You are in: eMedicine Specialties > Pediatrics: Surgery > General Surgery Gastrointestinal Bleeding: Surgical PerspectiveArticle Last Updated: Jun 16, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Robert Arensman, MD, Professor of Surgery, Louisiana State University; Consulting Staff, Section of Pediatric Surgery, Ochsner Clinic Foundation Robert M Arensman is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the History of Medicine, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Surgical Association, Association for Academic Surgery, Louisiana State Medical Society, and Southern Medical Association Coauthor(s): Lisa P Abramson, MD, Fellow, Department of Pediatric Surgery, Children's Memorial Hospital of Chicago Editors: Denis Bensard, MD, Director, Pediatric Trauma, Division of Pediatric Surgery, Children's Hospital of Denver; Associate Professor, University of Colorado Health Sciences Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Gail E Besner, MD, Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine and Public Health; Director, Pediatric Surgical Research, Department of Surgery, Children's Hospital; H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina; Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago Author and Editor Disclosure Synonyms and related keywords: gastrointestinal bleeding, gastrointestinal hemorrhage, GI bleeding, GI hemorrhage, stress gastritis, hemorrhagic disease of the newborn, swallowed maternal blood, anal fissures, necrotizing enterocolitis, NEC, malrotation with volvulus, peptic esophagitis, gastritis, gangrenous bowel, milk protein allergy, peptic ulcer disease, polyps, Meckel diverticulum, Meckel's diverticulum, esophageal varices, gastric varices, inflammatory bowel disease, IBD, infectious diarrhea, vascular lesions INTRODUCTIONSection 2 of 9
  Gastrointestinal (GI) bleeding in infants and children is a fairly common problem but it is usually limited in volume, allowing time for diagnosis and treatment. GI bleeding accounts for 10%-15% of referrals to pediatric gastroenterologists. The initial approach to all patients with significant GI bleeding is to assure patient stability, establish adequate oxygen delivery, place intravenous access, initiate fluid and blood resuscitation, and correct any underlying coagulopathies. For upper GI bleeding, a nasogastric tube is placed to confirm the presence of fresh blood and to evaluate the degree of active bleeding. If fresh or active bleeding is confirmed, use esophagogastroduodenoscopy (EGD), which determines the source of upper GI bleeding in 90% of children when performed in the first 24 hours. Alternatively, colonoscopy identifies the cause of bleeding in 80% of children with lower GI bleeding. In cases of episodic or obscure bleeding, nuclear medicine radionucleotide studies or arteriography are used to assist in identifying the site of blood loss. Radionuclear imaging with technetium-labeled red blood cells can be used to detect bleeding as tiny as 0.1 mL per minute. This technique is somewhat imprecise; however, it may direct localization for either selective angiography or provide some direction for laparotomy search and resection, a notoriously difficult process for the control of GI bleeding. Arteriography can detect bleeding at a rate of 0.5 mL per minute and offers the advantage of treatment as well as diagnosis. The treatment consists of embolization and intra-arterial administration of vasoconstrictors. Because GI bleeding occurs in children of all ages and results from many diagnoses, the topic is most comprehensible for further discussion with the division of patients into 4 diagnostic age groups. COMMON CAUSES OF BLEEDING IN NEONATESSection 3 of 9
Upper gastrointestinal tract bleeding in neonatesStress gastritis Stress gastritis occurs in up to 20% of patients cared for in the neonatal intensive care unit. Prematurity, neonatal distress, and mechanical ventilation are all associated with stress gastritis. For most neonates so afflicted, the diagnosis is presumptive. Definitive diagnosis is made with upper endoscopy demonstrating erythema, diffuse bleeding, erosions, or ulcerations of the gastric mucosa. Treatment is supportive and includes adequate resuscitation to reduce the underlying hypoxemia, nasogastric suction, and intravenous H2 blockers. Recent studies have advocated identifying high-risk neonates and treating them prophylactically with acid-reducing agents. Extremely rarely, continued or massive hematemesis despite medical therapy leads to operative interventions such as gastric resection, vagotomy and pyloroplasty, or antrectomy and vagotomy. Hemorrhagic disease of the newborn Hemorrhagic disease of the newborn is a self-limited bleeding disorder resulting from a deficiency in vitamin K–dependent coagulation factors. The levels of clotting factors II, VII, IX, and X decline rapidly after birth, hitting their nadir at 48-72 hours of life. In 0.25-0.5% of neonates, severe hemorrhage may result. Prophylactic vitamin K administration in the newborn period virtually eliminates hemorrhagic disease of the newborn. If hemorrhagic disease occurs, administration of 1 mg of vitamin K intravenously generally stops the hemorrhage within 2 hours. If the clinical condition warrants, fresh frozen plasma and packed red blood cells are administered in addition to the vitamin K. Swallowed maternal blood Infants who swallow maternal blood during delivery may present with hematemesis during the first few days of life. This diagnosis is confirmed using the Apt test, performed by placing blood obtained from the neonate's stomach on a piece of filter paper and mixing it with 1% sodium hydroxide. Maternal hemoglobin is reduced to a yellow color, and fetal hemoglobin is resistant to reduction and remains pink or bright red. Absence of fetal hemoglobin eliminates the diagnosis of acute upper GI bleeding. Lower gastrointestinal tract bleeding in neonatesAnal fissures Anal fissures are the most common cause of GI bleeding in infants. They produce bright red blood that streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline. Diagnosis is made by anal examination, sometimes performed with a nasal speculum. Further tests are unnecessary, and treatment consists of stool softeners and rectal dilation. Necrotizing enterocolitis Necrotizing enterocolitis (NEC) in most neonates is diagnosed from the history and clinical presentation. Aggressive medical resuscitation with bowel rest, antibiotics, total parenteral nutritional, and nasogastric decompression is the standard treatment (see Necrotizing Enterocolitis). Nonoperative management has a 70-80% recovery rate, but for those neonates in whom conservative therapy is unsuccessful because of progressive sepsis, bowel perforation, or persistent bleeding, urgent laparotomy or drain placement is required. Recurrent bleeding in a baby who has recovered from NEC may indicate a second occurrence of the disease or an enterocolitis stricture. Malrotation with volvulus Malrotation (see Intestinal Malrotation) is suspected with the sudden onset of melena in combination with bilious emesis in a previously healthy, nondistended baby. Immediate upper GI contrast study should be performed to confirm the diagnosis of malrotation with midgut volvulus. Immediate laparotomy reveals the anomaly and allows derotation of the bowel, assessment of intestinal viability, possible bowel resection, and performance of a Ladd procedure. COMMON CAUSES OF BLEEDING IN CHILDREN AGED 1 MONTH TO 1 YEARSection 4 of 9
Upper gastrointestinal bleeding in children aged 1 month to 1 yearEsophagitis Peptic esophagitis caused by gastroesophageal reflux (GER) is the most common cause of bleeding in this age group. Infants present with regurgitation, dysphasia, odynophagia, and failure to thrive. Diagnostic workup often begins with a barium swallow. Other diagnostic modalities include pH probes, esophagoscopy, esophageal manometry, and nuclear medicine studies. Treatment begins with acid-reducing agents, thickened feeds, upright positioning, and prokinetic agents. Antireflux procedures are rarely performed to control bleeding but may be necessary to treat other complications (eg, apnea, esophageal stricture, lung disease) of gastroesophageal reflux refractory to medical therapy. Gastritis is primary or secondary in etiology. Primary gastritis is associated with Helicobacter pylori infection and is the most common cause of gastritis in children. Other causes of primary gastritis are nonsteroidal anti-inflammatory drug (NSAID) use, Zollinger-Ellison syndrome, and Crohn disease. H pylori is detected using serum immunoglobulin G (IgG) levels, rapid urease testing (CLOtest), or mucosal biopsies. Treatment is a combination of H2 blockage, antibiotic therapy, and bismuth. Secondary gastritis occurs in association with severe systemic illnesses that result in mucosal ischemia and produce diffuse erosive and hemorrhagic gastric mucosa. Correction of the underlying metabolic derangements and acid reduction result in successful treatment in most patients. Lower gastrointestinal tract bleeding in children aged 1 month to 1 yearAnal fissures Anal fissures produce bright red blood that streaks the stool or causes spots of blood in the diaper. The cause is a tear at the mucocutaneous line, most commonly located dorsally in the midline. Diagnosis is made by anal examination, sometimes performed with a nasal speculum. Further tests are unnecessary, and treatment consists of stool softeners and rectal dilation. Intussusception Intussusception is the most likely cause of lower GI bleeding in infants aged 6-18 months. Episodic abdominal pain that is cramping in nature, vomiting, a palpable sausage-shaped mass, and currant jelly stools are findings present in children with intussusception. Venous hypertension in the intussusceptum results in the passage of blood and mucus, producing the jellylike appearance of the stool. However, stool color may range from bright red to maroon. Lower GI bleeding is associated with intussusception in 53% of cases. Ultrasonography may be employed as the initial diagnostic study to avoid a more invasive barium or pneumatic enema. The ultrasonographic finding of a pseudokidney sign is pathognomonic for intussusception. Because ultrasonographic studies are only diagnostic, many clinicians choose to proceed directly to barium, saline, or pneumatic enema, which are both diagnostic and potentially therapeutic. Successful reduction is achieved in up to 90% of cases. If enema is unsuccessful, then laparotomy and manual reduction or resection of the intussusception becomes necessary. Gangrenous bowel Gangrenous bowel is the next most common cause of lower GI bleeding in this age group. Causes include malrotation with volvulus, omphalomesenteric remnant with volvulus, internal hernia with strangulation, segmental small-bowel volvulus, and, rarely, sigmoid volvulus. These children present with evidence of bowel obstruction, abdominal distension, dehydration, and peritonitis. Upper and lower contrast studies aid in diagnosis; however, laparotomy is usually necessary for definitive treatment. Milk protein allergy Milk protein allergy causes a colitis that may be associated with occult or gross lower GI bleeding. It is the most common allergy observed in infancy and is caused by an adverse immune reaction to cow's milk. In addition to bleeding, symptoms include diarrhea, weight loss, vomiting, and irritability. Milk protein allergy is a clinical diagnosis, and symptoms generally resolve in 48 hours to 2 weeks after withdrawal of the offending milk product. COMMON CAUSES OF BLEEDING IN CHILDREN AGED 1- 2 YEARSSection 5 of 9
Upper gastrointestinal tract bleeding in children aged 1-2 yearsPeptic ulcer disease When a child is older than 1 year, peptic ulcer disease is the most common cause of hematemesis. The etiologies are similar to those mentioned in the discussion of Gastritis above. NSAID use also is associated with peptic ulcer disease in children older than 1 year. When an H pylori–negative ulcer is diagnosed, a fasting plasma gastrin level is measured to exclude Zollinger-Ellison syndrome. Most of the ulcers occurring in children of this age range are secondary to other systemic diseases, such as burns (Curling ulcer), head trauma (Cushing ulcer), malignancy, or sepsis. Significant upper GI bleeding is evaluated with immediate endoscopy for both diagnosis and treatment. Cautery is used to establish hemostasis from a bleeding ulcer, and biopsies are taken if warranted. Therapy for peptic ulcer disease in children mimics that in adults and centers around acid reduction and control of the underlying condition. Obstruction and/or persistent bleeding are indications for surgery. Gastritis See Gastritis under "Upper gastrointestinal bleeding in children aged 1 month to 1 year." Lower gastrointestinal tract bleeding in children aged 1-2 yearsPolyps Most polyps in persons of this age group are the juvenile type and are located throughout the colon. These are benign hamartomas and usually require no treatment because they autoamputate. Children present with painless bleeding per rectum, which often streaks the stool with fresh blood. Colonoscopy is the diagnostic evaluation of choice because it allows examination of the entire colon and potential excision of bleeding polyps when they are identified. Colonoscopy is helpful in diagnosing other polyposis syndromes such as familial polyposis and adenomatous polyps. Meckel diverticulum Meckel diverticulum occurs in 2% of the population; GI bleeding is the most common presentation of this congenital anomaly in children younger than 4 years (22%). Bleeding may be brisk, transfusion is often required, and the mean initial hemoglobin level often is less than 8 g/dL. However, the bleeding is usually self-limited and resolves spontaneously with episodic recurrences. The pathogenesis of GI bleeding from a Meckel diverticulum is ileal ulceration caused by acid secretion from the ectopic gastric mucosa. Erosion into small arterioles leads to painless brisk rectal bleeding. The site of ulceration is generally at the base of the diverticulum where the ectopic mucosa and the normal ileum join. More rarely, the ulcer appears distally in the ileum. Technetium Tc 99m pertechnetate scanning is used to identify the Meckel diverticulum with 90% accuracy. This isotope has a high affinity for parietal cells of gastric mucosa and allows identification of normal and ectopic gastric mucosa. The use of H2 blockers, pentagastrin, and glucagon may enhance the accuracy of this test because H2 blockers inhibit excretion of the isotope, pentagastrin enhances gastric mucosal uptake, and glucagon inhibits peristalsis. Treatment is surgical resection after preoperative fluid resuscitation and adequate transfusion. A right lower quadrant incision is used, and the diverticulum is mobilized. Careful visual inspection and palpation locate the ectopic gastric mucosa and ulceration. If the ulcer is confined to the diverticulum, diverticulectomy alone is performed and closed in a transverse fashion with sutures or a stapling device. If the diverticulum is broad based or the ulcer cannot be included in the diverticulum specimen, segmental bowel resection is necessary with an end-to-end anastomosis. An appendectomy is often performed with the resection. COMMON CAUSES OF BLEEDING IN CHILDREN OLDER THAN 2 YEARSSection 6 of 9
Upper gastrointestinal tract bleeding in children older than 2 yearsEsophageal and gastric varices Esophageal varices result from portal hypertension regardless of the age group. The increased resistance to blood flow through the portal system is due to prehepatic, intrahepatic, and suprahepatic obstruction, but the most common causes of portal hypertension in children are portal vein thrombosis (prehepatic) and biliary atresia (intrahepatic). Varices secondary to portal vein thrombosis become apparent when a child is aged 2-3 years, and massive hematemesis may be the presenting sign. Bleeding from varices occurs in 80% of children with portal vein thrombosis by the time they are aged 6 years. After initial stabilization, upper endoscopy is the preferred diagnostic and therapeutic tool. The esophagus and stomach are assessed for the presence of varices and to exclude gastritis or ulcer disease as the source of bleeding. Gastric varices are most commonly found in the fundus. Once the diagnosis of gastric or esophageal varices is confirmed, treatment is initiated. Most episodes stop spontaneously and respond to blood products and careful monitoring. Pharmacologic therapy as necessary is directed at reducing the portal venous blood flow. Vasopressin, somatostatin, and beta-blockers have been used systemically to control bleeding varices. Balloon tamponade with a Sengstaken-Blakemore or Minnesota tube has had up to an 80% success rate at controlling bleeding varices, but rebleeding and serious complications such as pressure necrosis or misplacement makes this technique less useful. Endoscopic sclerotherapy controls bleeding with a success rate of 90-95%. Generally, endoscopic sclerotherapy is repeated in 2- to 4-week intervals after the acute bleed to prevent recurrence. Variceal banding has results comparable to sclerotherapy but is more difficult to perform in children because of the smaller size of the esophagus. For intrahepatic portal hypertension, transjugular intrahepatic portosystemic shunting (TIPS) provides temporary decompression of the intrahepatic portal vein into the hepatic veins. Surgical portosystemic or portoportal shunts are now reserved for refractory cases and/or when liver transplantation is not an option. Lower gastrointestinal tract bleeding in children older than 2 yearsPolyps The most common cause of lower GI bleeding in children older than 2 years is juvenile polyps, and this remains true until the patients are teenagers. Inflammatory bowel disease Inflammatory bowel disease (IBD) also becomes a more common cause in this age group. Bleeding is less common in individuals with Crohn disease than in persons with ulcerative colitis, but both may have bloody diarrhea as part of the clinical scenario. These children generally have the diagnosis of IBD well established before acute or chronic bleeding necessitates intervention. Acute or persistent bleeding with resultant anemia, despite maximal medical therapy, is considered an indication for surgery. Therapy for ulcerative colitis is a total proctocolectomy with an ileal pouch–anal pull-through. The goal of surgical treatment for persons with Crohn disease is resection of all grossly diseased bowels with primary anastomosis, provided previous surgery (or the current resection) has not created a short bowel situation. Infectious diarrhea Infectious diarrhea is suspected when lower GI bleeding occurs in association with profuse diarrhea. Recent antibiotic use raises suspicion for antibiotic-associated colitis and Clostridium difficile colitis. The prior should be self-limited and resolve after cessation of antibiotics, and C difficile colitis requires therapy with oral metronidazole or vancomycin. Escherichia coli and Shigella species are the 2 most common pathogens in infectious diarrhea. Treatment is supportive with antibiotic therapy as indicated. Vascular lesions Vascular lesions include a wide variety of malformations, including hemangiomas, arteriovenous malformations, and vasculitis. If these lesions are located in the colon, colonoscopy may be diagnostic and therapeutic. However, brisk bleeding may obscure the visual field, making localizing the bleeding impossible. Arteriography assists in localizing the source and embolizing the feeding vessel. Surgery is necessary when bleeding cannot be controlled using these techniques. Localization of hemorrhage in the small bowel is a challenge to the surgeons and may require intraoperative endoscopy to find the lesion. SUMMARYSection 7 of 9
Common Sources of Gastrointestinal Bleeding in Pediatrics
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastrointestinal Bleeding and Rectal Bleeding. MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
Gastrointestinal Bleeding: Surgical Perspective excerpt Article Last Updated: Jun 16, 2006 | ||||||||||||||||||||||||||||||||||||
