EM in 5: Peds Lower GI Bleed – Bloody Diaper

Author: Anna Pickens, MD (@AnnaEMin5, Creator of EMin5) // Reviewed by: Alex Koyfman, MD (@EMHighAK), Brit Long, MD (@long_brit), and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s edition of EMin5 by Dr. Anna Pickens.  Today we’ll review what to do when a parent shows up to the ED stating that their baby has blood in the diaper!  

So let’s start out with a case:

Mom brings in a 6 month old baby, otherwise healthy, non-toxic, complaining of blood in the diaper the last 2 days.  He is not vomiting, his abdomen is soft, he’s well hydrated, and doesn’t have a fever.   

Before panicking that you have a volvulus on your hands, let’s think through how to approach the differential for bloody stools in pediatric patients.

  • Blood or Not Blood?
  • Sick or Not Sick?
  • Then think through the differential by age.


First, let’s make sure this is actually blood. 

There are many mimics of blood that can turn stool red. 



Any guesses?

Yep, spicy hot cheetos!

Other foods:




Kool-aid / Popsicles / Juice:



How do we find out?  Hemoccult the sample if the diaper was brought in:

Also ask about other medications the child might be on:

(Pepto-Bismol and iron also turns stool melanotic / black in color)

If blood is confirmed, now start thinking about the differential based on if the child is sick or not sick:

Then break it down by age:  



Then rely on other clues in your history and physical.


Here’s some scenarios:

So to review:

  • Confirm that the stool is actually bloody (or that the blood is not coming from somewhere else)
  • Is the child sick or not sick?
  • Then break down the differential diagnosis by age


Suggested/Further Reading:

PEM Playbook – GI Bleeding in Children – emDOCs.net – Emergency Medicine Education

Wayne Wolfram. March 7, 2013. Pediatric Gastrointestinal Bleeding: Background, Etiology, Epidemiology


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