Young Child With Lower GI Bleeding

The Young Child With Lower
Gastrointestinal Bleeding Or
Intussusception
Abstract
Martin I. Herman, MD, FAAP, FACEP

Professor of Pediatrics, Attending
Physician, Emergency Medicine
Department, Sacred Heart
Childrens Hospital, Pensacola, FL
Angela K. Lumba, MD
Department of Pediatric Emergency Medicine, Rady Childrens
Hospital, University of California San Diego, CA
Heather Conrad, MD
Department of Pediatric Emergency Medicine, Rady Childrens
Hospital, University of California San Diego, CA
Ghazala Q. Sharieff, MD, FACEP, FAAEM, FAAP

Associate Clinical Professor, Childrens Hospital and Health
Center/University of California; Director of Pediatric Emergency
Medicine, California Emergency Physicians, San Diego, CA
Peer Reviewers
Elizabeth Mannick, MD
Assistant Clinical Professor, University of Hawaii Medical
School, Kapiolani Women and Childrens Medical Center,
Honolulu, Hawaii
Robert A. Wiebe, MD, FAAP, FACEP
Professor, Division of Pediatric Emergency Medicine, University
of Texas, Southwestern Medical Center at Dallas, Dallas, TX
CME Objectives
Upon completion of this article, you should be able to:
1.
Identify an appropriate differential diagnosis for LGI
bleeding based on the patients age.
2. Describe key features of the history and physical
examination that may identify intussusception in children
who present with LGI bleeding.
3. Determine appropriate indications for imaging modalities
in LGI bleeding and intussusception.
Date of original release: January 1, 2012
Date of most recent review: December 10, 2011
Termination date: January 1, 2015
Medium: Print and Online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see Physician CME
Information on the back page.
and Dentistry of New Jersey;

Pediatric Emergency Medicine
Tommy Y. Kim, MD, FAAP, FACEP
Director, Pediatric Emergency
Division, Medical Director - Pediatric Assistant Professor of Emergency
Medicine, Childrens Medical Center, Emergency Department, University
Medicine and Pediatrics, Loma
Atlantic Health System; Department
of Florida Health Science Center
Linda Medical Center and
of Emergency Medicine, Morristown
Jacksonville, Jacksonville, FL
Childrens Hospital, Loma
Memorial Hospital, Morristown, NJ Alson S. Inaba, MD, FAAP,
Linda, CA
Ran D. Goldman, MD
PALS-NF
Associate Professor, Department
Pediatric Emergency Medicine
of
Pediatrics,
University
of
Toronto;
Attending Physician, Kapiolani
Jeffrey R. Avner, MD, FAAP
Division of Pediatric Emergency
Medical Center for Women &
Professor of Clinical Pediatrics
Medicine and Clinical Pharmacology
Children; Associate Professor of
and Chief of Pediatric Emergency
and Toxicology, The Hospital for Sick
Pediatrics, University of Hawaii
Medicine, Albert Einstein College
Children,
Toronto,
ON
John A. Burns School of Medicine,
of Medicine, Childrens Hospital at
Honolulu, HI; Pediatric Advanced
Montefiore, Bronx, NY
Mark A. Hostetler, MD, MPH
Clinical Professor of Pediatrics and Life Support National Faculty
T. Kent Denmark, MD, FAAP, FACEP
Representative, American Heart
Emergency Medicine, University
Medical Director, Medical Simulation
Association, Hawaii and Pacific
of Arizona Childrens Hospital
Center; Associate Professor of
Island Region
Division of Emergency Medicine,
Emergency Medicine and Pediatrics,
Phoenix, AZ
Andy Jagoda, MD, FACEP
Loma Linda University Medical
Professor and Chair, Department
Center and Childrens Hospital,
Madeline Matar Joseph, MD,
of Emergency Medicine, Mount
Loma Linda, CA
FAAP, FACEP

Sinai School of Medicine; Medical
Associate Professor of Emergency
Michael J. Gerardi, MD, FAAP,
Director, Mount Sinai Hospital, New
Medicine and Pediatrics, Assistant
FACEP
York, NY
Chair for Pediatrics - Emergency
Clinical Assistant Professor of
Medicine Department, Chief Medicine, University of Medicine
Editorial Board
Volume 9, Number 1
Authors
Guest Editor
Lower gastrointestinal (LGI) bleeding in the pediatric patient 5 years

of age or younger is an uncommon ED presentation that causes
anxiety and concern both in the childs family and in the clinician.
A report from Boston Childrens Hospital in the early 1990s showed
that rectal bleeding was a presenting complaint in 0.3% of pediatric patients who visited the emergency department (ED) within a
1-year period. The emergency clinician may find this presentation
daunting, since the differential diagnosis of LGI bleeding includes
numerous age-specific disorders not found in the adult population,
ranging from self-limited anal fissures to surgical emergencies. The
time to diagnosis and reduction will influence morbidity and mortality in these patients; hence, the emergency clinician should have a
high index of suspicion as well as knowledge of current evidence for
diagnosis and treatment. This issue of Pediatric Emergency Medicine
Practice reviews the common differential diagnoses of LGI bleeding
in children younger than 5 years of age, relying on the best available
evidence from the literature. Readers will be able to apply clinically
appropriate guidelines regarding diagnosis and treatment in an effective and patient-specific manner. In particular, this article focuses on
the challenge of evaluating and managing the pediatric patient with
intussusception.
AAP Sponsor
January 2012
Gary R. Strange, MD, MA, FACEP

Professor and Head, Department
of Emergency Medicine, University
of Illinois, Chicago, IL
Christopher Strother, MD
Assistant Professor, Director,
Undergraduate and Emergency
Simulation, Mount Sinai School of
Medicine, New York, NY
Brent R. King, MD, FACEP, FAAP,

FAAEM
Professor of Emergency Medicine
and Pediatrics; Chairman,
Adam Vella, MD, FAAP
Department of Emergency Medicine, Assistant Professor of Emergency
The University of Texas Houston
Medicine, Director Of Pediatric
Medical School, Houston, TX
Emergency Medicine, Mount Sinai
Robert Luten, MD
School of Medicine, New York, NY
Professor, Pediatrics and
Michael Witt, MD, MPH, FACEP,
Emergency Medicine, University of
FAAP
Florida, Jacksonville, FL
Medical Director, Pediatric
Ghazala Q. Sharieff, MD, FAAP,
FACEP, FAAEM
Associate Clinical Professor,
Childrens Hospital and Health
Center/University of California;
Director of Pediatric Emergency
Medicine, California Emergency
Physicians, San Diego, CA
Emergency Medicine, Elliot Hospital

Manchester, NH
Research Editor
Lana Friedman, MD
Fellow, Pediatric Emergency
Medicine, Mount Sinai School of
Medicine, New York, NY
Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Lumba, Dr. Conrad, Dr. Sharieff, Dr. Mannick, Dr. Wiebe,
and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Case Presentation
A 3-year-old female presents to your ED with the chief
complaint of diffuse abdominal pain and nonbloody,
nonbilious vomiting over the past 2 days. Her mother tells
you that, after vomiting, the child becomes lethargic and
lies still in pain. These events are self-limited, lasting
a few minutes. The patient is otherwise healthy and has
been afebrile without diarrhea. On physical examination,
the child appears well and is interactive but is somewhat
listless. She has no fever and, except for a heart rate of up
to 115 beats per minute, her vital signs are within normal
limits. Auscultation of her abdomen indicates normoactive bowel sounds. Her abdomen is soft and distended,
with mild diffuse tenderness. A fecal occult blood test
comes back positive. Her intermittent abdominal pain
raises your suspicion for possible intussusception, which
is suggested by the presence of occult blood in the stool.
With many imaging modalities available, as well as consultants on hand, you suspect youll be able to confirm or
confidently rule out this diagnosis.
Introduction
The possibility of bleeding from the LGI tract in
a young child causes anxiety for the childs family. The general emergency clinician may find this
presentation daunting, since the differential diagnosis of LGI bleeding includes numerous agespecific disorders not found in the adult population.
Many emergency clinicians do not feel comfortable
discharging the pediatric patient with recent LGI
bleeding, and disposition can present a challenge.
By assessing for age-specific pathologies and obtaining a thorough clinical history and examination, the
emergency clinician will narrow diagnostic choices,
thereby optimizing management and further care of
the pediatric patient with LGI bleeding.

This issue of Pediatric Emergency Medicine Practice will review the common differential diagnoses
of LGI bleeding in children younger than 5 years of
age, relying on the best available evidence from the
literature. In particular, it will focus on the challenge
of evaluating and managing the pediatric patient
with intussusception. The emergency clinician will
be able to apply clinically appropriate guidelines regarding diagnosis and treatment in an effective and
patient-specific manner.
Critical Appraisal Of The Literature

A large number of articles have been published
regarding outcomes in patients with intussusception
who were treated with various modalities; specifically, hydrostatic and pneumostatic reduction and
surgery. Much of this research involved retrospective
cohort studies. This review focuses on these findings
in detail.
Pediatric Emergency Medicine Practice 2012 2

An extensive search of the literature on pediatric LGI bleeding and intussusception between 1970
and 2011 using Ovid MEDLINE and PubMed was
conducted. Keywords included pediatric GI bleeding,
intussusception, Meckel diverticulum, bowel malrotation,
milk-protein sensitivity, milk-protein allergy, pediatric
GI hemorrhage, blood per rectum, inflammatory bowel
disease, necrotizing enterocolitis, GI arteriovenous malformation, and pediatric rectal/anal trauma. The search
was limited to studies involving persons between 0
and 18 years of age.
Epidemiology And Etiology

Lower Gastrointestinal Bleeding
Lower gastrointestinal bleeding refers to blood

loss that occurs in locations distal to the ligament
of Treitz in the duodenum. A report from Boston
Childrens Hospital in the early 1990s showed that
rectal bleeding was a presenting complaint in 0.3%
of pediatric patients who visited the ED within a
1-year period.1

The causes of LGI bleeding in children are best
categorized according to age at presentation, although these groupings do overlap. Common etiologies of LGI bleeding are shown in Table 1. Causes
of LGI bleeding in developed countries differ from
those seen worldwide because of variations in the
prevalence of infectious diseases.

In children 5 years of age or younger, LGI bleeding is caused by infectious agents, venous and other
anatomic malformations, trauma, colitis, Meckel
diverticulum, or intussusception. (See Table 1.) The
most common cause of LGI bleeding in children 5
years of age and younger is anal fissures, which are
identified on physical examination.2

Malrotation is a congenital anomaly that occurs due to incomplete rotation and fixation of the
gut during intrauterine development. It is found
in 1 in 500 live births.3 This congenital abnormality
should be considered when LGI bleeding occurs in
the child with volvulus accompanied by obstruction
and bowel necrosis. Forty percent of children with
malrotation will present during the first week of life,
and up to 80% present before they reach 1 year of
age.4

In the newborn, milk-protein allergy is a common cause of allergic proctocolitis with rectal
bleeding. The median age of onset in cows milkprotein-sensitive enteropathy is 3.5 months.5 Allergic proctocolitis may present with hematemesis;
mucoid, bloody diarrhea; and/or chronic, watery
diarrhea. Given the allergic nature of this disease
process, infants who are solely breast-fed will present with symptoms later than formula-fed infants.5
When a massively bloody stool is evident, other
serious etiologies such as necrotizing enterocolitis or
malrotation should be investigated.6
www.ebmedicine.net January 2012

Infectious causes of LGI bleeding include Campylobacter, Shigella, enteroinvasive and enterohemorrhagic Escherichia coli, Salmonella, Yersinia, Clostridium
difficile, and Entamoeba histolytica. These pathogens
cause direct injury by attaching to and invading the
epithelium and mucosa, with subsequent stimulation of the leukocyte inflammatory response.7 C
difficile is known to give rise to pseudomembranous
colitis. Allergic proctocolitis due to milk-protein
sensitivity occurs via an IgE-mediated inflammatory
response.8

Trauma can cause LGI bleeding in the pediatric
population. Blunt and penetrating injuries to the abdomen can present with hematochezia. Sexual abuse
must be considered in a young patient with evidence
of anal trauma.9 Trauma to the bowel wall upon
straining or during passage of a hard stool or with
the introduction of a foreign body can result in rectal
bleeding. Even the seemingly innocuous insertion of
thermometers or enemas can cause rectal perforation
in the newborn.10,11 In addition, structures such as
polyps or venous malformations may bleed spontaneously upon trauma by passing stool.

Inflammatory bowel disease (IBD), such as
Crohn disease or ulcerative colitis, is rare in young
children but can result in LGI bleeding. The incidence of IBD in children is reported to range from
1.1 to 2.4 per 100,000 and appears to be increasing.
Fifteen percent of all diagnoses of IBD are made in
children younger than 6 years of age.12 The majority of pediatric patients with IBD (56%) are diagnosed with Crohn disease.13 Defective host mucosal
immune cells incite an inappropriate response to
microbial antigens, leading to inflammation and
ulceration.14 In ulcerative colitis, the inflammation
and ulceration are limited to the colonic mucosa,

almost always involve the rectum, and might extend
proximally. Crohn disease can occur anywhere
in the gastrointestinal (GI) tract, with transmural
ulceration and granuloma formation, and is known
to skip bowel segments, resulting in patchy areas of
disease.7
Intussusception
Intussusception is an important cause of occult or

gross LGI bleeding in the pediatric patient. Eighty
percent of children who present with intussusception
are 2 years old or younger, with the majority of cases
occurring in infants between 5 and 10 months of age.
The incidence of childhood intussusception is estimated to be 1 in 2000 live births in the United States,15
and a study from Australia cites an incidence of 1
out of 1450 pediatric ED visits.16 The ratio of occurrence in males to females is 3:2. There is no consensus
regarding the seasonality of this disorder.15,17

Intussusception is the leading cause of intestinal
obstruction in children 5 months to 3 years of age.18,19
It is also one of the most common causes of acute
abdominal emergency in young children.20,21 Morbidity and mortality are associated with the time to
diagnosis and the efficacy of management. In 2007,
Kaiser et al noted that symptoms lasting longer than
24 hours, as compared with those of shorter duration,
were associated with a greater need for surgery (73%
vs 45%; P < 0.001) and bowel resection (39% vs 17%;
P = 0.001).22 In the United States, mortality due to
intussusception is approximately 1% among children
who received an early diagnosis, fluid resuscitation, and therapy.23,24 Parashar et al reported that
intussusception-associated infant mortality rates were
2.3 per 1,000,000 live births during 1995-1997, with a
greater risk of dying among infants whose mothers
were younger than 20 years of age, nonwhite, and
unmarried, with an education level below grade 12.15
Intussusception is rare in adults, accounting for only
5% to 16% of reported cases.25

The causes of intussusception, both known and
postulated, are varied. Up to 90% of cases, particularly in young children, are idiopathic, and a clearly
identifiable origin or specific disease process cannot
be detected.20,26 The most common cause of intussusception is thought to be hyperplasia of ileal lymphoid
tissue (Peyer patches), which leads to telescoping of
the intestine.19,27 Such enlargement may be due to a
previous infection or may be a reaction to the intussusception itself.26,28 Ileal lymphoid hyperplasia has
also been associated with milk-protein allergy.29

In most children older than 5 years of age with
intussusception, a precipitating factor can be identified. Similarly, in infants younger than 3 months of
age, congenital anomalies such as Meckel diverticulum are often the cause.30 In all pediatric age groups,
Meckel diverticulum and polyps are the most
Table 1. Common Causes Of Lower

Gastrointestinal Bleeding By Age
Etiology
0 to 2
Months
> 2 Months
to < 2
Years
2 Years
to 5 Years
Anal fissures
Acute gastroenteritis
Intussusception
Necrotizing enterocolitis
Trauma
Coagulopathy
Hemorrhagic disease of the

newborn
Milk-protein allergy
Swallowed blood
Arteriovenous malformations x
Meckel diverticulum
Polyps
January 2012 www.ebmedicine.net
Pediatric Emergency Medicine Practice 2012
common pathologic lead points to cause intussusception.30 Both these conditions are also among the
lengthy differential diagnoses to be considered when
a child presents to the ED with LGI bleeding.
Pathophysiology
The pathophysiologic basis of all cases of LGI bleeding is mucosal insult via direct trauma, infectious insult, immunologic insult, or malformation. Mucosal
lesions are the most common cause of LGI bleeding
pathology, occurring due to irritation and inflammation of the intestine.
Risk Factors For Lower Gastrointestinal Bleeding
The risk factors for LGI bleeding in young children
are directly related to the potential etiologies. Most
obvious among these are coagulopathies or anatomic anomalies of the GI tract that would predispose to
disease. See Table 2 for risk factors for LGI bleeding.
Intussusception
Intussusception is an invagination, or telescoping, of a

segment of proximal bowel (the intussusceptum) into
an adjacent bowel segment (intussuscipiens). Abnormalities in the continuity of the gut mucosa, termed
lead point, create an area of traction in the bowel allowing for telescoping to occur and hindering synchronous peristalsis.31 Such discontinuity can be intramural, intraluminal, or extraluminal. The most frequent
site of intussusception is the terminal ileum.32

When the mesentery of the intussusceptum is
confined and compressed within the intussuscipiens, resulting venous congestion leads to edema
and ischemia. This edema can result in partial to
complete obstruction, perforation, and peritonitis.
Intussusception is the most common cause of smallbowel obstruction in children 3 months to 6 years of
age.19,20,33 Such insult to the mucosa can manifest as
LGI bleeding. Studies have shown that hematochezia is a presenting symptom in two-thirds of patients
with intussusception.23

Classically, the stool contains blood and mucus,
resembling redcurrant jelly.34 In 1997, Yamamoto
et al reported that 59% of children with intussuscep-
Table 2. Risk Factors For Lower

Gastrointestinal Bleeding

Anticoagulant use
Arteriovenous malformation
Polyps
Constipation
Coagulopathy
Prematurity
tion had hematochezia and 13% had redcurrant jelly

stool.34 Historically, redcurrant jelly stool is considered to be pathognomonic of intussusception; however, hematochezia and occult bleeding are much
more common.
Risk Factors For Intussusception
Although 90% of cases of intussusception in young
children are idiopathic, many risk factors can predispose to this disorder. Risk factors include:
Young age: Children between the ages of 6
months and 3 years are at much higher risk for
intussusception than adults. There is no familial
risk for this disorder. Intussusception in adults
is rare.
Previous disease: Children in whom intussusception was previously treated with surgical reduction are at risk for recurrence. Among those
treated with nonsurgical types of reduction,
there is a 10% recurrence rate.32
Viral illness: Children with a recent viral illness,
such as adenovirus or rotavirus infection, are at
a greater risk for intussusception, possibly due
to lymphoid hyperplasia in the GI tract. Mesenteric lymphadenitis is also a precipitating factor.
GI infection: Infection with parasites such as
Ascaris lumbricoides can lead to intussusception
secondary to heavy worm-loads.35
Vaccination status: Prior to the availability of
the Rotateq vaccine, children who received
the rhesus rotavirus tetravalent vaccine (RRTV,
Rotashield) were at greater risk for intussusception. Moreover, the patients affected
were younger and had higher rates of surgical
intervention than patients with intussusception who did not receive the vaccination.4,36 A
case-control analysis showed an attributable risk
of 1 in 9474 infants vaccinated.37,38 In July 1999,
less than 1 year after the license for this vaccine
was approved, the Centers for Disease Control
and Prevention and the American Academy of
Pediatrics suspended their recommendations to
administer this vaccine. In a 2006 study published in the New England Journal of Medicine, the
current pentavalent human bovine reassortment
rotavirus vaccine was shown to pose a risk of intussusception similar to that posed by placebo.39
Henoch-Schnlein purpura (HSP): Children
with HSP are at higher risk for intussusception
because of the formation of small-bowel hematomas. Major GI complications ensue in 5% of
pediatric patients with HSP, with intussusception being the most common.40
Cystic fibrosis: Patients with cystic fibrosis are
at higher risk for intussusception because inspissated stool with ileus can function as a lead
point/pathologic apex.41
Physical anomalies: Malrotation, intestinal
Prehospital Treatment
polyps, Meckel diverticulum, duplication cysts,

inverted appendiceal stumps, and colon cancer
can cause intussusception.42
Iatrogenic factors: As part of clinical care,
gastrojejunostomy, feeding tubes, and abdominal adhesions from previous operations may
become iatrogenic causes of intussusception.30
Malignancy: The presence of leukemia or lymphoma increases the risk for intussusception
because of possible lymphoid hyperplasia.
Prehospital treatment of LGI bleeding begins with

the initial evaluation of airway, breathing, and circulation. If a patient has lost a significant amount of
blood, he will show signs of shock such as tachycardia or hypotension. Intravenous (IV) fluid resuscitation should be started in cases in which the patient is
hypotensive, especially if ongoing blood loss is suspected. Prior to arrival in the ED, emergency medical services (EMS) staff and community physicians
must monitor blood pressure and heart rate while
the patient is being resuscitated. An assessment of
shock severity will aid in the resuscitative effort and
indicate whether intensive care unit (ICU) admission
will be required. Prehospital providers must communicate with the accepting medical facility before
transfer to confirm whether the facility can provide
pediatric intensive care, especially if hemorrhagic
shock is suspected.
Differential Diagnosis
The differential diagnoses in LGI bleeding in the

pediatric patient have been discussed in the Epidemiology And Etiology section, page 2. Nonetheless,
it is important to consider in the differential diagnosis causes unrelated to the GI tract, such as coagulopathy, vasculitis, trauma, the presence of a foreign
body, and the ingestion of substances that mimic the
appearance of blood. In young patients, coagulopathy may be the initial presentation in cases of LGI
bleeding.43-45
Vitamin K deficiency associated with hemorrhagic disease of the newborn is an early and
dramatic example of LGI bleeding unrelated to
the GI tract.
Idiopathic thrombocytopenic purpura can present with bruising and ecchymosis in addition to
GI bleeding.46
Patients with hemophilia are more likely to present with hemarthrosis, and GI bleeding is also a
possible presentation.47-49 In hemophilia A and
B, correction of factor deficiencies may be initiated in the ED.
Vasculitides, such as polyarteritis nodosa and
Sjgren syndrome, may present as GI hemorrhage due to mesenteric ischemia.50-52 In a
study that evaluated systemic vasculitis, 16% of
patients presented with GI bleeding.53
The use of certain medications and ingested substances can mimic the findings in rectal bleeding. For example, bismuth-containing medications and charcoal ingestion may be mistaken
for melena.
Red foods, vaginal bleeding, gross hematuria,
and lesions of the buttocks can falsely present as
hematochezia, especially on a diaper.
The ingestion of red meat, turnips, horseradish,
or vitamin C may be responsible for a false-positive result on the fecal occult blood test.
Emergency Department Evaluation

Although LGI bleeding is a relatively uncommon occurrence in children, presentations to the ED require
expertise in its management. In a cornerstone study
of almost 600 children by Bruce et al in 1987, 37%
had blood in their stool at the time of presentation.56

Intussusception should be suspected in the
young child who is lethargic with colicky abdominal
pain, vomiting, and LGI bleeding. The clinical triad
of intermittent abdominal pain, abdominal mass,
and redcurrant jelly stool at presentation is evident
in less than 50% of cases of intussusception.30,53 The
third sign of this triad redcurrant jelly stool will
be found in 100% of untreated cases as the bowel
becomes more edematous and intraluminal pressure
is increased.1,34
History
Obtaining details regarding the duration and

frequency of observed bleeding will differentiate
chronic from acute bleeding. The emergency clinician should ask about the quality and quantity of
stools and bowel movements. The number of bloody
bowel movements per day is important in order
to assess ongoing blood loss and the potential for
anemia. Hard stools or constipation suggests anal
fissure, bleeding hemorrhoids, or polyps. Gastrointestinal bleeding can also occur with fecal impaction
and subsequent obstruction. Bloody, mucoid diarrhea may be seen with acute gastroenteritis due to
infection with Campylobacter, Salmonella, Shigella, or
some strains of E coli.

The presence or absence of abdominal pain associated with LGI bleeding aids in diagnosis. Colicky
abdominal pain occurs in intussusception in 50% to
80% of cases,54-56 and 70% of these patients present
Intussusception
The differential diagnosis of intussusception is similar to those described for LGI and inclusive to all the
etiologies of LGI bleeding. See Table 1, page 3 for
causes of LGI bleeding in children, by age.
with gross or occult GI bleeding.57 Painful bleeding

is common in IBD, necrotizing enterocolitis, intussusception, and anal fissures. In general, bleeding
will be painless in the case of polyps, swallowed
blood, arteriovenous malformations, and milk-protein allergy. Meckel diverticulum can present with
voluminous blood loss in the absence of pain. Painless bleeding is not likely to be infectious in origin.58

The quality of the abdominal pain is also important to assess. It is useful to ask the patient or
parents to describe the pain. Pain that resolves upon
defecation is more common with IBD, whereas pain
that increases with bowel movements may be due to
hemorrhoids or anal fissures.

The location of abdominal pain can lend to specific diagnosis as well. Epigastric pain is typical of
gastritis and esophagitis.

It is important to quantify and qualify any history of vomiting. Vomiting is a common occurrence
in any GI disorder that results in partial or complete
obstruction. Bilious vomiting is suggestive of an
upper GI obstruction, such as one occurring at the
Ligament of Treitz. Acute and protracted vomiting
may be seen in children with acute gastroenteritis.

Fever is suggestive of infectious or inflammatory processes such as acute gastroenteritis, IBD, or
necrotizing enterocolitis.

A history of medication use must be reviewed
since some of the effects of certain medications may
mimic melena or hematochezia once the drug is digested. For example, the ingestion of ampicillin, iron
supplements, and bismuth subsalicylate may give
a false impression of melena. Medications such as
anticoagulants and nonsteroidal anti-inflammatory
drugs (NSAIDs) can also pose a risk for GI hemorrhage. Similarly, with the ingestion of dark-colored
or brightly colored foods such as beets, chocolate,
gelatins, or beverages, the stool may appear to contain blood on gross examination.59,60

A history of weight loss or failure to thrive
suggests chronic underlying disease. Weight loss
my indicate malignancy, IBD, cystic fibrosis, or
Hirschsprung disease. Acute onset of fatigue, near
syncope, or syncope may signal an acute blood loss.

The age of the child at presentation can help
clarify the diagnosis. For example, a newborn that is
breastfeeding from a mother with mastitis may have
swallowed maternal blood, or a newborn who was
born at home may not have received vitamin K at
birth.
Physical Examination
A thorough physical examination, including the

requisite evaluation of airway, breathing, and circulation, will indicate the childs hemodynamic status.
Signs of poor perfusion, such as weak peripheral
pulses with cool extremities, slow capillary refill,
and tachycardia suggest diminished intravascular
volume due to dehydration and bleeding. According

to the American Heart Association and the Pediatric
Advanced Life Support Guidelines, children will
manifest hypotension with an intravascular volume
loss of 30%.61 Hypovolemic pediatric patients can
maintain normal blood pressure through increases
in systemic vascular resistance, cardiac contractility,
and heart rate. These compensatory mechanisms
may make it very difficult for the clinician to identify a patient in compensated shock due to blood loss
until a significant blood volume has been lost.

The following findings on physical examination
will help narrow the diagnosis in LGI bleeding:
Nose and oral cavity: Inspect the nostrils for
dried blood suggestive of epistaxis from trauma,
coagulopathy, or spontaneous bleeding. Look
for oral lesions that may be associated with mucositis or polyposis syndromes such as PeutzJeghers syndrome.
Neck: Lymphadenopathy can be present in cases
of infection or malignancy.
Skin: Purpura and extensive bruising may indicate coagulopathy, sepsis, or trauma. Pallor can
reflect chronic blood loss.
Abdomen: A distended, tender abdomen can
reflect obstruction, perforation, trauma, or
peritonitis. Organomegaly or an abdominal
mass may represent intussusception, hepatitis,
or malignancy. Splenomegaly would raise the
possibility of variceal hemorrhage from portal
hypertension.
Genitourinary tract and rectum: Be thorough
and sensitive with respect to examining these
sites in the pediatric patient. A parent or guardian as well as a nurse should be present during
the examination. The patient should be examined in both the supine and prone positions to
allow adequate visualization of the genitalia
and anus.62 A careful examination may reveal
frank fissures or hemorrhoids and can help
confirm urinary or vaginal lesions, rather than
the GI tract, as the source of blood noted on
a diaper. Increased rectal tone might suggest
Hirschsprung disease, which can present as enterocolitis. If there is a suspicion of sexual abuse,
a more specialized examination is warranted.
Intussusception
Intussusception is not a likely diagnosis in children

over 3 years of age and is rare in children older than
age 5. In 10% to 20% of children who do have intussusception, diarrhea will be present, and vomiting
occurs 60% to 80% of the time.54,58 Children with
intussusception may also have a fever, the causes
of which are varied and include Henoch-Schnlein
purpura, viral infections, and possible bowel perforation and/or bowel necrosis.
Diagnostic Studies
enterocolitis.

Computed tomography (CT) can be useful for
identifying abscesses or fistulae associated with IBD.
Magnetic resonance imaging (MRI) is not applicable
in the setting of acute GI bleed because it is not as
easily obtained emergently, nor is it therapeutic.

Tissue biopsy is used to assess the patients immune response and to identify infectious organisms,
nerve plexuses, and smooth-muscle distribution. In
allergic proctocolitis due to milk-protein allergy, the
biopsy will show eosinophilic infiltration. This information would not be accessible in a timely fashion
to the emergency clinician and is more useful in the
inpatient setting to definitively identify proctocolitis
or Hirschsprung disease.

Endoscopy can localize the site(s) of bleeding
and identify lesions, growths, and malformations. It
can also be therapeutic in the case of polyps or arteriovenous malformations. The findings on colonoscopy that are associated with milk-protein allergy
include friable mucosa with erythema and erosions.
Laboratory Tests
Laboratory tests provide a tool to aid in patient

stabilization and in distinguishing potential etiologies. Most laboratory tests do not allow a definitive
diagnosis, however, and management decisions
should therefore be based on clinical examination
and diagnostic imaging.

The white blood cell count can show leukocytosis with infection as well as inflammatory processes,
and it is therefore nonspecific. Anemia occurs as a
result of chronic blood loss. Hematocrit may remain
stable in the setting of acute bleeding, but it is valuable as a baseline for serial measurements when
blood loss persists. Thrombocytopenia is seen in
Henoch-Schnlein purpura, which can be a cause of
intussusception. Coagulopathies themselves can be
the cause of GI bleeding. Eosinophilia may be present and represents an allergic component to disease
such as with milk-protein sensitivity. Likewise,
serum IgE may be elevated. Nonetheless, both these
findings are nonspecific.63

Blood urea nitrogen (BUN) is elevated in cases
of dehydration and may also be elevated with GI
bleeding owing to the breakdown of red blood cells
in the digestive tract. A fecal occult blood test will
differentiate real from factitious bleeding and is
useful in patients with a history of hematochezia or
suspected GI bleeding. Stool culture will identify
common bacterial infections that contribute to hemorrhagic gastroenteritis, which is part of the differential diagnosis for intussusception.
Intussusception Imaging Studies
Ultrasonography is an excellent imaging modality for diagnosing and assessing intussusception

because of its high sensitivity (97%-100%) and high
specificity (88%-100%) in detecting this disorder.64
Many institutions currently use ultrasound as a
first-line evaluation of LGI bleeding.65 A 7-year retrospective evaluation of ultrasound in patients with
intussusception showed a positive predictive value
of 86.6% and a negative predictive value of 99.7%.59

Ultrasound imaging allows for the visualization of lead points that would make intussusception more likely. The typical appearance of intussusception on ultrasound is the target sign (also
described as a bulls eye or coiled spring). This
sign reflects bowel loop invagination. However, a
similar donut sign may persist after therapeutic
reduction, which can make the diagnosis problematic. Donut signs are smaller than target signs and
have a single hyperechoic rim that is hypothesized
to represent edema of the ileocecal valve. These
suspicious intestinal structures resolve within 5 days
after reduction of intussusception.66

The use of enemas in conjunction with ultrasound for identifying intussusception as a cause of
LGI bleeding can also be used as therapy for this
disorder. (For specific information about the use of
ultrasonographic imaging during treatment, see
the section on Treatment of Intussusception, page
9.) This diagnostic test is contraindicated if perforation is suspected.

Abdominal radiographs can be an adjunct to
diagnosis in intussusception, although with a sensitivity of 45%, they are not as sensitive as ultrasonography. Radiographs are useful for detecting the
absence of bowel gas in the right upper quadrant as
Lower Gastrointestinal Bleeding Imaging

Studies
A variety of diagnostic studies can aid in determining the cause of suspected LGI bleeding in the
pediatric patient. By selecting appropriate imaging
modalities, the emergency clinician will minimize
exposure to radiation and effectively make the diagnosis. See Table 3, page 8 for a complete guide to
the preferred imaging procedures.

The abdominal radiograph is a common imaging modality that clinicians often order in the evaluation of pediatric LGI bleeding. It is useful in the
diagnosis of necrotizing enterocolitis by identifying
pneumatosis intestinalis and thickened bowel loops.
However, obstructions that may be seen on an x-ray
do not generally cause sudden GI bleeding, and
plain films are of limited value in the evaluation of
bleeding.

An upper GI series can be useful in the diagnosis of malrotation, duodenal atresia, and suspected
obstruction; however, it is not helpful for detecting
intussusception.7 A few reports have shown rectosigmoid and duodenojejunal narrowing to be associated with milk-protein allergy and associated allergic
well as the presence of a crescentic air pocket, which

represents the negative space between intussusceptum and intussuscipiens. The University of Montreal
recently studied radiographs in patients with intussusception by pediatric emergency clinicians. The
study showed that abdominal radiography supplemented the clinical suspicion for intussusception in
48% of actual cases (low sensitivity) and in 21% of
negative cases (low specificity); 41% of cases of con-
firmed intussusception were deemed equivocal, and

11% were incorrectly interpreted as being reassuring.

Abdominal CT can also be used to diagnose
intussusception. Diagnosis of intussusception by CT
is often incidental when such imaging was obtained
to evaluate for other causes of abdominal pain.
Computed tomography is not the test of choice to
diagnose intussusception because of its associated
radiation and lack of therapeutic functionality.
Table 3. Common Imaging Modalities In Lower Gastrointestinal Bleeding And Intussusception

Imaging Modality
Uses
Abdominal radiographs
Useful in
Pneumatosis intestinalis
Obstruction
Free air
Limited in
Identification or quantification of bleeding
Diagnosis of intussusception not sensitive (45%)67 but may show absence of bowel in the right upper quadrant or a crescentic air pocket suggestive of the negative space between intussusceptum and intussuscipiens68
Upper gastrointestinal series
Useful in
Milk-protein allergy
Enterocolitis
Malrotation
Duodenal atresia
Obstruction
Limited in intussusception
Barium or hydrostatic enema
Useful in both diagnosis and therapy of intussusception

Barium enema
Requires x-ray fluoroscopy
Poses risk of barium peritonitis and adhesions with perforation69
Hydrostatic enema
Uses a water-soluble medium or saline
Accompanies ultrasound
Causes fluid and electrolyte shifts, with perforation
Air-contrast enema
Poses lower radiation exposure

Results in fewer complications from perforation70,71
May cause tension pneumoperitoneum
Ultrasonography
Useful in diagnosing intussusception

Reveals target sign
Modality of choice for therapeutic reduction
Computed tomography
Useful in
Abscesses or fistulae
Intussusception (although not the test of choice)
Limited by radiation exposure
Magnetic resonance imaging
Not applicable in the setting of acute gastrointestinal bleeding

Not easily obtained
Not therapeutic
Mucosal biopsy
Useful in
Detecting immune response
Detecting infection
Identifying nerve plexus for underlying disorders such as Hirschsprung disease
Assessing smooth muscle distribution
Endoscopy/colonoscopy
Useful in
Bleeding
Localizing lesions, growths, and malformations
Therapy
Treatment

Radiation exposure is lower with pneumatic aircontrast enema than with barium enema. The rates
of complications and sequelae due to perforation
with use of air-contrast enema are also lower when
compared with other reduction media.76 Tension
pneumoperitoneum is a rare, but significant, complication that must be kept in mind if air-contrast
reduction is selected.77

Numerous studies have been conducted to
evaluate and compare the benefits of various reducing agents. Hydrostatic reduction has been associated with a more constant colonic pressure when
compared with air reduction, suggesting that pneumatic reduction may result in a lower reported risk
of perforation.61 However, del-Pozo suggests that
the differences in perforation rates between these 2
types of enemas may be related to perforations that
occurred prior to reduction therapy and subsequent
increased pressure in the colon rather than to the
type of enema used.64 Overall perforation rates after
hydrostatic or air-contrast enemas have been reported to be 1% or less.68

An important consideration in pediatric patients
is the need to limit or avoid radiation exposure.
Radiation exposure is lower with air-contrast enema
reduction than with barium enema reduction and
is absent in ultrasound-guided enema reduction.
Although intussusception having a lead point is
not likely to be reduced by means of an enema, the
responsible lesion may be seen on fluoroscopy or
ultrasonography, thus aiding further management.27

The rates of intussusception recurrence with
all types of nonsurgical reduction range between
5% and 20%. According to Bajaj, recurrence rates of
enema-reduced intussusception are approximately
10%.32 Fifty percent of all recurrences occur within
48 hours of the initial reduction.79 Multiple recurrences occurred in approximately one-third of these
patients. In a study by Gonzlez-Spnola and delPozo, the rate of intussusception recurrence after
ultrasound-guided hydrostatic enema was 9.7%;
however, a delayed repeat attempt at reduction after
a period of rest increased the likelihood of success
without increasing the risk for perforation.79 Recurrence rates with barium enema were 11%, as compared with 8% with air-contrast enema. In 2007, Ko
reported that, unlike surgery, enema reduction is not
contraindicated when there are multiple recurrences.78 In fact, surgery is recommended only when recurrence of intussusception is irreducible or when a
pathologic lead point is identified.71 Surgery would
also be the treatment of choice in cases of perforation and peritonitis. The current literature indicates
a strong consensus for attempting enema reduction
even for intussusception recurrence in straightforward cases before resorting to surgical correction.
In the large majority of cases, pediatric LGI bleeding

does not lead to hemodynamic instability and can
be managed on an outpatient basis.1 However, if the
child is found to be hemodynamically unstable, 2
large-bore IV catheters should be placed to deliver
the appropriate fluid and blood products for resuscitation. If immediate IV access is not available, intraosseous lines should be placed to provide access
for fluid administration. Crystalloid fluid boluses
should be administered in increments of 20 mL/kg
to a total of 60 mL/kg within the first hour, with frequent reassessments between administrations. Blood
transfusion may be necessary to ensure adequate
blood oxygen-carrying capacity; blood is typically
administered in 10-mL/kg boluses.

Coagulopathies should be identified and corrected. Once a cause for the bleeding has been determined, surgical treatment or hospital admission for
monitoring may be necessary, especially if there is
clinically significant ongoing blood loss.
Intussusception
The treatment of intussusception consists of initial

stabilization, rehydration, and reduction. Often,
reduction is successful by means of enemas, with the
use of barium, water-soluble contrast media, water,
saline, or air as the reducing agent. Irreducibility
by means of enema reduction can be determined by
indicators of bowel ischemia on ultrasonography,
such as trapped fluid or the absence of blood flow
on Doppler scanning.

Nonsurgical methods for reducing intussusception include pneumatic air reduction, barium
enema reduction, and hydrostatic enema reduction
with water-soluble contrast. Ultrasound-guided
hydrostatic reduction of intussusception in children is ideal in that there is no risk of radiation, the
procedure is cost-effective, the complication rate is
low, and there is a high success rate in appropriately
selected patients.72 The presence of peritonitis is a
contraindication to nonsurgical reduction; however,
this condition is not likely to be confirmed by plain
radiographs prior to enema therapy. Ultrasonography with Doppler imaging may provide this valuable information.

Both barium and hydrostatic enema reductions are associated with few complications and are
considered safe.73,74 Barium enema therapy requires
x-ray fluoroscopy and therefore carries a risk of
barium peritonitis and adhesion formation if perforation occurs during reduction.75 Hydrostatic enemas with water-soluble media or saline can be used
in conjunction with ultrasound. Since hydrostatic
reduction does not require fluoroscopy, exposure to
radiation is not a concern.
Risk Management Pitfalls For Lower Gastrointestinal Bleeding

1. The 6-month-old patient had a vague history
of colicky abdominal pain, but he appeared
well in the ED. This looked like a milk-protein
allergy.
Intussusception classically presents with colicky
abdominal pain, and the patient may appear
well between painful episodes. A positive fecal
occult blood test can support a suspicion of
intussusception, although it may also be positive
in the child with milk-protein allergy. History is
an important tool in narrowing the differential
diagnosis. Milk-protein allergy is not likely to
begin acutely in this older patient. Ultrasound
should be used to diagnose intussusception.
Observation in the ED may also be warranted if
ultrasound is unavailable, and it may be helpful
in deciding whether to obtain a CT scan, which
would expose the patient to radiation.
2. The 10-year-old patient had colicky abdominal pain, but she was too old to have intussusception.
Although intussusception is most common in
younger patients, it can occur at any age. The
incidence of intussusception associated with a
pathologic lead point increases with age.
3. Intussusception in the 3-year-old patient was
successfully reduced, and though she appeared
well, I decided to admit her for observation,
since 50% of recurrences occur in the first 48
hours.
Hospital admission is not indicated in the easily
and successfully reduced case of idiopathic
intussusception if, after a period of observation
in the ED, the patient returns to baseline status
and tolerates oral intake without vomiting
or pain. Hospital admission to monitor for
recurrence after a simple reduction in the wellappearing patient is not warranted and imposes
significant costs on the healthcare system.
Family counseling must be given, as well as
clear discharge instructions regarding returning
to the ED in the event of abdominal pain,
vomiting, or bloody stools.
4. The patient had frank hematochezia, but

it didnt resemble redcurrant jelly stools, so
intussusception was lower on my differential.
Although it is considered the classic
presentation, intussusception does not
commonly present with redcurrant jelly stools.
Frank hematochezia is a presenting sign in about
60% of cases of intussusception.
5. Though this patient appeared well, the stools
were grossly bloody, which warranted an indepth work-up.
Many food products and medications may
give the false appearance of bloody stools. The
presence of blood should be confirmed with a
fecal occult blood test prior to initiating further
evaluation in the stable patient.
6. I thought my patient had intussusception,
but her abdomen was tender and it was more
efficient to obtain a CT scan to rule out other
possible GI pathologies, like appendicitis.
Ultrasonography is a sensitive and specific
imaging modality for intussusception. If
available, an ultrasound examination will spare
the patient exposure to the radiation from a
CT scan. If the ultrasound result is negative or
inconclusive, CT would be the next option.
7. It was the middle of the night and the ultrasound technician wouldnt be available for another 4 hours. Although I thought the patient
had intussusception, he appeared well, so I
waited until the tech arrived.
Ultrasonography is the best imaging choice
for diagnosing intussusception and will avoid
unnecessary radiation exposure from CT.
However, a delay in diagnosis and therapeutic
reduction can increase the risk for complications.
If ultrasound is unavailable and you suspect
intussusception, a CT scan should be obtained.
Special Circumstances
Controversies And Cutting Edge
Henoch-Schnlein purpura is a form of vasculitis

that can directly contribute to LGI bleeding. It may
also indirectly cause LGI bleeding when hematomas
form in the wall of the small bowel, acting as lead
points for intussusception and subsequent bleeding. Intussusception associated with HSP typically
occurs after the resolution of HSP-associated abdominal pain. In some circumstances, bleeding can
be massive and constitutes the main presenting sign
of this disorder.80

The pediatric oncology patient is at risk for
chemotherapy-induced mucositis, steroid- and
stress-induced bleeding ulcers, and chemotherapyor cancer-related liver damage all of which predisposes to bleeding esophageal varices. Immunosuppression with coexisting coagulopathies will further
contribute to bleeding. For these reasons, admission
and close monitoring of the child with cancer who
presents with LGI bleeding is recommended.

Child abuse is a serious concern in the pediatric
population and can cause LGI bleeding. Unreported
or unevaluated blunt abdominal trauma that occurred several days prior to presentation should
raise concern about possible hematoma formation.
Penetrating injuries should be considered, and a
thorough physical examination is in order for any
child with rectal pain or bleeding.

Premature infants may have immature gut colonization, poor feeding tolerance, and aberrant GI
motility. They are also at higher risk for necrotizing
enterocolitis, which can result in significant morbidity and mortality.

Children born at home are at risk for hemorrhagic disease of the newborn if they have not been
given vitamin K postpartum. This condition may
present as GI hemorrhage.

There are circumstances that may lead to a false
diagnosis of LGI bleeding. Examples include the use
of medications or the ingestion of certain foods that
can cause the stool to appear bloody. Brisk upper GI
bleeding can present as rectal bleeding. Ingestion of
blood from epistaxis or swallowed maternal blood
during the birthing process can cause fecal-occultpositive stools. A common scenario in the pediatric
ED involves an otherwise healthy 3-day-old infant
born by vaginal delivery presenting with a history
of bloody stools or bloody emesis. Once it is determined that the child is hemodynamically stable with
normal findings on abdominal and rectal examinations, a positive fecal occult blood test is confirmed.
To distinguish whether the occult blood is, in fact,
the infants rather than swallowed maternal blood,
the Apt-Downey test may be employed; however,
the history and clinical examination should be sufficient if there is no other reason to suspect GI bleeding.81
Pediatric patients can return home from the ED after

a straightforward and successful reduction of intussusception if they meet discharge criteria. Several
studies have evaluated postreduction complications. In one report, children with an uncomplicated
course prior to reduction in whom intussusception
was hydrostatically reduced by barium enema and
who had a normal postreduction examination and
successful oral feeding had a low risk of complications during the 24-hour period after the procedure.82 In a large retrospective study of uncomplicated intussusception reductions in healthy children,
recurrence rates were not affected by observation in
the ED or hospital. There were no adverse outcomes
reported, and 50% of recurrences occurred within
the first 24 hours, whereas the remainder occurred
within the next 10 months.10 Previous studies have
shown that 30% of recurrences occur within the first
48 hours.83 With supportive studies, the emergency
clinician can feel confident about discharging pediatric patients after successful, uncomplicated reductions if the patient meets discharge criteria (see the
Disposition section), has reliable family support,
and lives within close proximity to a hospital.
Disposition
In the majority of ED visits by pediatric patients
with LGI bleeding, the cause is benign (eg, anal fissures, swallowed maternal blood, or milk-protein
allergy).1 Most of these patients can be discharged
home for observation by their primary care physician and can be given instructions about changes in
diet once other, more concerning, differential diagnoses have been ruled out. Lower gastrointestinal
bleeding in children is typically not life-threatening.
If a stable GI lesion is suspected, consultation with
a gastroenterologist and appropriate follow-up are
prudent measures.1 Notably, 10% to 20% of referrals
to pediatric gastroenterologists are for complaints of
Figure 1. Sample Discharge Instruction

Discharge Instructions
Your child was evaluated in the emergency department for lower
gastrointestinal bleeding.
Bleeding was likely caused by _______________. After careful evaluation and management in the ED, your child is clinically stable to be
discharged home with close monitoring and follow-up by your primary
care physician.
Please return to the ED if your child has worsening abdominal pain,
persistent or severe vomiting, large amounts of bleeding, or weakness or is unable to tolerate fluids.
11
upper and lower GI bleeding.84

Children with LGI bleeding due to intussusception can be discharged home contingent on several
factors, as noted in the Controversies And Cutting
Edge section.

In general, the possibility of acute and persistent GI bleeding or acute hemodynamic instability
warrants hospital admission. For example, a patient
with a profusely bleeding Meckel diverticulum with
tachycardia should be managed in the hospital. The
patient with prolonged intussusception or difficult
or unsuccessful reduction should also be admitted.

The following criteria for discharge home
highlight important clinical requirements for any
pediatric patient with intussusception and/or LGI
bleeding (see Figure 1):
1. Hemodynamic stability, with the expectation
that stability will be maintained.
2. Resolution of significant acute bleeding.
3. Resolution of or tolerable, mild abdominal pain.
4. Successful oral intake.
5. Reliability of follow-up with the primary care
physician.
6. Family communication and understanding of
discharge instructions, including reasons to
return to the ED if signs or symptoms recur.

Pediatric patients with the following conditions
will require admission for close monitoring or for
further evaluation and possible treatment:
1. Hemodynamic instability, with pronounced
tachycardia or hypotension.
2. Ongoing significant blood loss evidenced by
continued tachycardia, hypoxia, or weakness.
3. Need for imminent surgery.
4. Inability to tolerate oral intake because of either
refusal or frequent vomiting.
Summary
Lower gastrointestinal bleeding in the pediatric patient 5 years of age or younger is an uncommon ED
presentation that causes anxiety and concern both
in the childs family and in the clinician. There are
numerous causes of LGI bleeding in this age group,
ranging from self-limited anal fissures to surgical
emergencies. Age and presentation significantly
narrow the large list of differential diagnoses in this
patient population.

Intussusception is an important age-specific
cause of obstruction and LGI bleeding in young
pediatric patients. The time to diagnosis and reduction will influence morbidity and mortality in these
patients; hence, the emergency clinician should have
a high index of suspicion as well as knowledge of
current evidence for diagnosis and treatment.
Case Conclusion
After determining that the patient was hemodynamically
stable, you bypassed the abdominal x-ray and ultrasound
studies and instead ordered imaging that is both
diagnostic and therapeutic for suspected intussusception.
You chose ultrasound-guided hydrostatic reduction,
which posed no radiation risk and provided more
constant pressure in the colon during administration.
Her intussusception was reduced with relative ease in the
ED. She remained clinically stable and was able to tolerate oral intake. Because of the uncomplicated reduction
and her hemodynamic stability as well as her reliable
home environment you discharged the patient to
follow up with a gastroenterologist or primary medical
doctor the next day.
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study of rotavirus vaccination and intussusception. Pediatr
Infect Dis J. 2001;20410-416. (Cohort; 56,253 patients)
Vesikari T, Matson DO, Dennehy P, et al. Safety and efficacy
of a pentavalent human-bovine (WC3) reassortant rotavirus
vaccine. N Engl J Med. 2006;354:23-33. (Randomized control
trial; 2066)
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of Henoch-Schnlein purpura. J Paediatr Child Health.
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Holmes M, Murphy V, Taylor M, et al. Intussusception in
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cohort; 6021)
Fox VL. Gastrointestinal bleeding in infancy and childhood.
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Brown DL, Kouides PA. Diagnosis and treatment of inherited factor X deficiency. Haemophilia. 2008;14:1176-1182.
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Gla I, Tth L, Szegedi L, et al. Gastric bleeding in a patient
with rheumatoid arthritis complicated by immune thrombocytopenic purpura. Joint Bone Spine. 2008;75:350-352. (Case
report)
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Am J Perinatol. 1994;11:192-193. (Case report)
Ziemski JM, Szczepanik AB, Misiak A, et al. Endoscopic
injection treatment of gastrointestinal bleeding in hemophiliacs. World J Surg. 1996;20:1166-1170. (Prospective cohort; 89
patients)
Forbes CD, Barr RD, Prentice CR, et al. Gastrointestinal
bleeding in haemophilia. Q J Med. 1973;42:503511. (Review)
Guillevin L, Le Thi Hound D, Godeau P, et al. Clinical
findings and prognosis of polyarteritis nodosa and ChurgStrauss angiitis: A study of 165 patients. Br J Rheumatol.
1988;27:258-264. (Retrospective cohort; 165 patients)
Scott DG, Bacon PA, Elliott PJ, et al. Systemic vasculitis in a
district general hospital 1972-1980: clinical and laboratory
features, classification and prognosis of 80 cases. Q J Med.
1982;51:292-311.
Lopez LR, Schocket AL, Standford RE, et al. Gastrointestinal
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55.*
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59.*
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66.
67.
68.
69.
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71.
72.
involvement in leukocytoclastic vasculitis and polyarteritis

nodosa. J Rheumatol. 1980;7:677-684. (Retrospective case
series; 80 patients)
Pagnoux C, Mahr A, Cohen P, et al. Presentation and outcome of gastrointestinal involvement in systemic necrotizing vasculitides: analysis of 62 patients with polyarteritis
nodosa, microscopic polyangiitis, Wegener granulomatosis,
Churg-Strauss syndrome, or rheumatoid arthritis-associated
vasculitis. Medicine (Baltimore.) 2005;84:115-128. (Case series;
62 patients)
Meier DE, Coln CD, Rescorla FJ, et al. Intussusception in children: international perspective. World J Surg.
1996;20:1035-1039. (Review)
Immordino PA. Intussusception in children: a review of
10 years experience in a community hospital. Conn Med.
Bruce J, Huh YS, Cooney DR, et al.Intussusception: evolution of current management. J Pediatr Gastroenterol Nutr.
Losek JD, Fiete RL. Intussusception and the diagnostic value
of testing stool for occult blood. Am J Emerg Med. 1991;9:1-3.
(Retrospective cohort; 96 children)
Holtz L, Neill M, Tarr P. acute bloody diarrhea: a medical emergency for patients of all ages. Gastroenterology.
Silber G. Lower gastrointestinal bleeding. Pediatr Rev.
Fleischer GR, Ludwig S, eds. Synopsis of Pediatric Emergency
Medicine. 4th Ed. Lippincott, Williams and Wilkins. 2002:95.
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Ralston M, Hazinski MF, Zaritsky AL, et al. Pediatric Advanced Life Support Provider Manual. Dallas,TX. American
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Sheldon CA. The pediatric genitourinary examination. Inguinal, urethral, and genital diseases. Pediatr Clin North Am.
2001;48:1339-1380. (Review)
Odze RD, Wershil BK, Leichtner AM, et al. Allergic colitis in
infants. J Pediatr. 1995;126:163-170. (Review)
del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in
children: current concepts in diagnosis and enema reduction.
Radiographics. 1999;19:299-319. (Systematic review)
Hryhorczuk AL, Strouse PJ. Validation of US as a first-line
diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol. 2009;39:1075-1079. (Retrospective
cohort; 814 patients)
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donut sign. Pediatr Radiol. 1994;24:156-160. (Case series; 30
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Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr
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West KW, Stephens B, Vane DW, et al. Intussusception:
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study of mortality and morbidity of contrast media and standardized fecal dose in the peritoneal cavity. Pediatr Radiol.
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Daneman A, Alton DJ, Ein S, et al. Perforation during attempted intussusception reduction in children: a comparison
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Krishnakumar, Hameed S, Umamaheshwari. Ultrasound
guided hydrostatic reduction in the management of intussusception. Indian J Pediatr. 2006;73:217-220. (Case series; 25
patients)
73. Chan KL, Saing H, Peh WC, et al. Childhood intussusception: ultrasound-guided Hartmanns solution hydrostatic reduction or barium enema reduction? J Pediatr Surg.
1997;32:3-6. (Case control; 46 patients)
74. Crystal P, Hertzanu Y, Farber B, et al. Sonographically
guided hydrostatic reduction of intussusception in children.
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75. Humphry A, Ein SH, Mok PM. Perforation of the intussuscepted colon. AJR Am J Roentgenol. 1981;137:1135-1138.
(Retrospective case series; 850 patients)
76. Maoate K, Beasley SW. Perforation during gas reduction of
intussusception. Pediatr Surg Int.1998;14:168-170. (Retrospective case series; 650 patients)
77. Guo JZ, Ma XY, Zhou QH. Results of air pressure enema reduction of intussusception: 6,396 cases in 13 years. J Peadiatr
Surg. 1986;21:1201-1203. (Retrospective study, 6396 children)
78. Ko HS, Schenk JP, Trger J, et al. Current radiological
management of intussusception in children. Eur Radiol.
79.* Gonzlez-Spnola J, Del Pozo G, Tejedor D, et al. Intussusception: the accuracy of ultrasound-guided saline enema and
the usefulness of a delayed attempt at reduction. J Pediatr
Surg. 1999;34:1016-1020. (Cohort study; 195 children)
80. Alvarez-Caro F, Concha-Torre JA, Garca-Hernndez I, et al.
Massive lower gastrointestinal haemorrhage, successfully
treated with corticosteroids, as main symptom of SchnleinHenoch purpura. Rheumatol Int. 2009;29:1491-1494. (Case
report)
81. Moustafa MH, Taylor M, Fletcher L. My two-weekold daughter is throwing up blood. Acad Emerg Med.
2005;12:775-777. (Case report)
82. Bonadio WA. Intussusception reduced by barium enema.
Outcome and short term follow-up. Clin Pediatr (Phila).
1988;27:601-604. (Retrospective case review; 88 patients)
83. Eshel G, Barr J, Heiman E, et al. Incidence of recurrent
intussusception following barium vs air enema. Acta Pediatr.
1997;86:545-546. (Retrospective case review; 97 patients)
84. Wolfram W. Pediatric gastrointestinal bleeding. eMedicine.
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article/940176-overview. Last viewed December 13, 2011.
6. The emergency clinician should ask about

the quality and quantity of stools and bowel
movements in order to:
a. Assess ongoing blood loss and the potential

for anemia
b. Gather information from the patient in

regards to anal fissures, bleeding

hemorrhoids, or polyps
c. Both A and b
d. None of the above
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7. Abdominal radiographs are NOT useful in

identifying:
a. Obstruction
b. Free air
c. Bleeding
d. Pneumatosis intestinalis
1. A report from Boston Childrens Hospital in

the early 1990s showed that rectal bleeding was
a presenting complaint in what percentage of
pediatric patients who visited the ED within a
1-year period?
a. 0.03%
b. 0.3%
c. 3%
d. 30%
8. Ultrasound is an excellent diagnostic imaging

modality for intussusception and, unlike CT, it
does not carry the risk of radiation exposure.
a. True
b. False
2. The causes of LGI bleeding in children are best

categorized according to:
a. Age at presentation
b. Male versus female patients
c. Time of day
d. None of the above
9. Although both barium and hydrostatic enemas

pose a low risk for complications in reduction,
hydrostatic enema:
a. Does not need to be performed under

fluoroscopy, thus sparing the patient the

radiation risk associated with the use of
barium
b. Uses a water-soluble medium or saline
c. Causes fluid and electrolyte shifts, with
perforation
d. All of the above
3. Intussusception is:
a. The leading cause of intestinal obstruction

in children 5 months to 3 years of age
b. One of the most common causes of acute

abdominal emergency in young children
c. An important cause of occult or gross LGI

bleeding in the pediatric patient
d. All of the above
10. Which of the following is not a criterion for

discharge home for a pediatric patient with
intussusception or LGI bleeding?
a. Inability to tolerate oral intake because of

either refusal or frequent vomiting
b. Hemodynamic stability, with the

expectation that stability will be maintained
c. Resolution of significant acute bleeding
d. Resolution of or tolerable, mild abdominal
pain
4. The pathophysiologic basis of LGI bleeding is

mucosal insult via:
a. Direct trauma
b. Infectious insult and immunologic insult
c. Malformation
d. All of the above
5. Which of the following is NOT a risk factor for
LGI bleeding?
a. Anticoagulant use
b. Diarrhea
c. Polyps
d. Prematurity
15
Coming In Future Pediatric Emergency

Medicine Practice Issues

Constipation
Managing The Pediatric Airway
Sinusitis
Appendicitis
Croup
The Limping Child
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The Young Child With Lower

Martin I. Herman, MD, FAAP, FACEP

Ghazala Q. Sharieff, MD, FACEP, FAAEM, FAAP

and Dentistry of New Jersey;

Lower gastrointestinal (LGI) bleeding in the pediatric patient 5 years

Gary R. Strange, MD, MA, FACEP

Brent R. King, MD, FACEP, FAAP,

Emergency Medicine, Elliot Hospital

Critical Appraisal Of The Literature

Epidemiology And Etiology

Lower gastrointestinal bleeding refers to blood

and ulceration are limited to the colonic mucosa,

Intussusception is an important cause of occult or

Table 1. Common Causes Of Lower

Hemorrhagic disease of the

January 2012 www.ebmedicine.net

Pediatric Emergency Medicine Practice 2012

Intussusception is an invagination, or telescoping, of a

Table 2. Risk Factors For Lower

Pediatric Emergency Medicine Practice 2012 4

tion had hematochezia and 13% had redcurrant jelly

polyps, Meckel diverticulum, duplication cysts,

Prehospital treatment of LGI bleeding begins with

The differential diagnoses in LGI bleeding in the

Emergency Department Evaluation

Obtaining details regarding the duration and

Pediatric Emergency Medicine Practice 2012

with gross or occult GI bleeding.57 Painful bleeding

A thorough physical examination, including the

volume due to dehydration and bleeding. According

Intussusception is not a likely diagnosis in children

www.ebmedicine.net January 2012

Laboratory tests provide a tool to aid in patient

Intussusception Imaging Studies

Ultrasonography is an excellent imaging modality for diagnosing and assessing intussusception

Lower Gastrointestinal Bleeding Imaging

Pediatric Emergency Medicine Practice 2012

well as the presence of a crescentic air pocket, which

firmed intussusception were deemed equivocal, and

Table 3. Common Imaging Modalities In Lower Gastrointestinal Bleeding And Intussusception

Upper gastrointestinal series

Barium or hydrostatic enema

Useful in both diagnosis and therapy of intussusception

Poses lower radiation exposure

Useful in diagnosing intussusception

Magnetic resonance imaging

Not applicable in the setting of acute gastrointestinal bleeding

Pediatric Emergency Medicine Practice 2012 8

www.ebmedicine.net January 2012

Lower Gastrointestinal Bleeding

In the large majority of cases, pediatric LGI bleeding

The treatment of intussusception consists of initial

Pediatric Emergency Medicine Practice 2012

Risk Management Pitfalls For Lower Gastrointestinal Bleeding

Pediatric Emergency Medicine Practice 2012 10

4. The patient had frank hematochezia, but

www.ebmedicine.net January 2012

Controversies And Cutting Edge

Henoch-Schnlein purpura is a form of vasculitis

Pediatric patients can return home from the ED after

Figure 1. Sample Discharge Instruction

Pediatric Emergency Medicine Practice 2012

upper and lower GI bleeding.84