Paediatric Acute care Guidelines PMH Emergency Department

Gastrointestinal bleeding in children is a relatively common presentation to emergency departments.

This guideline looks at lower GIT causes of bleeding. Please refer to Gastrointestinal Bleeding – Upper GIT for upper GIT causes.

Background

  • Rectal bleeding can present as malaena or haematochezia
  • Malaena (altered dark blood) suggests an upper GI cause of bleeding
  • Haematochezia (bright red blood) suggests colonic or rectal source of bleeding
  • Most causes are non life threatening

Assessment

Haemodynamically unstable, shocked or persistent large bleeding

  • Pallor, tachycardia, delayed perfusion, hypotension 
    • Large bore IV access x2
    • Fluid resuscitation 20ml/kg 0.9% saline (repeat as necessary)
    • +/- blood transfusion 
    • Early senior clinician input

Haemodynamically Stable Patients

  • Consider non GIT causes of blood
    • Swallowed blood – maternal (breastfed infants), large epistaxis
    • Food which can mimic blood – red food colouring, beetroot
  • Thorough history will help determine the source of bleeding

History

Important points to ask in history:

  • Neonates – was vitamin K given at birth?
  • Pain
  • Vomiting and diarrhoea
  • Constipation
  • Fever
  • Weight loss
  • Non Steroidal Anti Inflammatory Drug use
  • Family history of bleeding disorders, inflammatory bowel disease, peptic ulcer disease, polyposis

Differential Diagnosis

Causes of lower GI bleeding vary according to age.

Diagnosis

Neonatal Period

  • Swallowed maternal blood
  • Anorectal fissure
  • Allergic colitis
  • Necrotising Enterocolitis
  • Midgut volvulus with malrotation

Infants

  • Anal fissure
  • Allergic colitis
  • Intussusception
  • Infectious colitis
  • Meckel’s Diverticulum

Older Children

  • Anal fissure
  • Infectious colitis
  • Inflammatory Bowel Disease
  • Juvenile polyps
  • Henoch-Schonlein Purpura
  • Meckel’s Diverticulum

Swallowed Maternal Blood

  • There may be a history of maternal mastitis or painful, cracked nipples. APT-Downey test will detect maternal blood in baby’s stool

Malrotation with Midgut Volvulus

  • Usually present in neonatal period with abdominal distension and vomiting
  • Up to 20% will have rectal bleeding (malaena or haematochezia)
  • Upper GI contrast study and surgical referral in suspected cases

Anorectal Fissure

  • History of painful bowel motions, straining, constipation
  • Bright flecks or streaks of blood on surface of stool
  • Fissure may be seen on external examination
  • Treat with stool softeners and topical analgesia

Allergic Colitis

  • Food protein induced colitis – commonly cow’s milk protein
  • Mucousy bloody stool in otherwise healthy infant
  • Treatment is eliminating causative protein in diet – usually results in improvement of symptoms within 72 hours
  • Self resolves by 6-18 months age
  • Arrange follow up with General Paediatrian

Infectious Colitis

  • Fever, abdominal pain and bloody diarrhoea
  • Usually self limiting course
  • Salmonella, Shigella, Campylobacter, Clostridium difficile are common pathogens
  • If systemically unwell (especially young infants), admission is warranted for treatment with antibiotics (refer to Antibiotic guideline)

Intussusception

  • “Red Currant Jelly” stool is a late sign of intussusception
  • Ultrasound, surgical referral and air enema in suspected cases
  • Refer to Intussusception guideline

Inflammatory Bowel Disease

  • Crohn’s Disease or Ulcerative Colitis
  • Suspect if chronic abdominal pain with weight loss and bloody stool
  • Investigations – iron deficiency anaemia, raised ESR and CRP, elevated faecal calprotectin
  • Refer to gastroenterology for investigation and endoscopy

Juvenile Polyps

  • Benign hamartomas present with painless rectal bleeding
  • May be familial polyposis syndrome
  • Colonoscopy is diagnostic

Meckel’s Diverticulum

  • Painless rectal bleeding – may be massive haemorrhage
  • Fluid resuscitation +/- blood transfusion as required
  • Meckel’s scan is diagnostic
  • Surgical resection is the treatment for symptomatic Meckel’s Diverticuli

We want your feedback!

Help us provide guidelines that are useful to you, the clinician.

Give feedback here