How is the cause of pediatric gastrointestinal (GI) bleeding diagnosed?

Updated: Dec 19, 2018
  • Author: Wayne Wolfram, MD, MPH; Chief Editor: Robert K Minkes, MD, PhD  more...
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For upper GI bleeding, a nasogastric tube can be placed to confirm the presence of fresh blood and to evaluate the degree of active bleeding. If fresh or active bleeding is confirmed, esophagogastroduodenoscopy (EGD) can determine the source of upper GI bleeding in 90% of children when performed in the first 24 hours. Alternatively, colonoscopy identifies the cause of bleeding in 80% of children with lower GI bleeding.

In general, trace or small amounts of blood that are a 1- or first-time occurrence are not of emergent concern. Children rarely require an extensive laboratory workup or invasive procedures, and parents can be advised to observe the child at home to see if these situations arise again.

Patients with substantial upper or lower GI bleeding, as determined from their history or examination, should receive a complete blood count (CBC), coagulation studies, and a chemistry panel. The CBC reveals anemia and thrombocytopenia.

A normal hematocrit may provide false reassurance regarding some children with hypovolemia and hemoconcentration.

Leukocytosis with increased bands may indicate an infectious etiology or complication responsible for the bleeding.

Elevated, abnormal prothrombin time indicates coagulopathy (ie, disseminated intravascular coagulation) or profound impairment of liver synthetic function.

A prolonged activated partial thromboplastin time indicates a hemophiliac patient or coagulopathy.

A chemistry panel may reveal a high blood urea nitrogen (BUN) level, suggesting an upper GI source that has had time to allow the body to reabsorb blood leading to a higher BUN level compared with a lower GI source.

For children who have tenderness in the right upper quadrant or a history suggestive of liver disease, aspartate aminotransferase and alanine aminotransferase enzyme levels may indicate hepatitis and increased risk of portal hypertension.

The history should also be used as a guide with regard to when fecal leukocytes, parasites, or cultures should be ordered, if an infectious etiology is suspected.

In cases of episodic or obscure bleeding, nuclear medicine radionucleotide studies, arteriography, and wireless video capsule endoscopy are used to assist in identifying the site of blood loss.

Radionuclear imaging with technetium-labeled red blood cells can be used to detect bleeding at a rate as low as 0.1 mL per minute. This technique is somewhat imprecise; however, it may direct localization for either selective angiography, suggest a need for video capsule endoscopy, or provide some direction for laparotomy search and resection, a notoriously difficult process for the control of GI bleeding.

Arteriography can be used to detect bleeding at a rate of 0.5 mL per minute and offers the advantage of providing treatment and diagnosis. The treatment consists of embolization and intra-arterial administration of vasoconstrictors.

When arteriography and nuclear scanning fail to diagnose or localize the cause of bleeding, further options remain, including repeat endoscopy and push enteroscopy (often also referred to as double balloon endoscopy or enteroscopy). [6]

In many cases, wireless video capsule endoscopy reveals the cause noninvasively, but its main disadvantage is the inability to collect tissue samples for biopsy examination. [7]

If all else fails, diagnostic laparoscopy and intraoperative endoscopy can be performed as means of last resort.

An age-specific discussion of diagnostic workups for GI bleeding follows.

Go to Imaging of Upper Gastrointestinal Bleeding and Imaging of Esophageal Varices for complete information on these topics.

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