Chapter 24
Rectal Bleeding
David I. Campbell
Key Points
››Bleeding from proximal to the duodeno jejunal flexure will give rise to hematemesis and malaena but may give rise to passage of bright red stool in cases of rapid transit.
››Necrotizing enterocolitis is a common cause in premature neonates.
››Dairy allergy, infections such as Salmonella, E. coli, Shigella, intusussception are common causes in infants and toddlers.
››Inflammatory bowel disease, rectal polyps, anal fissures are common in older children.
››Treatment depends on underlying etiology.
24.1 General Principles
The following issues need to be considered in the history as they affect diagnosis and hence management:
1.Is this bloody diarrhoea?
2.Is this acute or chronic (acute on chronic)?
3.Are there any features to suggest upper GI bleeding (hematemesis and melaena)?
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Sites of bleeding proximal to first loops of jejunum likely to have signs of upper GI bleeding, including melaena and hematemesis. Rapid transit would lead to bright red bleeding. This phenomenon is quite common in pediatrics. Causes of upper GI bleeding vary from trivial (swallowed blood in breast fed infant, or nose bleeds to catastrophic hemorrhage from esophageal varices). If in doubt consult with a pediatric gastroenterologist.
Consider the following differential diagnosis in
Older children: inflammatory bowel disease, infection, polyps, fissures.
Fissures: Usually secondary to constipation or idiopathic. If associated with induration, multiple or with skin tags, consider Crohn’s disease. Also a feature of child sexual abuse.
24.2 Neonates and Newborn
In newborns and young infants rapid transit can deliver unaltered blood to the terminal large bowel, obscuring the fact that the source of bleeding may be the upper GI tract.
Hemorrhagic disease of the newborn (HDN) is a vitamin K deficiency state, more common in breastfed infants and newborn. Bleeding can be from any site, but is often the GI tract. This condition is rare in babies given supplemental vitamin K at birth. HDN is a cause of hemorrhagic cerebrovascular accidents in young infants.
Necrotizing enterocolitis (NEC) is rare in term babies, but should be considered in any form of rectal bleeding in neonates. NEC is an idiopathic condition; most prevalent in the extremely premature when enteral feeding begins. Translocation of bacteria from gut lumen, vascular thrombosis leads to gut ischemia and infarction with pneumatosis coli.When advanced the abdomen is discolored, the baby shocked and peritonitic. Unless babies are fasted and treated with IV antibiotics, it progresses to intestinal perforation and peritonitis with a high mortality rate. Suspected cases should be referred to a pediatric surgeon.
Newborns with rectal bleeding may have rare diseases such as arterio-venous malformations affecting the GI tract,
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these babies usually have cutaneous hemangiomas as well. Most cases of rectal bleeding in new born should be investigated by a pediatric medical team.
24.3 Infants and Young Toddlers
Defining whether the rectal bleeding is part of a bloody diarrheal illness is important.
Causes of bloody diarrhoea:
1.Infection (bacterial: Salmonella, Shigella, Campylobacter and more notably E. coli). Usually early on there is a history of fever, pus or mucus are passed in the stool. Stools should be sent for microscopy and culture for three reasons, even if the treatment is conservative. Firstly, for public health reasons, secondly to identify specifically E. coli 0157 which is a causative agent for hemolytic uremic syndrome (HUS). Children with D+ HUS (i.e., HUS with diarrhoea), usually carry E. coli 0157 and often need renal support or expert assessment by pediatric nephrologists. The final reason is that treatable causes such as Entamoeba histolytica, are diagnosed on microscopy (and can be treated with oral metronidazole).
2.Dairy allergy (allergic enterocolitis). Usually these are not well young, but young infants that appear well that have mucousy, blood stained, loose frequent stools. The child usually is thriving and may be breast feeding. It is now known that microgram quantities of lactalbumin, lactoglobulin and casein proteins from cow’s milk are found in human breast milk within a few hours of ingestion.1 Any form of cow’s milk infant formula will produce the same reaction in the susceptible infant. A 2 week dairy free diet using an extensively hydrolyzed formula, or an amino acid based formula, is the gold standard test for dairy allergy.2
3.Intussusception. This is a life threatening condition more common from 6 months of age, but can occur at any age (but the etiology is different).Children have usually started weaning. The history is of episodes of crying (screaming) associated with pallor (rather than flushing which is normal).
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The child is unwell and the stools are classically described as redcurrant jelly.An abdominal mass on the right hand side is a classical finding, but smaller intussusceptions may not be palpable and an abdominal ultrasound should be performed to identify the intussusception employed to detect the apex of the intussusception. Children must be urgently referred to see a pediatric surgeon.
4.Perianal fissure. If the history is of a child straining to pass a large hard stool and intermittently there may be signs of bright red blood separate to the stool, then there should be a perianal fissure. Treat such children with laxatives.
24.4 Older Children
1.Inflammatory bowel disease. Either UC, Crohn’s or indeterminate colitis will cause bloody diarrhoea. In all forms of IBD causing bloody diarrhoea the bleeding will be more prominent if the distal colon is affected. Associated symptoms of colitis/proctitis will be present: urgency, mucus, tenesmus, nocturnal diarrhoea, gastrocolic reflex (passage of stool after eating). Symptoms are chronic (or acute on chronic). Abdominal pain is a prominent feature.
2.Polyps. Painless rectal bleeding is the cardinal features on history. Usually a solitary juvenile polyp is the cause of painless rectal bleeding.Treatment is by therapeutic endoscopy and will require pediatric gastroenterology or surgical assessment. Rarely do forms of familial adenomatous polyposis cause bleeding.
3.Infection: as above
4.Perianal fissures. Treat with laxatives and GTN paste.
24.5 Conclusion
Age of child, presence of signs of upper GI bleeding and whether the bleeding is acute or chronic alter differential diagnosis and hence management.