GI Bleeding in

Children
Maria Christina H. Ventura, MD, DPPS
July 8, 2010

 Bleeding may occur anywhere along

the GI tract

Identification of the site may be

challenging

The least likely site of

bleeding
Small intestine
Except in Meckels diverticulum

wherein there is painless bleeding

The most common

cause of bleeding
Erosive damage to the mucosa of the
GI tract

Variceal bleeding secondary to portal

hypertension also occurs frequently.

Rare cause of bleeding

in children

Vascular malformations

Clinical Definition

HEMATEMESIS
HEMATOCHEZIA
MELENA

Upper vs. Lower GI

Bleeding
Acute Upper GI bleeding usually

presents with hematemesis or the

passage of melena

Acute Lower GI bleeding usually

presents with hematochezia

Severe Acute GI bleeding may

present with hematochezia because

the blood is not altered during the
very rapid transit the digestive tract.

 Children with profuse upper and

lower GI bleeding can present with

hypovolemia and shock.

CLUES
History
Physical Examination
Laboratory and Radiographic
techniques

Clinical Algorithm
Infants and Neonates
Common Causes
Bacterial Enteritis
Milk protein allergy
Intussusception
Swallowed maternal blood
Anal Fissure
Lymphonodular hyperplasia

Infants and Neonates

Rare Causes
Volvulus
Necrotizing enterocolitis
Meckel diverticulum
Stress ulcer, stomach
Coagulation disorder ( Hemorrhagic Disease
of the Newborn )

Clinical Algorithm
Children
Common Causes
Bacterial enteritis
Anal Fissure
Colonic Polyps
Intussusception
Peptic Ulcer/ Gastritis
Swallowed epistaxis
Mallory Weiss Syndrome

Children
Rare Causes
Esophageal varices
Esophagitis
Meckel Dicerticulum
Lymphonodular hyperplasia
HSP
Foreign body
Hemangioma, AV Malformation
Sexual abuse
HUS
IBD
Coagulopathy

ADOLESCENT
Common Causes
Bacterial enteritis
IBD
Peptic Ulcer/ Gastritis
Mallory Weiss Syndrome
Colonic Polyps

Adolescent
Rare causes
Hemorrhoids
Esophageal varices
Esophagitis
Telangiectasia Gay bowel disease
Graft versus Host disease

angiodysplasia

Indirect Imaging
Arteriography
Scintigraphy
CT Scan
MRI

UPPER GI Causes
Vascular lesions in the small bowel
Peptic Ulceration
Meckels diverticulum
Esophageal varices
Malignancy

Peptic Ulceration
Ulcers and gastritis are classified as
primary ( peptic) or secondary

caused by factors known to affect the

intergrity of the gastric or duodenal
mucosa.

Primary : chronic, duodenal and

related to H. pylori gastritis

Secondary : usually acute and gastric

Peptic Ulcer
ULCER : a disruption of the intestinal

epithelium exposed to acid or pepsin

EROSION : superficial ulcer

Ulcers are usually 1 cm of less in
diameter

Gastritis : inflammation of the gastric

mucosa without disruption of the
mucosa

Factors in the
development of
gastritis

mediators of mucosal inflammation of

the gastric mucosa :Oxygen free
radicals, lymphokines and monokines

Mucosal defense mechanisms:

surface water-unstirred water
layer

intestinal and pancreatobiliary

sources of bicarbonate

 surface active hydrophobic

phospholipids in the mucosal

area

mucosal blood flow

rapid rate of cell replacement
enhanced by factors ( EGF)

Duodenal Ulcers
Increased acid secretion
Acid secretion does not correlate
with with ulcer size or duration of
symptoms.

Family history : 20 -25%

Partially due to the known clustering
of H. pylori in families

OTHER FACTORS
Blood Type O
cigarette smoking
climatic conditions
dietary habits ( consumption of
alcohol)

emotional stress

 Factors related to acid are more

important in duodenal ulcers

Tissue resistance is of more

importance in gastric ulcers

Primary Peptic ulcers

Manifestations : pain. vomiting and
chronic gastrointestinal blood loss
and a strong familial incidence

Primary gastritis due to H pylori

usually occurs with primary peptic

ulcers

1st month of life : gastrointestinal

bleeding and perforation

Primary Peptic ulcers

Between the neonatal period and 2
years old :

recurrent vomiting
slow growth
gastrointestinal hemorrhage

Primary Peptic ulcers

Preschool children
periumbilical postprandial pain
is often elicited

vomiting and hemorrhage

Primary Peptic ulcers

After 6 years old :
similar symptoms in children
epigastric abdominal pain
acute or chronic GI blood loss
often leading to IDA

predominantly male

Secondary Peptic Ulcers

Usually due to sepsis in infants
Respiratory or cardiac insufficiency
Trauma or dehydration
Stress ulcers and erosions associated
with burns are Curling ulcers

Associated with normal gastric

secretions ; Common in burn patients

(>25 % BSA)

Secondary Peptic Ulcers

Cushing ulcers
Follows head trauma or surgery
Associated with gastric
hypersecretion

Most are aysmptomatic

May be associated with severe
hemorrhage or perforation

ANAL Causes
Hemorrhoids
Fissure
Perianal abscess/ fissure
Anal carcinoma

Hemorrhoids
Usually uncommon in children
Usually benign
When seen, must suspect portal
hypertension

Avoidance of chronic constipation,

fecal impaction or other irritating
local factors

Anal Fissure
Small laceration of the

mucocutaneous junction of the anus.

Acquired lesion secondary to the

forceful passage of a hard stool,
mainly seen in infancy.

Fissures appear to be the

consequence and not the cause of

constipation.

Anal Fissure
Usually a history of constipation is
elicited.

painful bowel movement

Patient retains the stool voluntarily to
avoid a painful bowel movement

Bright red blood on the surface of the

stool

Anal Fissure
Inspection of the Anal area
Infants hips are put in acute flexion
Buttocks are separated to expand the
folds of the perianal skin

Fissure becomes evident as a minor

laceration

(+) TAG

Anal Fissure
The most important element in the

treatment is for the parents to

understand the origin of the
laceration and the mechanism of the
cycle of constipation.

Goal of the treatment : REVERSE the

CYCLE

soft stools to avoid overstretching

Anal Fissure
Stool softener
Avoid hard stools and diarrhea
Treat the primary cause of
constipation

Perianal Abscess and

Fistula
Two different groups of pediatric
patients

Infants without predisposing

conditions

Older children with predisposing

conditions

Infants
relatively common
usually boys < 2 years old
benign self-limited condition
the abscess has a communication
with one of the crypts of the
pectinate line of the anal canal

Infants
The abscess eventually drains through
an orifice in the perianal area

Then inflammation subsides

But, a fistula remains that

communicates with the affected crypt

to the perianal external orifice

Fistula becomes chronic but usually

disappears spontaneously before 2yrs.

Infants
low grade fever, mild rectal pain,
area of perianal cellulitis

No evidence indicates that antibiotics

are useful in these patients

When the patient is extremely

uncomfortable, the abscess can be

drained under local anesthesia

Children
Children >2 years old with perianal
or perirectal abscess and with a
predisposing illness.

Drug-induced or autoimmune

neutropenia, leukemia, AIDS, DM,

Crohn disease, prior rectal surgery,
immunosuppresant drugs

More serious condition

Children

Prognosis is related to the

predisposing disease

Abscess may be deep and may

rapidly expand

RECTAL Causes

Polyp
Carcinoma
Proctitis

Juvenile Colonic Polyp

MOST COMMON childhood bowel
tumor

3-4% in less than 21 years old

Rarely appear before 1 yr. of age
Mostly between 2-10 years old
Usually proximal in the descending
colon

 Bright red painless rectal bleeding

during or immediately after a bowel

movement

Colonoscopy
Removal of the polyp

Familial Polyposis
Syndromes
Familial Adenomatous Polyposis Coli
Gardner Syndrome
Peutz-Jeghers Syndrome

COLONIC Causes
Polyp
Cancer
Diverticular diseases
Colitis ( Inflammatory, Infective or
Ischemic)

Angiodysplasia