Lower Gastrointestinal Bleeding

Although gastrointestinal bleeding is worrisome for parents, unlike adult medicine, it is rarely associated with malignancies in pediatrics. 

Testing for Blood in the Stool

  1. Hemocult or Hematest. The test material contains peroxide which interacts with peroxidases in hemoglobin to cause a color change
    1. False negatives can be caused by large amounts of ascorbic acid in the diet or if intestinal bacteria degrade hemoglobin to porphyrin. 
    2. False positives can be caused by large amounts of rare red meat and certain vegetables:broccoli, cauliflower, turnips, radishes, and cantaloupe.
  2. Foods and medicines that can make stool appear bloody
    1. Red licorice
    2. Red pop, Koolaid, jello
    3. Beets
    4. Iron
    5. Pepto Bismol
Upper vs. Lower Intestinal Tract Bleeding
  1. If there is blood on the surface of the stool this is usually of anal-rectal origin
  2. Bright red blood mixed in with stool usually is from below the ligament of Treitz but could be from above if massive
  3. Melana or tarry stools are usually above the ligament of Treitz
Evaluation of Bleeding
  1. History
    1. Amount of blood and appearance of stool. (Bright red blood vs. tarry stools)
    2. How long has there been bleeding?
    3. Associated symptoms of fever, weight loss, diarrhea, vomiting, constipation, pain, change of appetite, 
    4. Diet
    5. Travel 
    6. Family History
    7. Growth
  2. Physical Exam
    1. Pallor
    2. Rashes, petechiae, purpura, hemangiomas, jaundice, telangiectasias 
    3. Mouth lesions
    4. Abdominal exam for masses, tenderness
    5. Rectal exam
    6. Vital signs
    7. jaundice(hepatic failure) or cutaneous bruising
Commom Etiologies of Rectal Bleeding
  1. Neonatal 
    1. Necrotizing enterocolitis- usually in preterm 
    2. Hirchsprung's disease associated with enterocolitis
    3. Malrotation and associated volvulus
    4. Swallowed blood- Do anApt test to differentiate fetal from adult hemoglobin
    5. Coagulaopathy
  2. One month to 2 years
    1. Anal or rectal fissures- (most common in <1 year olds) may be associated with painful bowel movements
    2. Formula intolerance
    3. Meckel's diverticulum - disease of 2's (2 inches long, 2 feet from the ileocecal valve, 2% of the population, most common diagnosied in the first 2 years of life, 2 types of tisuue present) 
    4. Hirschsprung's disease
    5. Intussusception- most common in the ileocecal area
    6. Lymphonodular hyperplasia
    7. Infectious diarrhea
    8. HUS
    9. HSP
  3. Two to 5 years old
    1. Polyps- may have large amount of bleeding and often pass spontaneously
    2. Infectious diarrhea- either viral or bacterial
  4. Five years to adolescence
    1. Similar to younger with the addition of Inflammatory Bowel Disease
Evaluation
  1. The evaluation of the infant or child with blood in their stools is dependent on the history, general condition of the child, growth and development, amount of blood in the stool, the condition of the child including heart rate, blood pressure, amount of discomfort, and degree of anemia, if any. If necessary, the child should be stabilized.
  2. After a thorough history and physical exam, a CBC, reticulocyte count, smear, and platelet count should be performed. If the child is ill appearing, a type and cross match should be done. If the child is not ill and massive bleeding is not suspected, an outpatient evaluation may be performed.
Reference
  1. Silber, Gary. Lower Gastrointestinal Bleeding. Pediatrics in Review. September 1990.
  2. Squires. RH. Gastrointestinal Bleeding. Pediatrics in Review. 1999; 20:95-101.
  3. Causes of Rectal Bleeding.  Pediatrics in Review. November 2001
  4. Lake A. Food-Induced Eosinophilic Ptroctocolitis.  Journal of Pediatric Gastroenterolgy and Nutrition.  Jan 2000
  5. O'Hara SM.  Gastrointestinal bleeding.  Radiologic Clinics of North America 1997;35 (4) 879-95