NSAID injury Usually hematemesis, rectal possible Epigastric pain, coffee-ground emesis >2 YEARS OLD
Inflammatory bowel disease Usually rectal Crampy pain, poor weight gain, diarrhea
Pseudomembranous colitis Rectal History of antibiotic use, bloody diarrhea
Juvenile polyp Rectal Painless, bright red blood in stool; not massive
Nodular lymphoid hyperplasia Rectal Streaks of blood in stool, no other symptoms
Mallory-Weiss syndrome* Hematemesis Bright red or coffee-ground, follows retching
Hemolytic uremic syndrome Rectal Thrombocytopenia, anemia, uremia
Hemorrhoids Rectal Dilated external veins, blood with wiping
NSAID, Nonsteroidal anti-inflammatory drug. *Common patient receive adequate resuscitation with fluid and blood products before moving ahead with diagnostic testing.
GI bleeding has different causes at different ages (Table 126-11).
Red substances in foods, beverages, or medications (such as cefdinir) occasionally can be mistaken for blood. A test for occultblood is worth performing whenever the diagnosis is in doubt.
The GI tract may not be the source of the observed fecal blood.A history of cough and examination of the mouth, nostrils, andlungs is needed to exclude these as a source of hematemesis.Blood in the toilet or diaper may be coming from the urinarytract, vagina, or even a severe diaper rash. If the bleeding is GI, it is important to determine the source as high in the GI tract ordistal to the ligament of Treitz. Vomited blood is always proximal. Rectal bleeding may be coming from anywhere in the gut.When dark clots or melena are seen mixed with stool, a higherlocation is suspected, whereas bright red blood on the surface ofstool probably is coming from lower in the colon. When upperGI tract bleeding is suspected, a nasogastric tube may be placedand gastric contents aspirated for evidence of recent bleeding.
The location and hemodynamic significance of the bleeding can also be assessed by history and examination. The parents should be asked to quantify the bleeding. Details of associated symptoms should be sought. Assessment of the vital signs including orthostatic changes when bleeding volume is large, pulses, capillary refill and assessment of pallor of the mucous membranes provides valuable information. Laboratory assessment and imaging studies should be ordered as indicated (Table 126-12).
Coagulation tests: prothrombin time, partial thromboplastin time Tests of liver dysfunction: AST, ALT, GGT, bilirubin Occult blood test of stool or vomitus Blood type and crossmatch
Evaluation of Bloody Diarrhea Stool culture, Clostridium difficile toxin Sigmoidoscopy or colonoscopy CT with contrast
Evaluation of Rectal Bleeding with Formed Stools
Evaluation of Hematemesis
Evaluation of Bleeding with Pain and Vomiting (Bowel Obstruction)
ALT, Alanine aminotransferase; AST, aspartate aminotransferase; CBC, complete blood count; CT, computed tomography; GGT, γ-glutamyltransferase; GI, gastrointestinal.
Hematemesis or rectal bleeding Place NG tube Blood in stomach Yes Shock, orthostatic hypotension, poor perfusion Yes Transfer to intensive care unit Vital signs stabilized? Intravenous bolus of 20 mL/kg saline or lactated Ringer's solution Check CBC, PT, PTT, platelets Transfuse with PRBCs, FFP Platelets as required Endoscopy, imaging studies or surgery as required for diagnosis and management No Leave tube in place, monitor output
Treatment of GI bleeding should begin with an initial assessment, rapid stabilization, and a logical sequence of diagnostic tests. When a treatable cause is identified, specific therapyshould be started. In many cases, the amount of blood is small,