Pediatric Smackdown: GI Bleed

May 19, 2025 EMRAP

Ilene Claudius, MD; Jeff Seiden, MD; and Al Sacchetti, MD

Dr. Ilene Claudius, Dr. Jeff Seiden, and Dr. Al Sacchetti discuss the management of pediatric gastrointestinal (GI) bleed based on the age and general appearance of the patient. Their conversation covers can’t-miss diagnoses in patients with hematemesis or blood stool in both the neonate and infant/toddler age groups.

• Neonates with hematemesis
  • Most cases are due to breastfeeding and maternal blood from cracked nipples.
    • May perform an Apt test to confirm that it is maternal blood.
  • Verify that patients have received their vitamin K shot at birth.
  • Esophagitis and gastritis/stress ulcers are less common causes to consider.
  • Most neonates who are well appearing and feeding normally can be discharged home without further workup.

• Neonates with blood in the stool
  • Evaluate for anal fissure.
  • This is often due to a milk or soy protein allergy.
    • May suggest dietary changes
  • Dark blood mixed in with stool, especially loose stool, is more concerning.
  • Consider necrotizing enterocolitis, even in full-term patients.
    • May obtain a plain film of the abdomen to screen for pneumatosis
• Non-neonates with blood in the stool
  • Meckel’s diverticulum typically occurs around 2 years of age.
    • Consider admission for technetium-99m scan if there is a large amount of blood, persistent blood in the stool, or anemia on blood work.
  • Mimics of blood in the stool:
    • Patients who have eaten berries, beets or red food dyes (eg, Hot Cheetos, fruit punch)
    • Cefdinir can cause stool to appear melanotic
• Non-neonatal patients with hematemesis
  • Evaluate for epistaxis or other sources of swallowed blood.
  • Patients with frank hematemesis or underlying liver disease should get blood work and be admitted.

PEARL: Most well-appearing pediatric patients do not require workup and can be safely discharged with good return precautions.