Management of Rectal Bleeding in the PICU

Jan 25, 2026

A dramatic pediatric case of massive rectal bleeding sparks a practical walkthrough of stabilization and resuscitation. They explore age-based causes for lower GI bleeding and when to use imaging versus endoscopy. Management of inflammatory bowel disease in acute care gets attention, including steroids, escalation to biologics, and nutritional rehabilitation with multidisciplinary planning.

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INSIGHT

Physiology Of Hemorrhagic Shock

Significant blood loss (about 30–40% of blood volume) is typically required to cause hypotension in older children and adults.
Tachycardia is an earlier, more sensitive sign of shock than hypotension and should prompt resuscitation.

INSIGHT

Prevalence And Presentation Of Lower GI Bleeds

Lower GI bleeding accounts for about 20–25% of pediatric GI bleeds presenting to the ED.
Hematochezia typically indicates a distal source but can occasionally arise from massive upper GI bleeding.

ADVICE

Stabilize Before You Image

Stabilize airway, breathing, and circulation first and obtain good vascular access before diagnostic imaging.
Use CT angiography for unstable patients and aim for endoscopy for stable patients because it can be diagnostic and therapeutic.

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In this episode of "PICU Doc On Call," Drs. Pradip Kamat and Rahul Damania discuss the acute management of a 14-year-old boy with severe rectal bleeding and hypertension, ultimately diagnosed with inflammatory bowel disease (IBD). They review the approach to pediatric lower GI bleeding, diagnostic workup, and imaging, emphasizing early recognition and resuscitation. They outline IBD management, including steroids, biologics such as infliximab, and nutritional support, while highlighting the importance of screening for infections before immunosuppression. The episode provides practical insights for PICU physicians on handling acute GI emergencies in children.

Show Nighlights:

Clinical case of a 14-year-old male with hypertension and rectal bleeding.
Diagnosis of inflammatory bowel disease (IBD) following significant blood loss.
Approach to pediatric rectal bleeding and its implications.
Diagnostic workup including laboratory tests and imaging modalities.
Management strategies for IBD in acute pediatric care.
Importance of early recognition and resuscitation in cases of shock.
Physiological principles related to blood loss and shock in children.
Differential diagnoses for lower gastrointestinal bleeding in pediatrics.
Initial evaluation and stabilization protocols for pediatric patients.
Nutritional support and multidisciplinary care in managing IBD.

References:

Romano C, Oliva S, Martellossi S, et al. Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology. World J Gastroenterol. 2017;23(8):1326-1337.
Pai AK, Fox VL. Gastrointestinal bleeding and management. Pediatr Clin North Am. 2017;64(3):543-561.
Padilla BE, Moses W. Lower gastrointestinal bleeding and intussusception. Surg Clin North Am. 2017;97(1):63-80.
Kaur M, Dalal RL, Shaffer S, Schwartz DA, Rubin DT. Inpatient management of inflammatory bowel disease-related complications. Clin Gastroenterol Hepatol. 2020;18(11):2417-2428.
Ashton JJ, Ennis S, Beattie RM. Early-onset paediatric inflammatory bowel disease. Lancet Child Adolesc Health. 2017;1(2):147-158.
Bouhuys M, Lexmond WS, van Rheenen PF. Pediatric inflammatory bowel disease. Pediatrics. 2022;150(6):e2022059341.
Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053-1060.
Conrad MA, Rosh JR. Pediatric Inflammatory Bowel Disease. Pediatr Clin North Am. 2017 Jun;64(3):577-591.
Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Aug;67(2):257-291, correction can be found in J Pediatr Gastroenterol Nutr 2020 Dec;71(6):794.