CHAPTER 33 ■ GASTROINTESTINAL BLEEDING LENORE JARVIS INTRODUCTION Gastrointestinal (GI) bleeding is a relatively common problem in pediatrics Over one 12-month study period at a large urban pediatric emergency department, complaints of rectal bleeding accounted for 0.3% of all visits Upon the patient’s arrival, the emergency physician must first assess the need for cardiovascular resuscitation and stabilization However, most children who arrive in the ED with an apparent GI bleed have an acute, self-limited GI hemorrhage and are hemodynamically stable In most cases of upper and lower GI bleeding, the source of the bleeding is inflamed mucosa (infection, allergy, drug induced, stress related, or idiopathic) The emergency physician must be vigilant in differentiating inflammatory conditions that are often selflimited from causes that may require emergent surgical or endoscopic intervention, such as ischemic bowel (intussusception, volvulus), structural abnormalities (Meckel diverticulum, angiodysplasia), and portal hypertension (esophageal varices) Acute GI bleeding rarely represents a surgical emergency In the previously noted study, only 4.2% of 95 patients required a blood transfusion or an operative intervention INITIAL ASSESSMENT The clinician should sequentially assess the patient through the following questions: Is the patient in hemorrhagic shock (see Chapter 10 Shock )? Is the patient really bleeding? Is the bleeding coming from the GI tract? If so, how severe is the bleeding? Is it upper or lower GI bleeding? What is the age-related differential diagnosis based on pertinent history, physical examination, and diagnostic tests? GI Bleed Imitators Many substances ingested by children may simulate fresh or chemically altered blood Red food coloring (found in cereals, antibiotics and cough syrups, Jell-O, and KoolAid), as well as fruit juices and beets, may resemble blood if vomited or passed in the stool Medications such as antibiotics (cefdinir—which can cause “brick-red” stools), iron supplementation, and bismuth (in Pepto-Bismol) may cause the stool to look melanotic or bloody Foods such as dark chocolate, spinach, cranberries, blueberries, grapes, or licorice may also produce dark-colored stools In these cases, confirmation of the absence of blood with Gastroccult (vomitus) or Hemoccult (stool) tests will allay parental anxiety, as well as prevent unnecessary concern and testing A careful search for other causes of presumed GI bleeding (recent epistaxis, dental work, menses, and hematuria) should be sought Hematemesis (vomiting of blood) also