Evidence Based Strategies: Best Practices and Evidence Regarding Emergent Management of GI Bleeds

Column Author:  Sarah Gwazdacz, MD | Chief Resident

Column Editor:  Angela D. Etzenhouser, MD, FAAP | PHM Director of Safety, PHM Director of Safety; Associate Program Director, Pediatric Residency Program

Acute gastrointestinal bleeds (GIB) in the pediatric population can be a nebulous presenting symptom with a wide differential diagnosis ranging from self-resolving mucosal bleeding to life-threatening hemorrhages. Studies have found that the incidence of emergency department (ED) visits for pediatric GIB is increasing. Therefore, it is important that providers have knowledge around triage and management of this complaint.

When a child presents with an overt GIB, regardless of the etiology, initial steps should include assessment of hemodynamic stability. If tachycardia, delayed cap refill, cool mottled skin, changes in mental status, or respiratory distress are present, appropriate resuscitation should follow. If the patient is stable but demonstrates risk factors for severe bleeding (see below) the patient should not be allowed to eat.

Signs and Symptoms Concerning for Severe or Ongoing Bleeding:

• Physical exam suggestive of hypovolemia
• Hemoglobin </=7 g/L
• Required 40 ml/kg of fluid resuscitation in the past two hours
• Complex chronic conditions including technology dependence
• History of variceal bleeding
• Concerning amount of blood loss

Early coordination with gastrointestinal (GI) specialists and pediatric surgery (if ongoing uncontrolled hemorrhage) is recommended to assist with transfer and providing specific stabilization recommendations.² Transfer by a pediatric critical care transport team to Children’s Mercy Adele Hall campus or whichever tertiary pediatric center is nearest you is recommended. While awaiting transfer, critical labs should be obtained, and vitals should be checked frequently. Acid-blocking medications should be started. The provider should be prepared to administer intravenous fluid and/or blood products where available for resuscitation if needed.

Critical Labs to Obtain:

• I-Stat hemoglobin
• CBC
• BMP
• Hepatic function panel
• Coagulation studies
• Type and cross
• Blood culture* (if concerned for variceal bleeding)

For all patients, a focused history and physical exam of critical elements should be obtained to help identify a source (Table 1). Although inquiring about the volume of blood lost can be valuable, studies have shown that parents often overestimate this value, whereas health care workers will underestimate.³

Table 1: History and physical exam elements to help identify the source of gastrointestinal bleeding                                                                                                                            If a child is hemodynamically stable with minimal blood loss and no concerning signs on history or physical exam, additional workup is often unnecessary. Stool studies can be helpful in instances of lower GI bleed as they can provide a more precise indication of intestinal inflammation compared to serum studies.² Infectious etiologies can be ruled out using stool studies. Elevated fecal calprotectin levels can be associated with inflammatory bowel disease and necrotizing enterocolitis. Fecal calprotectin levels can be followed outpatient and help determine follow-up need. If no infectious etiology is detected, endoscopic evaluation is recommended for calprotectin levels >250 mc/mg.⁴

In the ED, imaging may help determine the patient’s disposition depending on the differential (see below). Although endoscopy studies can be both diagnostic and therapeutic for GIB, they cannot be done in most EDs. Tools such as the Sheffield and the Glasgow-Blatchford scoring systems can be used to help identify patients with upper GI bleeds who require urgent endoscopy and admission.⁵

Imaging That Could Be Obtained in the ED That Could Assist in Diagnosis Depending on Differential:

• Plain film
  • Bowel obstruction or perforation
  • Opaque foreign bodies
• Ultrasound
  • Intussusception lead point
  • Abnormal positioning of the mesenteric vein or “whirlpool sign” in volvulus
  • Signs of portal hypertension resulting in varices
• Upper GI series – if concern for volvulus to identify corkscrew appearance
• Computer tomography angiography – arterial or venous active bleeding if at least 0.3 mL/min of blood loss⁶

Overt GIB in most children is often self-limited and can be managed outpatient. However, providers should promptly evaluate for shock, and should consider a wide differential based on history and exam. GI specialists are available to answer questions regarding next steps of care and recommendations for follow-up. If the patient remains stable and able to discharge, it is important to discuss return precautions including severe abdominal pain, increased bleeding, or pre-syncopal symptoms. For more information on the ED management of GIB, see the Children’s Mercy evidence based clinical pathway here: https://www.childrensmercy.org/siteassets/media-documents-for-depts-section/documents-for-health-care-providers/block-clinical-practice-guidelines/mobileview/acute-gi-bleed-algorithm-ed.pdf.

References: 

1. Pant C, Olyaee M, Sferra TJ, Gilroy R, Almadhoun O, Deshpande A. Emergency department visits for gastrointestinal bleeding in children: results from the Nationwide Emergency Department sample 2006–2011. Curr Med Res Opin. 2015;31(2): 347-351. doi:10.1185/03007995.2014.986569
2. Kostyuk O, Luyt K. Pediatric gastrointestinal bleeding: identification and management in the emergency department. Pediatr Emerg Med Pract. 2024;21(9):1-32. PMID: 39173112.
3. Tebruegge M, Misra I, Pantazidou A, et al. Estimating blood loss: comparative study of the accuracy of parents and health care professionals. Pediatrics. 2009;124(4):e729-e736.
4. Bouhuys M, Lexmond WS, van Rheenen PF. Pediatric inflam­matory bowel disease. Pediatrics. 2023;151(1):e2022058037.
5. Schluckebier D, Afzal NA, Thomson M. Therapeutic upper gastrointestinal endoscopy in pediatric gastroenterology. Front Pediatr. 2021;9:715912.
6. Piccirillo M, Pucinischi V, Mennini M, et al. Gastrointestinal bleeding in children: diagnostic approach. Ital J Pediatr. 2024;50(1):13.