12.2 Acute Pediatric Gastrointestinal Hemorrhage & Endoscopic Triage

Acute Pediatric Gastrointestinal Hemorrhage and Endoscopy

Quick answer: Stabilize the child and involve the team that can control the bleeding. A brisk upper source can cause hematochezia. In a stable newborn with a credible maternal source, an Apt-Downey test on a suitable fresh sample can guide the evaluation. Painless episodic rectal bleeding suggests Meckel diverticulum. Suspected variceal hemorrhage calls for early octreotide and coordinated therapeutic endoscopy after initial resuscitation.

Recognize the likely source

The ligament of Treitz is the conventional boundary between upper and lower GI bleeding. Hematemesis and coffee-ground emesis suggest an upper source. Coffee grounds are altered blood and do not establish that bleeding has stopped. Melena often comes from the upper tract but can occur with a more distal source. Maroon or red stool often reflects distal bleeding, although brisk upper bleeding can pass rapidly. Color alone cannot determine rate, severity or precise site. Ask about epistaxis or oral bleeding, retching, NSAIDs, anticoagulants, ingestion and liver disease. Examine the nose and mouth, abdomen and perianal area as appropriate. Check for splenomegaly or known portal hypertension. CHOP upper GI bleed pathway · ACR pediatric GI bleeding

AAP food allergy guidance

With severe abdominal pain and suspected IgA vasculitis, evaluate urgently for intussusception. Blood pressure and urinalysis assess kidney involvement. Fever, distension and explosive or bloody diarrhea in a child with Hirschsprung disease can indicate associated enterocolitis. Consult surgery for resuscitation and severity-based antibiotics and rectal irrigation. Avoid a contrast enema during an acute episode. If STEC is suspected in bloody diarrhea, send stool testing for O157 and Shiga toxin or its genes and monitor for hemolytic uremic syndrome. Avoid antibiotics directed at suspected STEC and avoid antimotility agents. IgA vasculitis guidance · APSA Hirschsprung-associated enterocolitis guidance · CDC STEC clinical guidance · IDSA infectious diarrhea guideline

Apt-Downey test. For a well newborn with fresh visibly bloody stool or emesis and a credible maternal source, ask the lab whether it accepts the specimen. In the alkali test, HbF is relatively resistant and remains pink. Predominantly adult hemoglobin denatures and becomes yellow-brown. The latter supports swallowed maternal blood in this setting. Tarry or otherwise unsuitable samples, recurrent bleeding and clinical instability require other evaluation. An ill infant needs immediate assessment and resuscitation while the source is investigated. Original Apt and Downey test · U.S. laboratory specimen guidance

Meckel diverticulum. Persistence of the vitelline duct can leave a true diverticulum on the antimesenteric ileum. Ectopic gastric mucosa can secrete acid and ulcerate nearby ileum, causing painless episodic maroon or red stool. Once the child is stable and active bleeding has stopped, technetium-99m pertechnetate scintigraphy can detect functioning ectopic gastric mucosa. The tracer is taken up by mucin-producing cells. Acid secretion is a separate function of parietal cells. A negative scan cannot exclude all Meckel diverticula. Ongoing brisk bleeding requires a different localization plan, chosen with GI, surgery and radiology. SNMMI/EANM Meckel scintigraphy standard · ACR pediatric GI bleeding

Stabilize and determine transfusion needs

1. Assess mental status, airway protection, oxygenation and perfusion. Obtain airway expertise and suction for ongoing large-volume hematemesis or impaired consciousness. Prepare for possible worsening hemodynamics during induction while another team member establishes vascular access and begins resuscitation.
2. Obtain two IV lines when feasible or use intraosseous access if IV access would delay care. Keep the child fasting, obtain CBC, type and crossmatch, coagulation studies including fibrinogen if major bleeding, chemistries and liver tests, and follow perfusion and serial hemoglobin. An early hemoglobin may underestimate the magnitude of acute blood loss. Tachycardia, pallor, altered mentation and delayed refill can appear before hypotension.
3. Start blood promptly in life-threatening hemorrhage based on perfusion and ongoing loss. Use judicious crystalloid while blood is being obtained if needed. Activate the pediatric massive transfusion protocol for ongoing severe loss. TAXI suggests an initial RBC:plasma:platelet ratio from 2:1:1 to 1:1:1 in pediatric hemorrhagic shock, based on limited evidence. Reassess as the bleeding slows and follow temperature, ionized calcium, fibrinogen and other coagulation markers. Massive transfusion for shock and giving plasma solely to correct an elevated INR in cirrhosis are separate decisions.
4. Once shock and uncontrolled bleeding have resolved, use a restrictive approach where appropriate. For critically ill children with non-life-threatening bleeding, TAXI recommends red cells below 5 g/dL and consideration from 5 to 7 g/dL. Pediatric variceal consensus uses a threshold near 7 g/dL and a target of 7–9 g/dL after initial stabilization, largely from adult data. Consider oxygen delivery, cardiac physiology and rebleeding, and avoid overtransfusion in portal hypertension. CHOP pathway · Pediatric TAXI bleeding consensus · Pediatric variceal consensus

Source-directed drugs and hemostasis

Suspected varices. Start IV octreotide early with GI and critical care input. It reduces splanchnic flow and portal inflow. A pediatric consensus example is about 1 mcg/kg IV as a loading dose (maximum 50 mcg), then 1–2 mcg/kg/hour (maximum 50 mcg/hour), commonly continued for 2–5 days after endoscopy according to response and the local pathway. Check glucose and hemodynamics. For example, a 24 kg child given 1 mcg/kg followed by 1 mcg/kg/hour receives 24 mcg, then 24 mcg/hour. Early IV antibiotics are recommended for cirrhotic portal hypertension with acute variceal bleeding, with local selection and duration. The pediatric evidence for this prophylaxis is limited. An elevated INR in cirrhosis alone does not justify routine plasma. Pediatric variceal consensus · U.S. pediatric octreotide series · U.S. octreotide label

Possible nonvariceal upper bleeding. A pediatric pathway may use high-dose IV pantoprazole for clinically significant suspected nonvariceal bleeding. Follow the institutional dose and reassess after endoscopy. The U.S. label does not establish IV pantoprazole for GI hemorrhage. GI may select IV erythromycin before endoscopy to improve visualization when substantial gastric blood or clot is expected. Avoid letting adjunct medications delay source control. CHOP pathway · U.S. pantoprazole label

Timing and technique. Contact pediatric gastroenterology early for significant bleeding. The 2026 pediatric variceal consensus recommends esophagogastroduodenoscopy (EGD) within 24 hours after initial resuscitation. Older European pediatric guidance favors earlier EGD, within 12 hours in children with known esophageal varices or major bleeding with ongoing support. Escalate uncontrolled hemorrhage immediately with GI, anesthesia, interventional radiology and surgery as appropriate. Stable lower bleeding follows a separate evaluation, with colonoscopy after adequate preparation when indicated. The accompanying chart compares how upper GI bleeding presented among 32 children in one UK tertiary-center series. The categories describe symptoms. They do not estimate the distribution of causes. Pediatric variceal consensus · ESGE/ESPGHAN pediatric endoscopy guideline · UK pediatric cohort

• Esophageal varices: Band ligation when technically feasible. Sclerotherapy is an option if the small esophageal lumen or visualization prevents banding. Gastric fundal varices may need tissue adhesive or radiologic treatment depending on expertise and anatomy.
• High-risk nonvariceal lesions: Select mechanical clipping, thermal treatment or other hemostasis according to the lesion. If epinephrine injection is used for a bleeding ulcer or Dieulafoy lesion, add definitive mechanical or thermal treatment.
• Persistent or recurrent variceal hemorrhage: Coordinate repeat endoscopic or interventional treatment. Balloon tamponade is a temporary specialist bridge in selected patients with a protected airway. Device choice and size matter. TIPS can decompress portal pressure in selected patients. A meso-Rex bypass can restore physiologic portal flow in appropriate extrahepatic portal venous obstruction with suitable anatomy. Hepatology may also evaluate for transplantation. Pediatric variceal consensus · ESGE/ESPGHAN pediatric endoscopy guideline