Gastrointestinal bleeding lower GIT

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide staff with the assessment and management of lower gastrointestinal bleeding in children.

Background 

  • 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.
  • 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 (NSAID) use
  • Family history of bleeding disorders, inflammatory bowel disease, peptic ulcer disease, polyposis

Differential Diagnosis

Causes of lower GI bleeding vary according to age.

Neonates Infants Older children
Swallowed maternal blood
Anorectal fissure
Allergic colitis
Necrotising enterocolitis
Midgut volvulus with malrotation 
Anal fissure
Allergic colitis
Intussusception
Infectious colitis
Meckel's Diverticulum
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 a general paediatrician.

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. 

 

Intussusception

  • 'Red Currant Jelly' stool is a late sign of intussusception
  • Ultrasound, surgical referral and air enema in suspected cases.

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

  • Hamartomas (benign focal malformation) 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.

Bibliography

  1. Fleisher, Gary R. Ludwig, Stephen. Textbook of Pediatric Emergency Medicine, 6th Edition. 2010

Endorsed by:  Director, Emergency Department   Date:  Feb 2018


 Review date:   Feb 2021


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