Lower gastrointestinal bleeding in children: Causes and diagnostic approach
- Nishaben Patel, MD
Nishaben Patel, MD
- Assistant Professor Pediatric Gastroenterology & Nutrition
- University of Rochester Medical Center
- Marsha Kay, MD
Marsha Kay, MD
- Chair, Department of Pediatric Gastroenterology and Nutrition
- Cleveland Clinic
- Section Editors
- Stephen J Teach, MD, MPH
Stephen J Teach, MD, MPH
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics and Emergency Medicine
- George Washington University School of Medicine and Health Sciences
- Melvin B Heyman, MD, MPH
Melvin B Heyman, MD, MPH
- Section Editor — Gastroenterology
- Professor of Pediatrics
- University of California, San Francisco
Lower gastrointestinal bleeding (LGIB) in infants and children is commonly encountered in clinical practice, although its epidemiology has not been well studied [1-5]. In a large series from 1994, rectal bleeding was the chief complaint in 0.3 percent of more than 40,000 patients presenting to a pediatric emergency department (ED) in Massachusetts . Bleeding was considered to be life-threatening in only four patients (4.2 percent), three of whom had ileocolic intussusception and one of whom had bleeding from a Meckel's diverticulum. In a subsequent nationwide study, 11.6 percent of pediatric patients presenting to the ED with gastrointestinal bleeding were admitted to the hospital, suggesting that most cases presenting to the emergency department with gastrointestinal bleeding are not life-threatening . Approximately 30 percent of the overall cases presenting to the ED were classified as LGIB, 20 percent were upper gastrointestinal bleeding, and the remainder were unspecified.
This topic review will discuss the evaluation of LGIB that presents with bright red blood per rectum, for which the most likely causes are organized by age group. The evaluation of children presenting with hematemesis or other signs of upper gastrointestinal bleeding (UGIB) are discussed separately (see "Approach to upper gastrointestinal bleeding in children"). Many of the causes of LGIB that are listed here are discussed in detail in separate topic reviews.
●Upper gastrointestinal bleeding (UGIB) refers to bleeding that originates from the gastrointestinal (GI) tract proximal to the ligament of Treitz (the junction of the duodenum and jejunum). It includes bleeding sources in the esophagus, stomach, and duodenum.
●Lower gastrointestinal bleeding (LGIB) refers to bleeding distal to the ligament of Treitz, and thus includes bleeding sources in the small bowel and colon. It is sometimes subcategorized as bleeding from the small bowel (sometimes termed mid-GI bleeding), or bleeding from the colon.
Gastrointestinal bleeding can be further categorized based on qualitative characteristics of the stool:
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- CAUSES OF BLEEDING
- Neonatal period
- - Swallowed maternal blood
- - Anal fissures
- - Necrotizing enterocolitis
- - Malrotation with midgut volvulus
- - Hirschsprung disease
- - Coagulopathy
- Infants and toddlers
- - Anal fissures
- - Milk- or soy-induced colitis
- - Intussusception
- - Meckel's diverticulum
- - Lymphonodular hyperplasia
- - Gastrointestinal duplication cyst
- - Infantile and very early onset inflammatory bowel disease
- Preschool period
- - Infectious colitis
- - Hemolytic-uremic syndrome
- - Henoch-Schönlein purpura (IgA vasculitis)
- - Juvenile polyps
- - Solitary rectal ulcer syndrome (SRUS)
- School-aged children and adolescents
- - Inflammatory bowel disease
- Rare causes of lower gastrointestinal bleeding
- DIAGNOSTIC APPROACH
- Testing for blood in the stool
- Physical examination
- Laboratory studies and imaging
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS