Lower GI Bleeding

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DESCRIPTION

Lower gastrointestinal bleeding (LGIB) is traditionally defined as bleeding that occurs distal to the ligament of Treitz. More recent adult guidelines suggest bleeding that is originating from the small bowel should be considered a separate entity with different algorithms for management. This chapter addresses bleeding from both the colon and small intestine. LGIB classically present with hematochezia, although practitioners should be aware that brisk upper GI bleeding can have the same presentation. More proximal bleeding will more often present with maroon or dark-colored stools.

EPIDEMIOLOGY

Incidence

  • The incidence of GI bleeding in children is not well established in the general population.
  • A 2020 single center study in the United Kingdom demonstrated that 0.14% of all presentations to the pediatric emergency department (ED) were due to LGIB, with constipation and gastroenteritis as the most common diagnoses.
  • Severe life-threatening LGIB is uncommon in pediatric patients.

ETIOLOGY

  • Several causes should be considered within all age groups.
    • Anorectal fissure
    • Upper GI sources including ulcer disease, liver disease, and trauma from feeding tubes
    • Enteric infections
    • Intussusception
    • Vascular malformations
    • Lymphonodular hyperplasia
    • Parasites
  • The likelihood of other etiologies depends on the age of onset.
    • Neonatal period (birth to 1 month):
      • Swallowed maternal blood (melena neonatorum)
      • Vitamin K deficiency
      • Duplication cyst
      • Hirschsprung disease enterocolitis
      • Meckel diverticulum
      • Malrotation with volvulus
    • Infancy (1 month to 2 years):
      • Food protein–induced allergic proctocolitis
      • Duplication cyst
      • Meckel diverticulum
      • Hirschsprung disease enterocolitis
      • Malrotation with volvulus
    • Preschool age (2 to 5 years):
      • Polyps
      • Meckel diverticulum
      • Inflammatory bowel disease
      • Hirschsprung disease enterocolitis
      • Hemolytic uremic syndrome
      • Henoch-Schönlein purpura (HSP)
      • Volvulus
      • Rectal prolapse/rectal ulcer
      • Child abuse
      • Perianal streptococcal cellulitis
    • School age (5 to 13 years):
      • Inflammatory bowel disease
      • Meckel diverticulum
      • Polyps
      • Hemolytic uremic syndrome
      • HSP
      • Intestinal ischemia
      • Neutropenic colitis (typhlitis)
      • Child abuse
      • Perianal streptococcal cellulitis
    • Adolescent (>13 years):
      • Inflammatory bowel disease
      • Hemolytic uremic syndrome
      • Midgut volvulus
      • Intestinal ischemia
      • Neutropenic colitis (typhlitis)
      • Polyps

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