8-year-old female with no significant past medical history, presenting with intermittent epigastric abdominal pain and fatigue x 2days. Patient also vomited once yesterday - nonbloody/nonbilious. Parents noted that her stools became black over the past 4 days. No diarrhea or constipation. Parents also tried giving Pepto-Bismol for her abdominal pain without relief of symptoms. No fever. No ingestion of foreign objects. No recent travel.
VS - Temp: 98.8F, HR: 120, BP: 110/65, RR: 20, SpO2: 99% on RA
Exam - Gen - NAD, head - NCAT, Pharynx - clear, MMM, conjunctival and oral mucosal pallor noted, Heart -tachycardic but regular rhythm, no m/g/r, Lungs - CTAB, no w/c/r, no tachypnea or retractions, abdomen - soft, epigastric tenderness, ND, no rebound or guarding, no HSM, skin -positive pallor noted, no rash, Extremities - FROM, no edema, erythema, ecchymosis, Neuro - CN 2-12 intact, nl strength and sensation, nl gait.
What's on the differential?
GI bleed (melena), ingested foods that turn stool dark, ingested Pepto-Bismol (bismuth turning stool black), swallowed blood not from GI tract?
Management?
Depends on the source of the bleed.
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GI bleeding
Hematochezia - Causes vary by age –
Infants (<1 yo) – Food-protein induced proctocolitis (milk-protein allergy), NEC, volvulus, swallowed maternal blood, infectious colitis, hemorrhagic disease of the newborn, Mallory-Weiss tear, Vitamin K. deficiency, Hirschsprung disease (toxic megacolon)
Children – infectious colitis, antibiotic induced colitis, Meckel’s diverticulum, intussusception, fissure, gastritis (H. pylori), caustic ingestion
Adolescents – infectious colitis, inflammatory bowel disease, Mallory-Weiss, PUD, varices, FB, HSP, HUS
Also consider DIC/coagulopathy, ITP, vasculitis, AVM, polyps, surgical complications
Upper GI bleeding vs lower GI bleeding – Presentation helps differentiate. Lower GI bleed is distal to the Ligament of Treitz (distal duodenum). In general, the darker the blood, the higher it originates in the GI tract
AGE (acute gastroenteritis) is the most common cause of lower GI bleeding – can be bacterial or viral. Can consider testing for bacterial pathogens – can be done outpatient.
Bacterial causes – salmonella, shigella, STEC (shiga toxin producing E.coli), E.Coli 0157:h7, Yersinia, Campylobacter
Viruses – Norovirus, enteric adenovirus, rotavirus
Don’t forget antibiotic-associated colitis – C.dif – make sure to ask in history.
Most Peds lower GI bleed is self-limited.
Gastric and duodenal ulcers are associated with significant bleeding events.
Need to consider severe bleeding – defined as:
· Hgb drop >= to 2 mg/L
· Need for blood transfusion
· Need for emergent endoscopy/colonoscopy (within 48 hrs)
Severe bleeding is often associated with melena, pallor, tachycardia, anemia, elevated BUN (from blood resorption) and low albumin.
Assessment -
Examination – quick look – pallor, fatigue, tachycardia – concerning for severe bleeding. On exam – also check for palpable liver of spleen – signs of portal HTN and thus possible variceal bleeding. Eval nose and pharynx to r/o non-GI source of bleed. Look for signs of liver dz/portal hypertension - scleral icterus, prominent abdominal venous pattern, ascites. Petechiae seen in HUS. Palpable purpura in HSP.
Is the patient really bleeding (and not just foods with red color or Pepto-Bismol with bismuth turning stool black)– and if so, it is really from GI tract (not swallowed epistaxis, etc,)
Is it upper or lower GI?
Gastric lavage helps determine UGI bleed source.
Think of age-related differential diagnoses
Ask if bloody stool is black/tarry, blood-streaked firm stool, bloody diarrhea. Ask if there is abdominal/rectal pain. Currant jelly stools in intussusception (late finding with bowel wall ischemia).
Ask family h/o bleeding d/o, familial polyposis. Ask about drug use - NSAIDs, Abx use - C.dif.
Work-up/Management – If significant bleeding - labs including coags, Type and Screen, CBC, CMP. IVF. Blood transfusion if needed. PPI (pantoprazole). Consider octreotide if variceal bleed from portal HTN. If likely concerning (active) UGI bleed – keep NPO and consider NG tube. Urgent endoscopy. 80-85% of UGI bleed stop spontaneously so might not need emergent endoscopy - may be done in 12-24 hours after admission.
Notable causes of GI bleed:
Esophageal and gastric varices are the most coming causes of severe UGI bleed - associated with portal hypertension due to hepatic and vascular d/o. Many are caused by hepatitis, congenital hepatic fibrosis, cystic fibrosis, biliary cirrhosis/biliary atresia; h/o omphalitis or h/o umbilical vein cannulation.
Angiodysplasia is a rare cause of GI bleeding but associated with massive hemorrhage. Often congenital - such as in Rendu-Osler-Weber syndrome and Turner syndrome with intestinal telangiectasia.
Meckel's diverticulum - Rule of 2s - commonly present at 2 years old, seen in about 2% of the population, 2 inches long, 2 feet from ileocecal valve painless hematochezia - can be massive hemorrhage.
HUS - from E.coli O157:H7 - bloody diarrhea with renal and hemolytic anemia and thrombocytopenia.
PUD - most common cause is H.pylori, followed by NSAIDs and steroids. Can be stress-induced, caustic ingestion. H.pylori higher prevalence in developing countries. Higher prevalence rates among family members - person to person transmission. Family h/o ulcer disease is present in 50% or more of children with duodenal ulcers. Children can p/w epigastric abdominal pain, vomiting, and GI bleeding - hematemesis or melena. If PE with significant tenderness, perform upright Abd XR to eval for perforation. Treat with antacids, PPIs in pts with anemia or moderate to severe PUD. First line therapy for H.pylori (official dx with histopathology on EGD) is PPI plus 2 Abx (amoxicillin, clarithromycin, or metronidazole for 10-14 days
Management of significant UGI bleed
For this case – Pt was pale, tachycardic, with melena on exam. Also took Pepto-Bismol that might turn stool black but exam concerning for true blood loss. Epigastric abdominal pain and melena point to more likely UGI bleed. Labs revealed Hgb 6.6 --> pt was transfused 1 unit of PRBCs. GI consulted – pt admitted for endoscopy and colonoscopy and Meckel scan. Meckel scan was negative. Endoscopy – visually noted nodularity in stomach and duodenitis raising suspicion for H.pylori. Colonoscopy negative. No active bleed noted. Pt was d/ced on omeprazole pending histopathology, and other GI labs including H.pylori testing.
GI bleed has a wide differential - make sure to keep that in mind along with the ages of presentation to help determine how to proceed. Thank you!
Happy pooping!