First thoughts – is this a space-occupying lesion? If you haven’t seen it already, please check out HeadSmart. It details presentations commonly associated with a brain tumour in each age group. Strabismus alone is a rare sign of a brain tumour in this age group; however, the associated papilloedema is concerning.

The fact that fundoscopy has been carried out on this child is a feat. It is often difficult to do this in an ED setting. Still, many departments have access to eye clinics or on-call ophthalmology with better equipment and a nicer setting, making getting a good view of the fundus easier. Papilloedema may be a sign of raised intracranial pressure and is worrying. This child needs imaging urgently. MRI is the modality of choice.

In this case, the MRI did not show a space-occupying lesion, and neither did it show hydrocephalus. What could be going on?

GI bleeds are categorized by location in relation to the Ligament of Treitz. Upper GI bleeds (UGIB) occur proximally, in the esophagus, duodenum, or stomach. They classically present with hematemesis, with either frank red blood or coffee-ground emesis, or melena. Less commonly, brisk UGIB can also present as hematochezia which can complicate the identification of the origin of the bleed in some cases. Lower GI bleeds (LGIB) occur distally, in the small bowel, colon and anorectum. In contrast, these usually manifest as hematochezia.