Clinical assessment

Firstly, assess the child for signs of haemodynamic instability, using an A-E approach, and resuscitate as required.

History¹

Use the history to gauge the severity of the problem, whether the child is at risk of haemodynamic instability, and to find any clues which could suggest the cause of the bleeding.

• Colour of stool – bright red/black or tarry
• Is it definitely blood? – have they recently eaten anything which could cause discoloured stool?
• Is it definitely from the GI tract? – consider haemoptysis or epistaxis as causes for blood passing through the GI tract
• Quantity of blood
• Any other GI symptoms – diarrhoea, vomiting, abdominal pain
• Any systemic upset – lethargy, weight loss
• Any other evidence of bleeding disorder – bruising easily/petechiae
• Recent travel
• Other medications – NSAIDs, anticoagulants
• Potential ingestion of harmful substances which could cause bleeding
• Trauma
• Co-morbidities e.g. liver disease
• Family history of GI disorders which could cause LGIB e.g. inflammatory bowel disease

Examination

Use the examination to look for signs of anaemia, which would prompt further investigations, bowel obstruction, which is a medical emergency, or any other indicators of the cause of the bleeding.

• Start with A-E assessment, importantly checking cardiovascular stability considering hypotension/tachycardia/prolonged CRT to be signs of significant blood loss and an indication that the patient needs rapid resuscitation.
• Check skin for pallor, abnormal bruising or petechiae and jaundice
• ENT examination for evidence of bleeding, check oral mucosa for ulceration
• Abdominal examination for any distension, pain on palpation, masses (think sausage shaped mass for intussusception) or organomegaly
• Perianal examination, assessing for anal fissures, external haemorrhoids or abscesses, evidence of nappy rash which could result in blood being found in the nappy
• A per rectum examination is rarely indicated in children in the emergency department