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.

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Aim

To guide Emergency Department (ED) staff with the assessment and management of lower gastrointestinal tract (GIT) bleeding in children.

Definition

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 GIT cause of bleeding.
Haematochezia (bright red blood) suggests colonic or rectal source of bleeding.
Most causes in children 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 sodium chloride 0.9% (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 age¹

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 bilious vomiting
Up to 20% will have rectal bleeding (malaena or haematochezia)²
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 hours³
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. Refer to Enteral Infection - ChAMP guideline.

Intussusception

'Red Currant Jelly' stool is a late sign of intussusception
More common presentations include acute, colicky abdominal pain and vomiting
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 may be diagnostic
Surgical resection is the treatment for symptomatic Meckel's Diverticuli.

References

Neidich GA, Cole SR. Gastrointestinal bleeding. Pediatr Rev. 2014 Jun;35(6):243-53; quiz 254. doi: 10.1542/pir.35-6-243.
Pediatric Surgery. 7th edition. Ed: Coran. Saunders, Elsevier Inc. 2012
Mousan G, Kamat D. Cow's Milk Protein Allergy. Clin Pediatr (Phila). 2016 Oct;55(11):1054-63. doi: 10.1177/0009922816664512.
Fleisher, Gary R. Ludwig, Stephen. Textbook of Pediatric Emergency Medicine, 6th Edition. 2010

Endorsed by:	Nurse Co-Director, Surgical Services	Date:	Apr 2022
		Review date:	Sep 2025

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