bleeding.

In small children the blood volume is limited, re-

quiring prompt recognition and action in settings where
obtaining venous access can be difficult. Tachycardia is often
the first sign that the child has lost significant volume and, ac-
cordingly, reduction in the heart rate is a sign that adequate
fluid resuscitation is under way. Initial fluid resuscitation be-
gins with normal saline or lactated Ringer solution given as a
20 mL/kg bolus. If there is no improvement in vital signs or
perfusion, a second bolus of crystalloid is given with transfu-
sion considered if there is continued evidence of bleeding and/
or a hematocrit level less than 20%.
With resuscitation under way, a few simple maneuvers can
be performed in order to identify the location of GI bleeding
and differentiate between upper and lower sources. In order
to differentiate between upper and lower GI sources of bleed-
ing, a nasogastric (NG) tube is placed and gastric lavage can
be used to help determine if there is ongoing upper GI (UGI)
bleeding. Return of coffee ground–appearing material or
bright red blood through the nasogastric tube is a good sign
that bleeding is proximal to the ligament of Treitz. Although
return of clear contents in the NG tube does not completely
rule out a UGI source, in the context of GI bleeding it usu-
ally signifies a more distal or lower GI bleed. Although
CHAPTER 89 examination of the infant or young child’s diaper may reveal
the classic currant jelly stool seen with intussusception
(Fig. 89-1), a rectal examination should also be performed
for the presence of blood, and verification of the bleeding
Gastrointestinal can be achieved with testing of the stool or emesis for blood.
Although the most likely sources of GI bleeding can often be
determined on the basis of the patient’s age, significant over-
Bleeding lap exists among age groups when formulating a differential
diagnosis. As such, utilization of a diagnostic algorithm can
assist the caregiver in identifying the location of GI bleeding
Patrick A. Dillon and Brad W. Warner (Figs. 89-2 and 89-3).
Determining whether bloody-appearing emesis or stool ac-
tually represents GI bleeding can be challenging. Some
ingested medications can cause GI bleeding; however, recently
Gastrointestinal (GI) bleeding in the pediatric population can ingested foods or medications may also cause red stools that
be sudden with the source easily identified or subtle, requiring can easily be mistaken for blood.2 Therefore a thorough
an extensive evaluation to identify the source of blood loss. patient and family history including a history of bleeding dis-
Despite the variance in presentation, a thorough knowledge orders, recent travel, sick contacts, and medications that may
of the potential pathology will give the caregiver the best affect platelet function or coagulation is crucial. In addition, a
chance for an accurate diagnosis and effective treatment. history of recently ingested food is important. Commonly
Most GI bleeding is associated with benign pathology and is ingested foods may simulate either bright red blood (e.g., food
self-limiting, but it is thought to account for upwards of coloring, colored gelatin or children’s drinks, red candy, beets,
10% to 15% of referrals to pediatric gastroenterologists.1 This tomato skins, antibiotic syrups) or dark stools mimicking
frequency requires a systematic approach focusing on the melena (e.g., bismuth or iron preparations, red meat, spinach,
location of bleeding and the age group, as well as recognition blueberries, grapes, licorice). In addition, iron in foods (red
that there is significant overlap between the age groups meat or spinach) or in vitamin supplements may cause dark
(Tables 89-1 and 89-2). stools and can be confused with melena.3,4 Medications
including rifampin, diazepam syrup, ampicillin, and phenol-
phthalein (found in some laxatives) can also cause red stools
that are mistaken for bloody stools.2 Because of the vari-
Resuscitation and Evaluation ables involved, chemical testing to determine the presence
------------------------------------------------------------------------------------------------------------------------------------------------
of blood in the emesis or stool is necessary. The widely
The initial evaluation of a patient with suspected GI bleeding available guaiac test is the current recommended qualitative
requires the caregiver to not only confirm the presence of method for confirming the presence of gross or occult blood
bleeding but also assess and resuscitate the patient appro- in emesis or stool.4 For this test, stool or emesis is obtained
priately. Initial evaluation should include the status of the and tested for the presence of blood by observation of the
patient’s airway, breathing, and circulation. A physical exam- conversion of guaiac from a colorless appearance to a blue
ination is performed to identify potential sources of the color when combined with the stool sample. Guaiac uses a

1147
1148 PART VII ABDOMEN

TABLE 89-1 TABLE 89-2

Causes of Upper Gastrointestinal Tract Bleeding Causes of Lower Gastrointestinal Tract Hemorrhage
Upper Gastrointestinal Bleeding Lower Gastrointestinal Bleeding
Age Common Less Common Age Common Less Common
Newborn Swallowed Coagulopathy Newborn (<1 mo) Anal fissure Thrombocytopenia
(<1 mo) maternal blood Necrotizing Vascular
Esophagitis Hemorrhagic disease of the enterocolitis malformations
newborn Malrotation with
Gastritis Sepsis volvulus
Infant Esophagitis Foreign body Hirschsprung-
(1 mo-2 yr) Gastritis NSAIDs related enterocolitis
Gastrostomy tube Hypertrophic pyloric Infant (1 mo to 2 yr) Anal fissure Thrombocytopenia
trauma stenosis Meckel diverticulum Foreign body
Peptic ulcer Intussusception Intestinal
Children Esophagitis Foreign body duplication
(2-12 yr) Lymphonodular Gangrenous bowel
Gastritis Vascular malformations hyperplasia
Adolescents Esophageal/Gastric Chemotherapy Infectious diarrhea
(>12 yr) varices Allergic proctocolitis
Peptic ulcer NSAIDs Eosinophilic
Gastrostomy tube Munchausen syndrome gastroenteropathy
trauma Children (2-12 yr) Polyps Henoch-Schönlein
Eosinophilic Adolescents (>12 yr) purpura
gastroenteropathy Lymphonodular Hemolytic uremic
Mallory-Weiss tear hyperplasia syndrome
Esophagitis Chemotherapy Meckel diverticulum Vascular
Gastritis NSAIDS malformations
Infectious diarrhea Chemotherapy
Esophageal/Gastric Eosinophilic
varices gastroenteropathy Anal fissure Intestinal
Peptic ulcer Mallory-Weiss tear duplication
Gastrostomy tube Eosinophilic
gastroenteropathy
trauma
Inflammatory bowel
NSAIDs, Nonsteroidal antiinflammatory drugs. disease
Infectious diarrhea Henoch-Schönlein
purpura
Anal fissure Chemotherapy
peroxidase-like activity found in hemoglobin to generate an Eosinophilic
oxidative reaction with a reagent to produce a blue color. gastroenteropathy
Because the guaiac test relies on peroxidase activity, any sub- Inflammatory bowel
stance that has peroxidase activity can cause a false-positive disease
result including rare red meat, horseradish, turnips, tomatoes,
and fresh red cherries.2 NSAIDs, Nonsteroidal antiinflammatory drugs.

Swallowed Maternal Blood Sources of Upper

------------------------------------------------------------------------------------------------------------------------------------------------

In the evaluation of a patient with a GI bleed, particular

Gastrointestinal Bleeding
------------------------------------------------------------------------------------------------------------------------------------------------

emphasis should be placed on the evaluation of a newborn

HEMORRHAGIC DISEASE OF THE NEWBORN
infant with hematemesis. In the differential diagnosis one
must consider that the infant may have swallowed maternal Hemorrhagic disease of the newborn (HDN) is a disorder that
blood during delivery. Utilization of the alum-precipitated results from a lack of vitamin K. However, since the introduc-
toxoid (APT) test is necessary to evaluate the newborn in this tion of routine vitamin K administration shortly after birth,
situation. This test, which mixes the blood containing emesis this condition is nearly nonexistent. Among infants receiving
with 1% sodium hydroxide, differentiates blood according to correct prophylaxis, the estimated incidence is 0.4 to 0.07 per
the reduction capabilities of hemoglobin. Fetal hemoglobin, 100,000 newborns per year.5,6 Vitamin K is a required cofac-
resistant to reduction, remains a pink or bright red color, con- tor in the clotting cascade essential for the synthesis of factors
firming the diagnosis of hematemesis. In contrast, maternal II, VII, IX, X, protein C, and protein S. In addition to the rel-
hemoglobin is reduced during this test, turning the blood a ative vitamin K deficiency at birth, infants at increased risk for
brown or rusty color. If the hematemesis is determined to the development of this disease include premature infants,
be swallowed maternal blood, the concern for GI bleeding those with altered bowel flora as a result of antibiotics, those
is essentially eliminated and no additional investigation or with fat malabsorption, and breast-feeding infants. Newborn
treatment is required.1,3 sepsis, as well as metabolic or ischemic injury to the liver, may
 CHAPTER 89 GASTROINTESTINAL BLEEDING 1149

birth effectively prevents all forms of HDN.) If the oral route

is chosen, multiple doses are recommended with doses given
at birth, 1 week, and 4 to 6 weeks of age.7

FIGURE 89-1 Infant with intussusception and currant jelly stool.
also cause a deficiency in clotting factors resulting in GI bleed-
ing.6 Also of concern is a small but growing subset of infants
who belong to parents who forego traditional medical care and
refuse vitamin K. These infants are at increased risk and their
parents should be advised of the potential risks to the infant.7
Current recommendations for all infants are the adminis-
tration of 1 mg intramuscular vitamin K at birth with intra-
venous administration if necessary. (Parenteral vitamin K at
GASTRITIS
Coffee ground gastric aspirate in neonates is most likely due to
stress gastritis. Especially at risk are those infants who are
premature, have experienced a stressful delivery, or are under-
going mechanical ventilation. The relationship between the
gastritis and etiology is not completely clear, but this type of
bleeding may affect up to 20% of patients in the neonatal
intensive care unit.8 Initial management consists of nasogas-
tric tube irrigation and exclusion of swallowed maternal blood
(Apt test) and coagulopathy as the cause. The infants are then
treated with either intravenous H2 blockade or proton pump
inhibitors. In the newborn period, if the bleeding is controlled
with the previously mentioned measures, endoscopy is not
required.
In older patients, gastritis and peptic ulcer disease may
be associated with Helicobacter pylori infection. The onset of
H. pylori can lead to gastritis, UGI bleeding, and anemia.
Although the definitive mechanism(s) are not completely
understood, an increasing body of literature supports an asso-
ciation between H. pylori infection and iron-deficiency anemia
in children.9 The pediatric population that appears to be the
most at risk for acquiring H. pylori includes children living in
low socioeconomic, crowded conditions with infected house-
hold members. In addition, adolescents, especially females,
appear to be more vulnerable to H. pylori infection and sub-
sequent anemia.10,11 Along with the stress gastritis seen in
the newborn, children who develop severe systemic illnesses

Presents with hematemesis, heme(+) gastric secretions or melena

Irrigate through nasogastric tube

to verify upper GI bleed bilious aspirate with no
blood = lower GI bleed, Fig. 89-3

Blood (+) Blood clears with irrigation

Observe, PPIs,
Neonate Infant Child H2 blockers, or antacids

• Gastritis?
• Swallowed • Esophagitis? • Esophagitis?
blood? • PUD? • Gastritis?
• Coagulopathy? • Hypertrophic • PUD?
• Gastritis? pyloric stenosis? • Varies?

Apt test, coagulopathy

(+) (–)
Ultrasound (projectile emesis) Endoscopy

Observe, Gastritis?
vitamin K
Nondiagnostic Diagnostic
(biopsy, sclerotherapy, ligation)

Bleeding (–) Bleeding (+)

Observe, PPIs, H2 blockers Vasopressin, angiography,

capsule endoscopy, push endoscopy,
laparoscopy

FIGURE 89-2 Diagnostic algorithm for upper gastrointestinal (GI) hemorrhage. PPI, Proton pump inhibition; PUD, peptic ulcer disease. (Modified from
Arensman RM, Browne M, Madonna MB: Gastrointestinal bleeding. In Grosfeld J, Oneil JA, Fonkalsrud EW, Coran AG [eds]: Pediatric Surgery, 6th ed.
Philadelphia, Elsevier, 2006.)
1150 PART VII ABDOMEN
Presents with heme (+) stool, rectal bleeding, hematochezia, or melena
Neonate
• Anal fissure?
• Necrotizing
enterocolitis?
• Malrotation
with volvulus?
Physical exam
(premature,
NICU)
Abdominal X-ray Upper GI
Necrotizing Malrotation
entercolitis
Supportive care, serial exams
FIGURE 89-3 Diagnostic algorithm for lower gastrointestinal (GI) hemorrhage. NICU, Neonatal intensive care unit. (Modified from Arensman RM, Browne
M, Madonna MB: Gastrointestinal bleeding. In Grosfeld J, Oneil JA, Fonkalsrud EW, Coran AG [eds]: Pediatric Surgery, 6th ed. Philadelphia, Elsevier, 2006.)
can develop gastritis and peptic ulcer disease. This includes
children in pediatric intensive care units, as well as those with
burns, trauma, and inflammatory bowel disease. Gastritis can
also result from mechanical means (foreign body, gastrostomy
tube) and the use of nonsteroidal anti-inflammatory drugs.
Regardless of the suspected mechanism of gastritis, appropri-
ate evaluation for most children includes upper endoscopy
with gastric biopsy so that an accurate diagnosis can be
established.8
ESOPHAGEAL VARICES
In the child with sudden and massive UGI bleeding, esopha-
geal varices with associated portal hypertension (PH) must be
considered. Bleeding from esophageal varices is a potentially
life-threatening event, and rapid resuscitation is required
often including the use of blood products and pharmacologic
agents for control of the bleeding. The PH that leads to the
development of esophageal varices is often extrahepatic,
resulting from thrombosis of the portal vein. A history of
previous umbilical vein catheterization or omphalitis may
provide the etiology of the portal vein thrombosis. In addition,
a history of biliary atresia may lead to portal vein thrombosis
and progressive liver disease causing intrahepatic portal
hypertension and esophageal varices.
The mainstay of diagnosis for esophageal varices is upper
endoscopy with utilization of esophageal banding or sclero-
therapy for definitive control of active bleeding and preven-
tion of further episodes. In addition to endoscopic control,
octreotide has been used successfully during acute GI bleeding
in children with PH. In a study of children with GI bleeding
related to PH, octreotide appeared to be effective in achie-
ving high rates of immediate bleeding control; however, the
role of octreotide in managing UGI bleeding in children
Irrigate through nasogastric tube
to verify lower GI bleed (heme (+) or bloody
aspirate = upper GI bleed, Fig. 87-1)
Infant Child
• Anal fissure? • Polyps?
• Milk protein allergy? • Meckel’s?
• Intussusception? • Vasculitis?
• Meckel’s? • Infectious colitis?
• Duplication? • Inflammatory bowel?
• Polyps? • Vascular lesion?
Physical exam Physical exam
Anal fissure
Ultrasound (bilious emesis), Stool cultures
barium enema, nuclear medicine scan,
Stool softeners, angiogram
sitz baths
Laparotomy Colonoscopy
Laparotomy (Ladd procedure)
unrelated to PH is less clear. The octreotide therapy also
appeared to be well tolerated in the pediatric study group with
few side effects.12 In addition to octreotide, sclerotherapy or
banding of esophageal varices, shunt procedures, and liver
transplantation should be considered depending on the un-
derlying disease process. Shunt procedures, which are used
sparingly, should still be considered selectively in children
with PH. This includes older children in whom a transjugular
intrahepatic portosystemic shunt procedure can be used safely
as a bridge to transplantation. Surgical shunt procedures are
reserved for children with compensated chronic liver disease
or extrahepatic portal vein obstruction who continue to bleed
despite endoscopic treatment or who have gastric varices not
amenable to endoscopic therapy.13
NONVARICEAL UPPER GASTROINTESTINAL
BLEEDING
Acute UGI bleeding not associated with esophageal varices
can occur from a variety of sources including gastric, duode-
nal, and jejunal ulcers. Although not as common, the caregiver
should also consider diffuse mucosal disease, Dieulafoy
lesions, and Mallory-Weiss tears. Rarely, bleeding in children
can be seen with vascular malformations and GI stromal
tumors. Treatment options are often determined by dividing
lesions into those that are amenable to endoscopic therapy
and those that are not. When deciding on a treatment plan,
consideration should also be given to the characteristics of
the pathology and the likelihood of continued bleeding or
high risk of recurrent bleeding after initial control. Lesions
associated with high rate ( 50%) of recurrent bleeding in-
clude actively bleeding ulcers discovered on endoscopy and
ulcers larger than 2 cm in diameter.14 Deep ulcers located
high on the lesser curvature of the stomach or along the
 CHAPTER 89 GASTROINTESTINAL BLEEDING 1151

posterior-inferior aspect of the duodenal bulb are also at risk superficial tear of the squamous lining of the anal canal. They
for recurrent bleeding because of their proximity to large are usually caused by the passage of a large, constipated stool
blood vessels. Dieulafoy lesions, with an isolated blood vessel with the child reacting by withholding stool, thereby increa-
protruding through a small mucosal defect, are also associated sing the constipation and initiating a vicious cycle.3,16
with a high complication rate if left untreated. In contrast, ul- Treatment is generally confined to stool softeners and sitz
cers that are relatively flat or those with overlying clot forma- baths with excision rarely indicated.
tion have a much lower incidence of recurrent bleeding.
Gastroduodenal vascular malformations also have a high risk
of recurrent bleeding if left untreated.15 MECKEL DIVERTICULUM
Meckel diverticulum (MD) is a common source for lower GI
bleeding in children. Although the exact incidence is difficult
OTHER CAUSES to quantify, a relatively small percentage (2% to 6%) of MD is
In the newborn period, hematemesis may also be the result of thought to become symptomatic. The presentation of MD can
a formula or cow’s milk allergy. Less commonly, this type of vary; however, in most pediatric series hemorrhage or obstruc-
allergy may develop in the breast-fed infant. Hematemesis tion were the most common presentations in children younger
may also be seen with partially obstructing lesions in the than 10 years of age.17–19 Presentation of MD with a bowel
UGI tract such as hypertrophic pyloric stenosis, duodenal obstruction, although less common, may also be in the form
or antral web, and prolapsed gastropathy. In these cases, of intussusception or volvulus involving the MD. In addition,
bleeding may arise from secondary peptic ulceration or me- children may also present with abdominal pain secondary to
chanical injury to the mucosa. Other reports of UGI bleeding diverticulitis or inflammation of the MD, which in some cases
in the newborn have included cases of gastric or duodenal may lead to perforation of the MD. Among symptomatic pa-
duplication cysts and heterotopic pancreatic tissue in the tients undergoing resection of an MD, approximately 60%
stomach.6 Although they are relatively uncommon regardless contain ectopic tissue with gastric mucosa the most common
of the age group, gastric polyps can also develop in children followed by pancreatic and colon tissue. For those with bleed-
(Fig. 89-4). The presentation of these polyps can vary from ing, nearly 80% of MD cases contain ectopic mucosa.19 The
hematemesis to occult bleeding with anemia, and definitive diagnostic test of choice for MD is a Tc99 sodium pertechne-
diagnosis is usually established with upper endoscopy. tate scintigraphy or “Meckel scan.” In order for the study to be
positive, the MD must contain ectopic gastric mucosa with
a positive scan showing abnormal isotope uptake outside
the stomach and bladder. The affinity of the isotope for
Sources of Lower parietal cells of gastric mucosa permits visualization of both
native and ectopic gastric tissue while the residual isotope is
Gastrointestinal Bleeding
------------------------------------------------------------------------------------------------------------------------------------------------ concentrated in the urinary bladder (Fig. 89-5).
The Meckel scan has a reported sensitivity of 25% to 92%;
ANAL FISSURE
however, the scan may have a false-negative rate that
During the first 2 years of life, anal fissure remains the most approaches one third of cases. False-negative results can be
common source of rectal bleeding. The blood is usually bright
red with streaks of blood on the outside of the stool, although
the child may also present with spots of blood in the diaper.
The fissure is located below the dentate line, is most often pos-
terior, and can usually be identified with a simple examination
of the anus. Anal fissures are painful and result from a

FIGURE 89-4 Gastric polyps seen at laparotomy. FIGURE 89-5 Ectopic gastric mucosa within a Meckel diverticulum (seen
at arrow).
1152 PART VII ABDOMEN
attributed to situations in which the intestinal transit is rapid.
In these cases, which can include children with an actively
bleeding MD, the technetium pertechnetate excreted may be
diluted and washed out so rapidly that a definite positive
emission image is not visualized. Other causes of GI bleeding
may also result in a false-positive Meckel scan. This includes
intestinal duplications, intussusception, vascular malforma-
tions, and inflammatory foci.17
Angiography can show the persistent omphalomesenteric
artery in most individuals with an MD. However, the recogni-
tion of a persistent vitellointestinal artery that arises from mid
or distal branches of the superior mesenteric artery may be
difficult because of overlying vessels, and super selective cath-
eterization of ileal arteries can be technically challenging in
a child. In addition to the technical challenges, a positive
study requires active bleeding to show a contrast blush.
This typically requires bleeding greater than 0.5 mL/min in
order to be visualized.20
Given the limitation of the Meckel scan, a child with
persistent bleeding and a high suspicion for an MD may
benefit from diagnostic laparoscopy (Fig. 89-6). In the context
of a negative workup, laparoscopy is a diagnostic, as well as
therapeutic, tool and in most cases is a safe and effective form
of management for simple and complex cases of MD.17,21,22
JUVENILE POLYPS
In young children, intestinal polyps are a most common
source of lower GI bleeding. Juvenile or retention polyps
are the most common type of polyp found in the GI tract
and usually appear in the first decade of life, with the peak in-
cidence between 3 and 5 years of age. Bleeding is typically
bright red and small in amount. The bleeding episode may
be painless, although cramping abdominal pain is the most
FIGURE 89-6 Meckel diverticulum seen at laparoscopy.
common complaint described for symptomatic GI tract
polyps. On occasion, a child with a pedunculated polyp lo-
cated in the distal colon may also present with a rectal mass
or prolapse of the polyp and the polyp can be palpated on rec-
tal examination (Fig. 89-7). Bleeding from the polyp is the re-
sult of one of two mechanisms. The polyp may outgrow its
blood supply and slough off the stalk, resulting in bleeding
from the remaining stalk, or bleeding may occur if the surface
of the polyp becomes friable from the flow of stool, causing the
surface to bleed. Juvenile polyps are usually hamartomatous
and account for 90% of all polyps found in children. The ma-
jority of these polyps is solitary and occurs in the left side of
the colon, with a predominance in the rectosigmoid area.16
Infectious Agents Associated
with Hematochezia
------------------------------------------------------------------------------------------------------------------------------------------------
GI infections should also be considered part of the differential
diagnosis in a child presenting with lower GI bleeding
(Table 89-3). Hematochezia associated with enteric infections
is often seen in the context of diarrhea, and, because of sim-
ilarities seen in the diagnostic workup, enteric pathogens can
be difficult to distinguish from inflammatory bowel disease
(IBD). Adding to the potential confusion is the fact that infec-
tious agents may coexist with IBD.1 Although a family history
of IBD does increase a person’s risk of acquiring this disorder,
and concern that bloody diarrhea represents new-onset IBD
is appropriate, patients with acute bloody diarrhea should
initially be tested for infectious colitis.23
While pursuing the potential source of GI blood loss, it is
necessary to obtain stool cultures to identify patients with
infectious causes so that they are appropriately treated
and infection control measures can be implemented. Stool
FIGURE 89-7 Rectal polyp undergoing transanal excision.
 CHAPTER 89 GASTROINTESTINAL BLEEDING 1153

TABLE 89-3
Infectious Agents Associated with Hematochezia
Clostridium difficile
Salmonella
Campylobacter
Shigella jejuni
Yersinia enterocolitica
Enteroinvasive Escherichia coli
Enterohemorrhagic E. coli
Aeromonas hydrophilia
Entamoeba histolytica
Cytomegalovirus

From Arain Z, Rossi TM: Gastrointestinal bleeding in children: An overview of

conditions requiring nonoperative management. Semin Pediatr Surg
1999;8:172-180.

cultures should be tested for pathogens that are likely to be

present in the local community and those that require med-
ical intervention. Ideally, the cultures should target Salmo-
nella, Shigella, Campylobacter, and Escherichia coli O157:H7.23
Severe Clostridium difficile infections can also be acquired in
the community and are not always associated with recent anti-
biotic use. It is also important to remember that patients
with acute bloody diarrhea could be infected with E. coli
FIGURE 89-8 Anorectal laceration sustained in nonaccidental trauma.
O157:H7, so rapid enteric microbiology evaluations should
be a priority in the initial evaluation.23,24

bleeding is extremely important even when bleeding cannot

Evaluation of Lower be controlled because location of the bleeding site helps to
direct the possible surgical approach.
Gastrointestinal Bleeding When endoscopic techniques have failed to identify
------------------------------------------------------------------------------------------------------------------------------------------------
the source of bleeding, angiography may be considered in
For children with bleeding of the lower GI tract, a thorough older children suspected of having arteriovenous malfor-
history and physical examination along with initial stool test- mations. In patients with small bowel polyps as the source
ing is necessary to rule out causes such as infective colitis and of bleeding, air contrast small bowel follow-through may
anal fissure as the source of bleeding before proceeding with be helpful to identify the polyps. The identification of these
endoscopy. In obtaining a complete history and physical ex- lesions allows for a successful operative intervention with
amination, the caregiver should also consider anorectal resection of the segment of arteriovenous malformation or
trauma as a source of GI bleeding (Fig. 89-8). Depending small bowel polyp.
on the age of the patient, an evaluation for anorectal trauma Controversy over the extent of endoscopic evaluation
may require an examination under anesthesia to not only necessary to completely evaluate the child with lower GI
identify the scope of injury but also provide appropriate bleeding remains. In some centers, endoscopy is limited to
therapy. In patients with suspected lower GI bleeding from examination of the rectum or sigmoid colon. Because most
an MD, a Meckel scan should be obtained after their resusci- pediatric polyps are located in the rectum and sigmoid colon
tation is complete. and can be removed with sigmoidoscopy, there is a high
For many children with GI bleeding, the most informative diagnostic yield with this approach.25 However, pathology
examination is colonoscopy. This procedure offers endoscopic located proximal to the sigmoid colon would be overlooked.
treatment of pathologic lesions and defines the extent of In centers performing complete endoscopic evaluation of the
disease. Because bleeding has often ceased at the time of the colon, numerous reports state that between 14% and 32% of
colonoscopy, there may be no blood in the colon or the distal patients may have either multiple polyps or polyps located
small intestine. When the source of bleeding is thought to be proximal to the sigmoid colon.25–27 Given the current data,
from a lower GI source and the colonoscopy is entirely nor- the potential for missed lesions, and continued improvement
mal, the bleeding source is presumed to be of small intestine in endoscopic techniques, most children undergoing lower
origin. In these cases, patients may be a candidate for push endoscopy are likely to benefit from a complete colonoscopy.
endoscopy. This endoscopic technique allows visualization In addition to proximal colonic polyps, inflammatory bowel
of the distal duodenum and proximal 3 to 5 feet of jejunum. disease was the most commonly established diagnosis in
Lesions that can be identified and sometimes treated by these those patients undergoing total colonoscopy. Inflammatory
endoscopic techniques include vascular malformations, bowel disease was significantly less likely to be diagnosed
polyps, and acute ulcers. Identification of the source of by limited endoscopic assessment of the rectum or colon.26
1154 PART VII ABDOMEN

Novel Techniques for Identifying and the more recent modality called double balloon endo-
scopy (DBE) should be considered. Both procedures can be
Gastrointestinal Bleeding technically difficult and limited by intestinal motility and
------------------------------------------------------------------------------------------------------------------------------------------------
looping with potential complications including postproce-
Traditional imaging studies have long been used by pediatric dure abdominal pain, bowel perforation, intussusception,
caregivers to assist in determining the site of GI bleeding. and pancreatitis. However, in a recent study of pediatric pa-
This includes UGI studies, contrast enemas, computed axial tients who underwent DBE, these complications were not en-
tomography (CT scan), and angiography and nuclear medi- countered and the procedure was well tolerated.30,33 For
cine studies. With growing concern over the amount of children, the procedure is performed under general anesthesia
radiation exposure that children are subjected to during these and either a transoral antegrade approach or retrograde ap-
imaging studies, alternative and novel techniques to identify proach passing the endoscope through the anus is used to
GI bleeding require consideration. achieve substantial evaluation of the small intestine.34 The po-
This includes the increased use of magnetic resonance tential advantage of DBE over imaging studies is not only the
imaging (MRI), which has been used to not only evaluate identification of obscure sources of GI bleeding but also the
and diagnose patients with Crohn disease but also identify a ability to be therapeutic. In the pediatric population, lesions
potential source of GI bleeding. For patients with severe small amenable to endoscopic therapy include control of bleeding
intestinal Crohn disease (deep ulcers, cobblestoning, stenosis, from vascular abnormalities, polypectomy in patients with
and prestenotic dilatation), the detection rates using MRI symptomatic Peutz-Jeghers syndrome, or balloon dilatation
compare favorably with conventional UGI studies. In addi- of an intestinal stricture, which can be seen in Crohn disease.
tion, MRI has been found to identify more abdominal pathol- In segments of the GI tract inaccessible to standard endoscopy,
ogy when compared with conventional enteroclysis. There the ability of DBE to be therapeutic may reduce the need for
are, however, several limitations regarding MRI and its ability surgical approaches in selected children.31,33,34
to identify potential sites of GI bleeding. The capacity of MRI
to detect more subtle lesions that are the source of GI bleeding
remains inferior to UGI studies, and the role of MRI in asses-
sing colonic inflammation in Crohn disease has yet to be
Pediatric Gastrointestinal
determined because most gastroenterologists still favor co- Vascular Anomalies
lonoscopy for evaluation of the colon and terminal ileum. ------------------------------------------------------------------------------------------------------------------------------------------------

Although MRI techniques hold great potential for detection GI vascular malformations are uncommon in the pediatric
of pediatric GI bleeding, current multidetector CT scans population. However, the anomalies are often associated with
provide rapid images of the GI tract with superior spatial familiar syndromes such as Klippel-Trénaunay syndrome,
and temporal resolution when compared with MRI.28,29 These Rendu-Osler-Weber syndrome, blue rubber bleb nevus syn-
current technical limitations often make MRI inferior when drome, and Proteus syndrome. Despite their rarity, the care-
compared with similar images obtained from a CT scan. giver should be aware of associated manifestations of these
Capsule or virtual endoscopy (CE) is another useful modal- syndromes to assist in determining the correct diagnosis
ity for the pediatric patient with obscure or occult GI bleeding and the potential source of GI bleeding.35 In addition to the
and may facilitate selection-appropriate therapy for individual previously mentioned syndromes, patients with Turner syn-
patients. CE is most effective evaluating the small intestine and drome can develop GI bleeding. This syndrome occurs in ap-
may produce a diagnostic yield approaching 70% in the eval- proximately 1 in 2500 live female births and represents a
uation of occult GI bleeding. Also, the sensitivity of CE for phenotype and constellation of physical abnormalities caused
small bowel vascular lesions is higher than standard small by loss of part or all of an X chromosome. The GI bleeding is
bowel contrast studies, enteroclysis, or angiography.30,31 thought to be secondary to intestinal telangiectasia with the
Limitations for CE within the pediatric population are primar- vascular anomaly occurring throughout the entire small
ily confined to capsule retention and possible obstruction at bowel, large bowel, and mesentery, with a preference for the
sites of stricture, which may be encountered in children with small intestine. Although the vascular malformation may
Crohn disease. In order to avoid this problem, a patency affect all layers of the bowel, the anomalies are frequently most
capsule can be used in high-risk patients. This capsule has prominent on the serosal surface, making preoperative detec-
a radiofrequency tag and a dissolvable lactose coating and tion difficult. Given the often obscure nature of the bleeding,
can be used to evaluate the risk of active capsule retention.31 upper endoscopy and colonoscopy are frequently negative in
Additionally, if the child is unable to swallow the capsule, Turner syndrome and capsule endoscopy should be strongly
endoscopic placement may be required; this can add to the considered for these patients.30,36
cost of the procedure.32
In pediatric patients with obscure bleeding and negative The complete reference list is available online at www.
upper and lower endoscopic evaluations, push endoscopy expertconsult.com.