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Lower GI Bleed, Part 1

Steven Erdman, MD and Ann Dietrich, MD
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20:38

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Ann and Steven Erdman discuss the diagnosis and differential for lower GI bleeds in pediatrics.

Pearls:

  • Blood in the stool is common and often caused by constipation and infection. A careful stooling history is diagnostically important.

  • Abdominal X-rays are not diagnostically valuable for constipation with the exception of a large stool ball seen in the pelvis.

  • In non-urgent situation workup for concern for lower gastrointestinal (GI) bleeding may consist of hemoccult testing for the stool, a hemoglobin level, testing for viral, bacterial or parasitic infection including film array, inflammatory markers for IBD, and coagulation studies and platelet levels for bleeding diathesis

  • A rule of thumb is that typically endoscopy is done for bleeding while imaging is done for pain.

 

  • How common is blood in the stool? Many people will see blood in the stool at some point but blood on the tissue is even more common so differentiating between these two is important.

  • What are the mimics of blood in the stool? Children have a limited ability to crush and grind food so many things are passed intact.

    • Anything that is red in the diet like tomatoes or red licorice can appear red.

    • Red medications or drinks like fruit punch or Jello can color the stool.

    • Other interesting mimic are medications like iron sulfate and bismuth from Pepto-Bismol can cause a false positive guaiac stool heme test.

  • How can we differentiate upper and lower gastrointestinal (GI) bleeding? First consider non-GI sources such as epistaxis with hematemesis. Blood is an irritant so it can be tricky to distinguish a source.

    • Abrupt brisk rectal bleeding can be bleeding from a gastric or duodenal ulcer.

    • Generally speaking “old blood” is black and more proximal in source and bleeding from the end of the colon is bright red.

    • The history is going to help us figure out the source as well as bleeding usually does not occur on its own.

  • What causes blood in the stool of infants? In very young and premature infants who are sick bleeding can come from a number of places including gastric ulcers and abdominal emergencies like midgut volvulus and necrotizing enterocolitis.

    • In a home birth situation you think about vitamin K deficiency but occult bleeding disorders can be a consideration for any child with bleeding.

    • In a neonate that does not appear ill consider swallowed maternal blood.

    • Infection will also be a potential etiology in all age groups.

    • In a healthy breastfed baby with small amounts of blood we can consider breast milk colitis. A similar reaction to formula is often more severe.

  • How do we manage breast milk colitis? This is an issue with antigen transfer from the mother’s diet to the breast milk. Many children can tolerate this small amount of bleeding and we do not always want to interfere with otherwise successful feeding.  

    • When we intervene it is usually with eliminating foods from the maternal diet. Typically starting with milk and then other common food allergies such as  soy, wheat, eggs, nuts (including peanuts), and fish and shellfish.

    • Some parents will note a clear cause and effect: "I went out and I had Italian food and fresh tomatoes and, within four hours, my baby started having irritability, my baby had a change in their stooling pattern."

  • How do we manage allergies to formula? These can be more severe and lead to an enteropathy picture and malabsorption. The first step is to go to a Casein Hydrolysate formula which is less expensive but not uniformly successful.

    • If this does not work progress to an amino acid based formula. This is a T-Cell driven response so unlike anaphylaxis and IgE mediated allergies it can take up to two weeks to see a response.

  • What are the  common causes of blood in the stool of a prepubescent child? Infection especially those that causes diarrhea are common but other chronic disease can start to appear at  this age.

    • Inflammatory bowel disease (IBD) typically may come along with fever, rash or joint pain, and weight loss.

    • Other vasculitides (such as Henoch-Schonlein Purpura  among others)  can present this way  at this age.

    • Microangiopathic hemolytic anemias such as Hemolytic Uremic Syndrome can be associated with  lower GI bleeding.

    • Congenital anomalies like Meckel’s diverticulum can present at this age.

      • A Meckel’s diverticulum is seen in 10% of the population but only a subset of these contain the gastric mucosa that is needed to cause the mucosal ulceration and bleeding.  They present with painless rectal bleeding.

    • Juvenile polyps can be a source of more intermittent painless rectal bleeding.

  • When should we get a Meckel’s scan? The classic story is an active preschool age child that starts to act tired and suddenly starts to pass blood. A Meckel’s scan uses a radioisotope that us taken up by the parietal cells, which are seen in gastric mucosa. In this case looking or ectopic gastric mucosa that can be present in the subset of Meckel’s that bleed from ulceration.

    • Meckel’s can cause bleeding by being a focus of volvulus (or intussusception) and lead to more intermittent bleeding. This may not show up on a Meckel scan. One adage is that if a child bleeds three times, they need a surgical exploration.

  • How do you examine the rectal area? No one questions the need to evaluate this area of a 12-month-old but people hesitate with older children.

    • It is still a critical part of the exam in older children and adolescents. Erdman will set this up with, "Look, we're going to need to talk about bottoms. We need to look at bottoms today." He likes to do rectal exams with the child lying on their back so he can maintain eye contact. If at first simple visual inspection is needed like with rectal pain this can be done with the child on their side.

  • What are the etiologies we consider in adolescents for GI bleeding? Like the younger children inflammatory bowel disease, either ulcerative colitis or Crohn's disease, can present with bleeding. Rarely they will present with bleeding alone.

    • Other considerations are constipation, polyps, vascular lesions, vasculitis like Henoch-Schönlein purpura, infection, hemolytic uremic syndrome, foreign body or abuse.

  • Do you have any tips for how to best communicate with gastroenterologists? With a referral for GI bleeding we really want to know the significance of the problem. “blood in the stool” is not enough.

    • It is good to know if there is confirmed GI bleeding in the form of hemoccult testing and to know if anemia is present.

    • It is helpful also to get the family members to look at the stool regularly so we know the extent of the problem and if constipation is present.

  • What other laboratory testing do we consider for GI bleeding? Depending on the situation there may be utility in testing for viral, bacterial or parasitic infection including film array, inflammatory markers for IBD, and coagulation studies and platelet levels for bleeding diathesis

  • When is endoscopy needed? One basic rule is that we do imaging for pain and endoscopy for bleeding. However we only want to do endoscopy when it I really needed. A colonoscopy in children is typically done under anesthesia and can cost $8,000 to $12,000.

  • How can we manage bloody stools? Constipation causes more minor bleeding than anything else. In  well appearing, hemodynamically stable patient without anemia a trial of laxative may be a good first step.

  • What is the utility of plain films in the diagnosis of constipation? The only abdominal X-ray that is meaningful is one with a large stool ball in the pelvis. This will typically be in a child who presents with leakage of loose stool. There is good evidence that there is not validity of abdominal X-rays in the diagnosis of constipation. There is also now controversy about the digital rectal exam in the GI community though Erdman still advocates it use as very hard stool on rectal exam would lead to treatment with laxatives and may avoid further diagnostic testing.

  • How should we deal with high volume GI bleeds? Bleeding from mucosal disease is typically a trickle. Large volume blood loss usually means a vessel is involved.

    • This often occurs in the upper GI tract like esophageal varices or a deep ulcer that has eroded into a vessel. This can also be from other arterial bleeds like an arteriovenous malformation or a congenital vascular birth defect called a Dieulafoy lesion. Management is getting to an emergency  setting and performing the fundamentals of resuscitation while getting the right consultants lined up.   

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The Young and the Ouchless Full episode audio for MD edition 168:06 min - 79 MB - M4AHippo Peds RAP January 2017 Summary 280 KB - PDF