Paeds · gastroenterology-hepatology-and-nutrition
Gastrointestinal bleeding
Also known as GI bleed · Haematemesis · Melaena · Haematochezia · Rectal bleeding in children · Upper gastrointestinal bleeding · Lower gastrointestinal bleeding · Meckel diverticulum bleed · Intussusception · Variceal bleeding
Fellowship guide to gastrointestinal bleeding in children, built around the upper versus lower split at the ligament of Treitz and the way the differential shifts with age. The page works from haematemesis, coffee-ground vomit, melaena and haematochezia through resuscitation, the Apt test, Meckel scan and endoscopy, and the age-anchored causes from swallowed maternal blood and necrotising enterocolitis in the neonate to intussusception and Meckel diverticulum in the infant, juvenile polyps and varices in the child, and inflammatory bowel disease in the adolescent.
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- Haematemesis or melaena with tachycardia, prolonged capillary refill, pallor or altered consciousness means major haemorrhage and demands two large-bore cannulae, crystalloid boluses and blood crossmatch now, not after the swallow is done
- A neonate with blood in the stool may have necrotising enterocolitis, malrotation with volvulus or vitamin K deficiency bleeding, and each can deteriorate within hours, so a well-looking neonate with rectal bleeding is still a surgical and haematological emergency until assessed
- Bright red blood per rectum in an infant with colicky pain, vomiting and a palpable abdominal mass is intussusception until proven otherwise, and currant-jelly stool is a late sign of ischaemia rather than an early clue
- Painless, massive bright red rectal bleeding in a toddler or young child is the classic presentation of a bleeding Meckel diverticulum and warrants a technetium-99m pertechnetate scan
- A child with liver disease or known portal hypertension who vomits blood has presumed variceal haemorrhage and needs resuscitation, vasoactive therapy and urgent endoscopy for band ligation
Life stages
Care settings
Clinical exam formats
Board mappings
- Upper versus lower gastrointestinal bleeding and the ligament of Treitz
- Age-anchored differential diagnosis of gastrointestinal bleeding in children
- Resuscitation of the child with major gastrointestinal haemorrhage
- Variceal bleeding and portal hypertension in children
- Meckel diverticulum and obscure small bowel bleeding
- Endoscopic and surgical management of refractory gastrointestinal bleeding
- The infant with rectal bleeding: intussusception, Meckel and anal fissure
- Interpreting the Meckel scan, abdominal ultrasound and endoscopy
- Fluid resuscitation and transfusion thresholds in paediatric haemorrhage
- Long case: the child with chronic liver disease and variceal bleeding
- Short case: assessment of the child with haematemesis
- Gastroenterology: upper and lower gastrointestinal bleeding
- Recognition and stabilisation of the acutely bleeding child
- Causes of gastrointestinal bleeding by age
- Intussusception, Meckel diverticulum and juvenile polyps
- Assessment of the child presenting with rectal bleeding
- Gastrointestinal bleeding in infants and children
- Intussusception and the currant-jelly stool
- Variceal haemorrhage and portal hypertension
- Patient Care: resuscitation and stabilisation of the child with gastrointestinal bleeding
- Medical Expert: gastrointestinal bleeding in children
Overview & Definition
Picture a toddler brought in screaming and clutching his belly, then passing a motion streaked with bright red blood, and a teenager who vomits what looks like coffee grounds. Both have gastrointestinal bleeding, yet the two stories point to completely different parts of the gut and demand different first moves. Gastrointestinal bleeding is any loss of blood from the alimentary tract from the mouth to the anus, and in children the colour of the blood, the age of the child and the stability of the circulation together set the direction of the whole assessment. [1] [3]
The single most useful anatomical fork is whether the bleeding lies above or below the ligament of Treitz, the fibromuscular band at the duodenojejunal flexure. Bleeding proximal to it is an upper gastrointestinal bleed and tends to appear as haematemesis, the vomiting of fresh red blood, or coffee-ground vomit, or as melaena, the black tarry stool produced when blood is digested as it transits the gut. Bleeding distal to the ligament is a lower gastrointestinal bleed and usually appears as haematochezia, bright red or maroon blood passed per rectum. [1] [4]
Most childhood gastrointestinal bleeding is minor and self-limiting, yet a small minority is life-threatening, so the discipline is to assess for haemodynamic compromise first in every case and only then reason about the likely cause. The age of the child narrows the differential powerfully, because a neonate, an infant, a school-age child and an adolescent each carry a recognisably different set of causes for the same symptom. Holding the upper versus lower split and the age band together is what turns a vague presenting complaint into a tractable clinical problem. [1] [2]
References12ShowHide
- [1]Piccirillo M; Pucinischi V; Mennini M; Strisciuglio C; et al Gastrointestinal bleeding in children: diagnostic approach. Ital J Pediatr, 2024.PMID 38263189
- [2]Novak I; Bass LM Gastrointestinal Bleeding in Children: Current Management, Controversies, and Advances. Gastrointest Endosc Clin N Am, 2023.PMID 36948753
- [3]Kocic M; Rasic P; Marusic V; Prokic D; et al Age-specific causes of upper gastrointestinal bleeding in children. World J Gastroenterol, 2023.PMID 38186684
- [4]Sahn B; Bitton S Lower Gastrointestinal Bleeding in Children. Gastrointest Endosc Clin N Am, 2016.PMID 26616898
- [5]Aboughalia HA; Cheeney SHE; Elojeimy S; Blacklock LC; et al Meckel diverticulum scintigraphy: technique, findings and diagnostic pitfalls. Pediatr Radiol, 2023.PMID 36323958
- [6]Hu Y; Wang X; Jia L; Wang Y; et al Diagnostic accuracy of high-frequency ultrasound in bleeding Meckel diverticulum in children. Pediatr Radiol, 2020.PMID 32076751
- [7]Dal Buono A; Gaiani F; Poliani L; Laghi L Juvenile polyposis syndrome: An overview. Best Pract Res Clin Gastroenterol, 2022.PMID 35988962
- [8]Grammatikopoulos T; McKiernan PJ; Dhawan A Portal hypertension and its management in children. Arch Dis Child, 2018.PMID 28814423
- [9]Vakaki M; Sfakiotaki R; Liasi S; Hountala A; et al Ultrasound-guided pneumatic reduction of intussusception in children: 15-year experience in a tertiary children's hospital. Pediatr Radiol, 2023.PMID 37665367
- [10]Yu MC; Tsai CL; Yang YJ; Yang SS; et al Allergic colitis in infants related to cow's milk: clinical characteristics, pathologic changes, and immunologic findings. Pediatr Neonatol, 2013.PMID 23445743
- [11]Su D; Yang M; Wang X; Li G; et al Risk factors for gastrointestinal bleeding in children with Henoch-Schönlein purpura. Front Pediatr, 2025.PMID 40336803
- [12]Ozdogan E; Caglayan LD; Mizikoglu O; Arikan C Upper Gastrointestinal Bleeding as the First Presentation of Eosinophilic Gastrointestinal Disease. JPGN Rep, 2020.PMID 37206599