Gastrointestinal Bleeding in Children
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Direct answer
Gastrointestinal bleeding in children is bleeding from any point between the mouth and the anus, and its cause depends strongly on age. Newborns mostly bleed from swallowed maternal blood or necrotising enterocolitis, while older children more often have peptic disease, Meckel diverticulum, polyps or colitis. The site decides the investigation: haematemesis and melaena suggest an upper source, whereas fresh red blood per rectum usually indicates a lower one.
What you must remember
- Upper versus lower source: haematemesis and melaena point to upper bleeding, while fresh red blood per rectum usually points to a lower source.
- Neonatal bleeding: swallowed maternal blood must be excluded with the Apt test, and vitamin K deficiency bleeding and necrotising enterocolitis are the next considerations.
- Infant rectal bleeding: cow's milk protein allergy causes blood-streaked stools with colitis, and anal fissure is a common benign cause.
- Toddler painless bleeding: Meckel diverticulum is the classic cause, while intussusception presents with colicky pain and redcurrant jelly stool.
- Adolescent upper bleeding: peptic ulcer disease, often linked to Helicobacter pylori, is a common cause, while oesophageal varices occur with portal hypertension.
- Mimics: swallowed epistaxis and certain red foods or drugs can mimic blood in vomitus or stool, so they are checked before extensive tests.
- Priority: resuscitation with fluids and blood comes before diagnosis, because massive bleeding can compromise the circulation.
A stepwise approach from site to source
Many children arrive with a small volume of blood, but the source can still be serious. The sequence below separates the site, the age and the pace of bleeding.
- Stabilise first: check airway, breathing and circulation, and replace fluid or blood when there are signs of shock.
- Locate the site: haematemesis, melaena or fresh blood per rectum tells you whether bleeding is upper, small bowel or colonic.
- Exclude mimics: look for swallowed maternal blood in the newborn, swallowed epistaxis, and food or drug colouring that mimics blood.
- Match the age: the likely cause in a neonate, infant, toddler or adolescent differs, and the age shapes the first test.
- Choose the test: endoscopy for upper bleeding, colonoscopy for lower bleeding, and a technetium-99m pertechnetate scan when Meckel diverticulum is suspected.
- Treat the cause: eradicate Helicobacter pylori for peptic ulcer, band or sclerose varices, and resect a bleeding Meckel diverticulum.
- Monitor and follow up: repeat haemoglobin to confirm the bleed has settled, and review for recurrence once the source is treated.
Where the exam tries to catch you
Gastrointestinal bleeding questions usually hinge on the age of the child and the site of the blood.
- Trap: assuming all bleeding from a newborn's gut is the infant's own blood. Correct: swallowed maternal blood must be excluded first with the Apt test, since it mimics true bleeding.
- Trap: choosing colonoscopy first for painless bleeding in a toddler. Correct: Meckel diverticulum is the classic cause, so a technetium-99m pertechnetate scan is the appropriate first test.
- Trap: attributing upper bleeding in every adolescent to varices. Correct: varices are the usual cause only when portal hypertension is present, and peptic or erosive disease is the main alternative without liver disease.
Frequently asked questions
Which investigation is used for suspected Meckel diverticulum?
A technetium-99m pertechnetate scan is the classic investigation for suspected Meckel diverticulum. It detects ectopic gastric mucosa, which takes up the isotope, but a negative scan does not fully exclude the diagnosis.
What is the Apt test used for in newborns?
The Apt test distinguishes fetal from adult haemoglobin in blood-stained vomitus or stool from a newborn. A pink colour that persists after alkali treatment indicates fetal haemoglobin, meaning the blood came from the infant, while a yellow-brown result indicates swallowed maternal blood.
Why is vitamin K given to all newborns?
Vitamin K is given to all newborns because they have low vitamin K stores and an immature coagulation system, which predisposes to vitamin K deficiency bleeding. Prophylaxis at birth prevents the classic and late forms of this bleeding.
Which is the commonest cause of upper gastrointestinal bleeding in adolescents?
Peptic ulcer disease is a leading cause of upper gastrointestinal bleeding in adolescents, often associated with Helicobacter pylori infection. Oesophageal varices are the important alternative when the adolescent has portal hypertension.
What does redcurrant jelly stool indicate in a child?
Redcurrant jelly stool, a mixture of blood and mucus, is the classic sign of intussusception in an infant or toddler. It usually accompanies colicky abdominal pain, vomiting and a palpable sausage-shaped mass, and it requires urgent assessment.