blood that does not readily clear indicates active bleeding. The absence of blood suggests bleeding originating distal to the ligament of Treitz, the tube may lodged in a large clot, or the lack of bleeding. However in studies in adults, there is a significant false negative rate of NG lavage in acute upper GI bleeding. Some centers prefer not to utilize nasogastric lavage because of a theoretical risk of dislodging a clot in the stomach or over a varix, although this is unlikely, or if they plan to perform urgent endoscopy to evaluate the bleeding source and the lavage will not provide additional useful information. Nasogastric lavage is often very helpful to the practitioner when making clinical decisions about the necessity of urgent medical interventions, severity and location of bleeding, as well as ongoing monitoring of bleeding, and in assuring good visualization during endoscopy.

Laboratory studies directed to assess blood volume status including a complete blood count (CBC), PT/International Normalized Ratio (INR), and a blood type and screen in case a transfusion is indicated, are usually the first line of tests obtained. The CBC should be interpreted using the mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) to assess the chronicity of the condition, or with appropriate medical history for hemoglobinopathy. Low MCV/MCH levels (microcytic, hypochromic) suggest chronic bleeding or acute on chronic condition, while normal levels indicate an acute blood loss. If the patient has folate or B12 deficiency the values may vary from the expected. These deficiencies often create a macrocytic process with an elevated MCV and MCH. Blood urea nitrogen (BUN) creatinine ratio may also be helpful in determining the source of bleeding. A ratio of >30 has 98% sensitivity and 68% specificity for upper GI bleeding. This occurs due to the rise in serum urea level as a byproduct of amino acid catabolism secondary to digestion of blood in the GI tract. To assess the severity of bleeding, serial CBCs can be obtained. If the history is suggestive of a nonemergent cause of bleeding, such as anal fissure, rectal polyp, or a simple nosebleed, limited laboratory studies are required and a CBC may suffice.

A lower GI bleeding is usually assessed through a combination of the above laboratory studies and the appearance of the rectal effluent or rectal exam. Although hematochezia is usually representative of lower GI bleeding, a brisk upper GI bleeding may cause this finding also.

• 2.
  

  Physical exam:

  
  
  
  
  • a.
    

    Vital signs: orthostasis, pulse pressure, urine output

    
    
  • b.
    

    General: appearance (well or ill), fever, mental status

    
    
  • c.
    

    Head, eyes, ears, nose, and throat: trauma, scleral injection, petechiae, lip and buccal mucosa pigmentation, epistaxis, erythema or burns to posterior pharynx, bleeding

    
    
  • d.
    

    Chest/Cardiovascular: tachycardia, murmur, capillary refill

    
    
  • e.
    

    Abdomen: tenderness, splenomegaly, hepatomegaly, caput medusae, distention, ascites

    
    
  • f.
    

    Genitourinary: fistula, swelling

    
    
  • g.
    

    Rectal: gross blood, melena, skin tags, tenderness, fissure, fistula, swelling, warmth

    
    
  • h.
    

    Dermatological: pallor, jaundice, rash, arteriovenous malformations, bruising, petechiae

  
  
  
  
• 3.
  

  Laboratory studies:

  
  
  
  
  • a.
    

    CBC

    
    
  • b.
    

    Prothrombin time/partial thromboplastin time/INR

    
    
  • c.
    

    Complete metabolic profile (electrolytes and liver function tests)

    
    
  • d.
    

    Type and screen

    
    
  • e.
    

    If significant loss: type and cross and fibrinogen level

    
    
  • f.
    

    Stool culture (Shigella, Salmonella, Yersinia, Campylobacter) with Escherichia coli O157:H7 assay, Clostridium difficile toxins A&B, Cryptosporidium and Giardia assay, and ova and parasite smear, if indicated by history

    
    
  • g.
    

    Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), gamma glutamyl transpeptidase (GGT), if indicated by history

    
    
  • h.
    

    Hemoccult and gastroccult testing

  
  

Initial Interventions

The child with gastrointestinal hemorrhage may present in stable condition or with various degrees of circulatory compromise including shock. While performing initial assessment the patient should be kept NPO (nil per os) in order to decrease the risk of further aggravating the bleeding and in anticipation of diagnostic tests or endoscopy that will require sedation, and intravenous (IV) access should be obtained. If ill appearing, two large bore IV lines should be placed. Depending on the need for initial fluid resuscitation, aliquots of 20 cc/kg of normal saline should be infused quickly (30-60 minutes) as per Paediatric Advanced Life Support (PALS) guidelines for shock. If blood loss is rapid, this volume may need to be replaced with packed red blood cells and appropriate clotting factors/fibrinogen depending on the condition. In case of a planned urgent endoscopic procedure, patients should have ample reserves to tolerate anesthesia. There is no single hemoglobin threshold that determines the need for transfusion in all children. A restricted transfusion threshold of 7 g/dL may be acceptable compared to a more liberal threshold of 9 g/dL in acute upper GI bleeding. The overall goal is for appropriate heart rate and blood pressure, as attempting to intervene with unstable vital signs and a low blood volume may cause more harm than benefit to the patient. Along with volume repletion, all equipment and support staff necessary for successful completion of the procedure should be readily available and when indicated, surgical backup should be considered.

Secondary Interventions/Further Testing: ( Box 13-5 and Box 13-6 )

Once the child is stabilized and initial testing results return, the practitioner needs to determine the source of bleeding. If it appears that the source of bleeding originated from outside of GI tract such as pulmonary or nasopharyngeal, the appropriate specialist should be consulted. Advanced imaging modalities (CT/MRI) could be ordered to assist in diagnosing these conditions. There are multiple causes of bleeding and no single algorithm will cover all of them, thus a careful individualized approach utilizing a variety of tests is needed. For exam­ple, large volume esophageal or gastric bleeding may be easier to identify and necessitate fewer studies than a slow indolent small bowel hemorrhage. Etiologies relating to specific bleeding lesions of the GI tract will be discussed here in more detail including a discussion of various imaging techniques. Infectious and autoimmune causes are covered elsewhere in this text.

Pediatric gastroenterologists should be skilled in a variety of endoscopic techniques described below. Some of these may require advanced skills for which additional endoscopic training may be required. It is advisable to have an experienced endoscopist available for assistance. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the American Society for Gastrointestinal Endoscopy (ASGE) have issued guidelines and competence requirements for individuals performing these procedures. Additionally, a discussion between the endoscopist and family/legal guardian should occur regarding the risks, benefits, alternatives, methods, and indications/purpose for the procedure. One should also consider limited ethical or legal capacity for a parent to refuse care for a life threatening condition. If a parent refuses intervention during the need for life saving therapy, legal assistance, court intervention, or social work consult should be obtained immediately.

Preparation for Procedure

Depending on the procedure of choice there are a variety of preparations that need to be made. The first is to assure that the patient is medically stable, especially for tests requiring sedation, and in the setting of anticipated ongoing and potentially severe bleeding. The second is to make sure that the support staff and all the necessary equipment are available for the procedure. If this is not possible, consideration for patient transfer to an appropriately equipped facility should be made.

The preparation for EGD mostly consists of adequate NPO time. This may differ depending on institutions’ sedation policy, but is approximately 2 to 3 hours for liquids and 6 hours for solids depending on the type of fluids ingested and patient’s age. The NG lavage can be very helpful in assisting with evacuation of blood and other gastric content to assure adequate endoscopic visualization of the mucosa. In the great majority of cases general anesthesia is administered by a dedicated anesthesia team providing the necessary level of sedation and analgesia, thus allowing the endoscopist to solely focus on the procedure at hand, especially for prolonged and therapeutic procedures. Endotracheal intubation is frequently utilized to prevent aspiration.

The preparation for colonoscopic examination requires not only the appropriate NPO time, but also a bowel purgative, which is of the utmost importance in order to assure proper mucosal visualization. If the endoscopist attempts to perform a colonoscopy without proper cleansing this will make a thorough exam very difficult and increase chance of complication. The bowel preparation for colonoscopy may need to be adjusted depending on the type of bleeding encountered and the endoscopist’s preference. For example, for patients with history of hematochezia and diarrhea secondary to presumed colitis, standard bowel preparation should suffice, while a patient with melena or maroon-colored stool may require a more aggressive approach with large volume (40 cc/kg/h) colon lavage, or until rectal effluent is clear. A variety of bowel preparations are available and a detailed review is available elsewhere.

There is an ongoing debate regarding video capsule endoscopy preparation. Some advocate colonoscopy-type preparation with or without simethicone, while others elect a prep similar to that for an EGD. A clinical report on pediatric bowel preparation, including liter­ature review and preparation recommendations from the NASPGHAN Endoscopy & Procedures Committee is pending publication and will be a valuable resource.