Pediatric Gastrointestinal Bleeding: Identification and Management in the Emergency Department

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Publication Date: September 2024 (Volume 21, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 09/01/2027.

Authors

Peer Reviewers

Abstract

Pediatric gastrointestinal (GI) bleeding ranges from mild and self-limited cases to severe episodes of hemorrhagic shock. A structured, age-specific approach is essential for the correct diagnostic workup and effective management. Collaboration with a multidisciplinary team, including pediatric surgery and gastroenterology specialists, may be necessary. The goal of managing pediatric patients with GI bleeding in the emergency department is to identify and treat severe cases, while avoiding unnecessary workup and admission for patients with mild or self-resolving cases. This issue provides a comprehensive review of the definitions, causes, and management strategies for upper and lower GI bleeding in children. It also highlights existing knowledge gaps and future research directions.

Case Presentations

A 2-year-old previously healthy boy presents with 2 episodes of rectal bleeding since yesterday evening…

• The boy’s parents report no vomiting or signs of pain. They brought a diaper with a large amount of bloody stool in it. They say the boy continues to tolerate his diet well.
• On examination, the boy has no fever, his heart rate is 130 beats/min, and his blood pressure is 95/50 mm Hg. His abdomen is soft and nontender, with no palpable masses, and his external perianal examination is normal.
• Considering the patient’s clinical presentation, which diagnostic and management steps would be most appropriate to prioritize?

A 2-week-old previously healthy full-term girl presents with complaints of bloody stools for the past 2 days…

• The parents report that the infant is exclusively breastfed. She had 3 to 4 episodes of red blood-tinged stool, with no changes in consistency. There is no evidence of vomiting or pain.
• Upon arrival at the ED, the infant appears well and is not in distress. She has a normal physical examination and vital signs, including a heart rate of 120 beats/min.
• Despite the infant’s reassuring appearance, you are considering whether to initiate further evaluation. What tests should you order? What is your differential diagnosis?

A 2-year-old boy status post Kasai procedure for biliary atresia at 3 months of age presents after 2 episodes of bright red hematemesis…

• The boy’s mother urgently brought him to the ED. He has no fever or diarrhea but has had a poor appetite for the last 2 days and has recently appeared more pale. She reports no similar episodes in the past.
• Upon arrival, the patient appears tired, is tachycardic with a heart rate in the 160s, has weak peripheral pulses, and a blood pressure of 70/35 mm Hg. His examination is notable for pallor, scleral icterus, and a palpable spleen below the costal margin. His abdomen is soft and nontender.
• Given the history of the Kasai procedure, how does this influence your initial differential diagnosis? What are the most critical steps in the workup and resuscitation of this patient?

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