Gastrointestinal Bleeding in Infants and Children

Abstract

1. John T. Boyle, MD* 1. *Clinical Professor of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pa; Division of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa After completing this article, readers should be able to: 1. Develop a differential diagnosis based on the clinical presentation of gastrointestinal (GI) blood loss. 2. Discuss the age-related causes of upper and lower GI bleeding. 3. Delineate the sequence of evaluation and decision process in a child who has GI bleeding. 4. Describe new medical therapies and endoscopic maneuvers to control GI bleeding. A previously well 3-week-old female infant presented with a 2-day history of rectal bleeding. Her parents described three to five loose stools per day mixed with bright and dark red blood and mucus. Associated symptoms included episodic nonbilious, nonbloody emesis and an erythematous rash on her arms and legs. The infant was receiving standard cow milk formula. Her weight gain and linear growth were excellent. The abdominal examination revealed no tenderness or organomegaly, and there were no anal fissures. Stool was guaiac-positive. The complete blood count (CBC) revealed normal hematocrit, mean corpuscular volume (MCV), platelet count, and white blood cell count. The total eosinophil count was mildly increased at 0.55×103/mm3. The stool culture was negative . Clostridium difficile toxin was present. Three days after having been switched to a protein hydrolysate formula, the infant's bowel frequency decreased to twice a day. Although the baby continued to appear well, with good weight gain and growth, her stools still contained gross strands of blood and mucus intermittently over the next 3 weeks. Flexible sigmoidoscopy at that time revealed moderate nodular lymphoid hyperplasia in the rectosigmoid region(Fig. 1). The colonic mucosa appeared normal otherwise. Biopsies from the sigmoid and rectum showed six eosinophils per high-power field, normal crypt architecture, and lymphoid nodules. The infant continued to receive the protein hydrolysate formula, and gross bleeding gradually resolved over the next 2 weeks . Figure 1. Nodular lymphoid hyperplasia: multiple submucosal nodules in the …