Gastrointestinal bleeding — structured clinical encounter

Station 1 — recognition

The examiner asks what worries me about this child and how I frame the problem. I explain that bright red blood per rectum in a well toddler with no pain and a normal perianal exam points to a lower tract source, and that a Meckel diverticulum and a juvenile polyp head the differential. I confirm first that he is haemodynamically stable, because a painless bleed can still be large enough to cause shock, and I note that the colour and the age together set the direction before any test. [1] [3]

Station 2 — resuscitation and assessment

Asked what I do first, I assess the airway, breathing and circulation, judging the haemodynamics from the heart rate, capillary refill and conscious level, because blood pressure is a late sign in children. He is stable, so I secure intravenous access and take blood for a full count, group and crossmatch, coagulation and electrolytes, and I keep him nil by mouth while I plan the investigation. If he were tachycardic with prolonged capillary refill I would give an isotonic crystalloid bolus of 10 to 20 mL per kg and move to blood products early. [2] [1]

Station 3 — investigation

Asked how I confirm the diagnosis, I arrange a technetium-99m pertechnetate Meckel scan, which detects the ectopic gastric mucosa that secretes acid and ulcerates the adjacent ileum. I explain that if the scan is negative but suspicion remains, high-frequency ultrasound may identify the diverticulum, and capsule endoscopy can localise an obscure small bowel source. I note that a juvenile polyp would instead be found and removed at colonoscopy, and that intussusception would be identified by the target sign on ultrasound, which is why the age and pain pattern matter. [4] [5]

Station 4 — definitive care

The scan confirms a Meckel diverticulum. Asked about the treatment, I describe surgical resection of the diverticulum and the affected segment of ileum, since the ectopic gastric mucosa will keep ulcerating until it is removed. I contrast this with the cause-specific treatment of the alternatives: intussusception reduced by enema, a juvenile polyp snared at colonoscopy, and allergic colitis settled by eliminating cow's milk protein. I emphasise that the definitive treatment follows the diagnosis, which follows the resuscitation. [4] [6]

Station 5 — disposition and family

Finally I address disposition and safety-netting. From a regional hospital this child needs a paediatric surgical centre, so I continue resuscitation and monitoring during retrieval. I counsel the family that surgical resection of a Meckel diverticulum usually gives an excellent outcome, and I make sure every clinician who later sees a child with gastrointestinal bleeding holds the same rule of assessing the circulation first, then localising by colour and age, and escalating for the severe or refractory case. [2] [1]