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. 

 

EXAMPLES:

Any guesses?

Yep, spicy hot cheetos!

Other foods:

Beets: 

 

Jello:

Kool-aid / Popsicles / Juice:

Markers:

Frosting:

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:  

SICK:

NOT SICK:

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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