GASTROINTESTINAL BLEEDING IN CHILDREN

Clinical Features

  • Gastrointestinal bleeding may present as blood in vomitus or in stool. In either case, there may be frank red blood or altered blood that would appear as coffee grounds or there may be black stool.
  • Bleeding could occur from the upper or lower gastrointestinal tract. The amount of bleeding varies depending on the
    cause of bleeding.
  • Massive bleeding can present with features of shock.

Common causes of features of upper gastrointestinal bleeding are:

  • For the newborn
    • Swallowed maternal blood: In this situation the baby looks well.
    • Stress ulcers often following birth asphyxia.
    • Coagulopathy: DIC associates with asphyxia, sepsis, vitamin K deficiency.
    • Necrotizing enterocolitis (NEC) – more common in sick preterm infants.

Infants and children

  • Swallowed blood following epistaxis (history of epistaxis).
  • Gastritis.
  • Oesophageal varices.
  • Gastric/duodenal ulcers.

For all ages, the common causes of lower gastrointestinal bleeding include the following:

  • Anal fissure
  • Infectious diarrhoea (including NEC in neonates, shigella, campylobacter, salmonella, amoebiasis, and schistosomiasis).
  • Coagulopathy due to bleeding disorders that include liver disease and DIC.
  • Intussusception that is more common in infants and young children.

Investigations

  • Full blood count and blood film
  • Group and cross match if excessive bleeding
  • Stool for occult blood
  • Stool culture or microscopy as indicated
  • Specific tests according to suspected cause of bleeding:
    • Endoscopy
    • Barium swallow or meal or enema
    • Septic screen
    • Abdominal x-ray for neonate with suspected NEC
    • Coagulation screen
    • Liver function tests
    • Abdominal ultrasound

Management

  • Initiate treatment for shock
  • Monitor vital signs half hourly until bleeding stops.
  • Transfuse as soon as blood is available.
  • Use nasogastric suction to assess blood loss and monitor continued bleeding.
  • Be ready to give more blood when needed.
  • Investigate and treat the underlying condition.