Previously, we have discussed conditions that lead to kids presenting with GI Bleeding. A recent outbreak of Salmonella inspired some conversation. Additionally we have touched upon intussusception, which is often considered, occasionally encountered, and always asked about on board examinations. But, let us not forget that there are other conditions to consider when evaluating the patient with lower GI bleeding.
a) A few conditions to consider by age:
i) Neonates and infants
(1) Hemorrhagic diseases of newborns
(2) Necrotizing enterocolitis
(3) Hirschsprung’s Disease (we’ve also talked about this one)
(4) Volvulus, Intussusception (although if you are seeing bleeding, the kid is likely super sick)
(5) Congenital anatomic anomalies (GI tract duplication)
(6) Milk or Soy protein induced colitis
(7) Ingestion of Maternal Blood (from birth canal or from cracked nipples during breast feeding) – good reason to check an Apt Test
BONUS MORSEL – Fetal hemoglobin is resistant to alkali denaturation, unlike adult hemoglobin. So, hemoglobin exposed to sodium hydroxide will denature if it is adult and remain intact if it is fetal.
ii) Toddlers and Preschoolers
(1) Meckel’s Diverticulum
(3) Juvenile Polyps
(5) HSP (also puts kid at risk for Intussusception)
(7) Infectious Colitis
(8) Milk/Soy protein colitis
iii) Older kids (>6yrs or so)
(1) Infectious colitis (Salmonella, Shigella, Yersinia, Campylobacter, EHEC, C.Diff)
(2) Inflammatory Bowel Disease
(3) These kids can still have intussusception, HUS, HSP, etc.
b) Meckel’s Diverticulum
i) The most common congenital abnormality of the small intestine
ii) Frequently other associated abnormalities (cardiac defects, abdominal wall anomalies, Down Syndrome, etc)
iii) Present in ~2% of the population.
(1) Remember the Rule of 2’s?
(a) 2% of population
(b) <2yrs of age (45% of symptomatic patients present by age 2)
(i) This leaves a lot who are either not symptomatic or present after 2yrs
(c) 2cm wide, 2cm long
(d) 2 feet from ileocecal valve
(e) 2 types of ectopic tissue (Gastric or pancreatic)
(i) For those not symptomatic, only 15% have ectopic tissue
(ii) 70% of symptomatic pts have ectopic gastric mucosa
(iii) 5% of symptomatic pts have pancreatic tissue
(2) These rules are more suggestions than written in stone
(1) Classic presentation is Painless Rectal Bleeding (40% present with GI Bleed)
(a) Bleeding is more often the presentation of older infants/toddlers (younger more likely with obstruction symptoms)
(b) Stools are often maroon
(c) Vomiting is often absent
(d) Bleeding can be intermittent!
(e) Bleeding can be severe enough to require transfusions.
(2) Can lead to obstruction (35%)
(a) In addition to adhesions or mechanical obstruction it can also be a lead point for Intussusception
(b) This is often the presentation of Meckel’s in the first few months of life.
(3) Can lead to local inflammation (17%)
(a) Can look similar to appendicitis!
(b) Ectopic tissue can lead to a hole in the intestine, which can lead to intrabdominal infection and/or localized abscess.
So, while you are evaluating that patient with GI Bleeding who looks “awesome” and really want there to be an anal fissure to blame, but don’t honestly see one… don’t forget that your DDx is a bit broader than fissure and milk protein induced colitis.
www.pediatricsurgerymd.org – “Meckel’s Diverticulum”
Hillemeier C, Gryboski JD. Gastrointestinal Bleeding in the Pediatric Patient. The Yale Journal of Biology and Medicine. 1984 (57), 135-147.