Was the substance truly blood Was it the patients blood

Many foods ingested by children mimic the appearance of blood. Food coloring is contained in fruit juices and gelatins. Breast-feeding infants may swallow maternal blood from cracked nipples.

D. Is bleeding coming from GI system? Does patient have any history of nasopharyngeal trauma, chronic nasal congestion, or epistaxis? Swallowed nasopharyngeal bleeding from trauma or mucosal ulceration can cause hematemesis. Was there a possible ingestion? Does patient regularly take medication(s)? Possible ingestions resulting in mucosal irritation include NSAIDs, aspirin, theophylline, steroids, batteries, and alcohol. In toddlers or mentally handicapped patients, consider the possibility of a foreign body.

Are there any other concurrent sites of bleeding (rectal, oral mucous, urinary tract, bruising)? Rule out a systemic problem such as coagulopathy or disseminated intravascular coagulation. What is the past medical history? Is there any history of umbilical artery catheterization, sepsis, previous episodes of bleeding from the GI tract or other sites; any past hematologic disorders or liver disease?

III. Differential Diagnosis. Always consider patient's age.

A. Swallowed Maternal Blood. Relatively common occurrence in infants during delivery or after breast-feeding from mother's irritated nipple. Common presentation is a well-appearing infant with hematemesis.

B. Gastritis or Ulcer. Causes in children are multifactorial and not completely understood. Can occur in a stressed preterm or a healthy term infant. May be related to maternal medications (eg, tolazoline, a-adrenergic agonists, or NSAIDs). Maternal cocaine use also can be a risk factor. Ingesting certain medications, including aspirin, NSAIDs, and steroids, is a risk factor. Hemodynamically significant GI bleeding can result from standard dosing of NSAIDs. Parents may not consider these as "medications," so ask specifically about their use. Stresses, including surgery, burns, increased intracranial pressure, or sepsis, can cause gastritis or ulceration. Other causes include mucosal irritation from milk-protein allergy, a lodged foreign body, gastrostomy tubes, or infection (Haemophilus pylor).

C. Esophagitis. Can result from gastroesophageal reflux disease (GERD). Children with bleeding esophagitis as a result of GERD are more likely to have a neuromuscular disease or hiatal hernia. Other causes of esophagitis include mechanical injury by a foreign body, chemical injury from caustic ingestion, medication (pill esophagitis), or infection (Candida albicans, Aspergillus, herpes simplex virus, cytomegalovirus).

D. Coagulation Disorders. Hemorrhagic disease of the newborn is rarely seen today because vitamin K administration at birth has become routine. Risk factors include altered bowel flora as a result of antibiotics or fat malabsorption (ie, cystic fibrosis). A coagulopathy can occur as a primary defect of the coagulation cascade (ie, hemophilia) or secondary to liver disease or disseminated intravascular coagulation as a result of overwhelming infection.

E. Varices. Variceal bleeding is rare in infancy, although gastroesophageal varices associated with portal hypertension are the most common cause of significant GI bleeding in older children. Gastroesophageal varices form in children with intrahepatic or extrahepatic causes of portal hypertension; rarely in association with congenital heart disease or vascular malformations. Portal vein thrombosis is a common cause of extrahepatic obstruction. Risk factors include omphalitis, history of umbilical vein cannula-tion, and dehydration. Intrahepatic portal hypertension is caused by hepatic parenchymal disorders. More common associated diagnoses include biliary cirrhosis with biliary atresia, hepatitis, congenital hepatic fibrosis, (^-antitrypsin deficiency, and cystic fibrosis.

F. Structural Anomalies. Include hypertrophic pyloric stenosis, duodenal web, and antral web. These anomalies usually present with emesis but may be associated with bleeding. GI duplication can occur anywhere in the intestinal tract, but it is most commonly found in the small bowel. These patients usually present with signs of GI tract obstruction and abdominal mass.

G. Vascular Anomalies. A rare cause of GI bleeding. These anomalies include focal lesions (hemangiomas or Dieulafoy lesion) or more diffuse lesions (hereditary hemorrhagic telangiectasia or Kasabach-Merritt syndrome).

H. Oropharyngeal Causes. Include epistaxis, facial trauma, and tooth extraction, resulting in swallowed blood.

I. Mallory-Weiss Tears. These mucosal lacerations of gastric mucosa are caused by significant vomiting.

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