Rectal bleeding in children

Rectal bleeding in children is less common than in adults. It can cause a great deal of anxiety amongst parents and thus requires appropriate assessment, explanation and reassurance. The vast majority of rectal bleeding in children is benign but it may indicate serious underlying pathology.

Epidemiology

The incidence and prevalence of rectal bleeding in children are poorly documented. Certain causes such as anal fissure are common in general practice. Overall it is not a common presentation in children attending hospital.

History

Questions to ask about the bleeding

• Is the bleeding acute or chronic?

• What is the colour of the blood? Is it bright or dark?
  

  • Melaena rather than bright red blood indicates bleeding is higher in the bowel (usually duodenal or above).

  • Anorectal disorders, anal fissures and distal polyps cause bright red bleeding. Dark blood or blood mixed with stool suggests more proximal source of bleeding.

  • Be aware that massive upper gastrointestinal bleeding can cause bright red rectal bleeding in children when transit time is short.

• What is the quantity of bleeding?

Questions to ask about other symptoms

Either accompanying or antecedent to the bleeding:

• Is there any vomiting? An infectious cause is suggested by diarrhoea and vomiting, fever, illness in others, recent travel, etc.

• Has there been any straining?

• What is the character of stools passed? Constipation and large hard stools predispose to fissures. Accompanying diarrhoea and signs of obstruction suggest intussusception, volvulus and, in some groups, even necrotising enterocolitis. Acute bloody diarrhoea in children is a medical emergency.

• Has there been any abdominal pain?

• Has there been any trauma?

Questions to ask about general health

• Is the child eating and thriving?

• Is there any past history of illness, including jaundice, blood disorders, or intrauterine or neonatal conditions?

Questions to ask about family history

• Is there any history of gastrointestinal disease (acute or chronic)?

• Is there any history of haematological disease?

• Is there a family history of polyps¹ ?

Questions to ask about medication

Particularly use of:

• Non-steroidal anti-inflammatory drugs.

• Steroids.

• Iron supplements.

• Any substances likely to colour the stool (liquorice, bismuth, etc).

Examination

• Look for signs of shock.

• Look for signs of bleeding from other areas (oropharyngeal, nasal, etc).

• Examination of the skin may reveal evidence of systemic disorders (for example, Henoch-Schönlein purpura and Peutz-Jeghers syndrome).

• Examine the abdomen. Look for signs of constipation. Hyperactive bowel sounds may occur with upper gastrointestinal haemorrhage.

• Examine the perianal area. Look for evidence of fissures or fistulas and assess perianal skin.

• Consider rectal examination. This may reveal polyps, masses or occult blood.

Differential diagnosis

The likely causes of rectal bleeding in children vary with age.

• Swallowed maternal blood:
  

  • Occurs in neonates.

  • Also found in regurgitated milk of breast-fed infants. Maternal nipples may be cracked and sore.

• Anal fissure:

  • Occurs in neonates and infants but also in older children.

  • Bright red blood and pain are features of this condition.

  • Fissure is visible on examination and no further investigation is required.

  • Stool softeners may be needed if the child is constipated.

Close-up view of anal fissure

By Bernardo Gui, Public domain, via Wikimedia Commons

• Volvulus:
  

  • Can occur in neonates and infants.

  • In neonates, it is heralded by sudden onset of melaena and bilious vomiting.

  • In infants, volvulus can also occur and presenting features include vomiting and abdominal distension.

  • Rectal bleeding occurs relatively late with development of gangrenous bowel.

  • Classic plain X-ray finding in midgut volvulus is the double bubble sign. Ultrasound can also be used.

• Intussusception:
  

  • Occurs most often between 4 and 10 months² .

  • Pain (paroxysms about every 10-20 minutes of colicky abdominal pain), distension, vomiting and a sausage-shaped mass are characteristic, as is the passage of blood and mucus in the form of redcurrant jelly stool.

  • Abdominal X-ray - may show dilated gas-filled proximal bowel, paucity of gas distally, and multiple fluid levels (but may be normal in the early stages).

  • Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance. It is a very effective modality and many consider it the investigation of choice.

• Polyps:
  

  • Generally, these cause painless recurrent bleeding¹ .

  • In infants and up to teenage years they are most often juvenile polyps which autoamputate and usually require no treatment.

  • Other polyposis syndromes are diagnosed at colonoscopy³ . Syndromes include juvenile polyps and polyposis, Peutz-Jeghers polyposis and familial adenomatous polyposis.

• Meckel's diverticulitis:
  

  • This is more common in children aged younger than 2 years, and in males^{4 5} .

  • The patient usually reports bright red blood in the stools. The amount may vary from minimal recurrent episodes to a large shock-producing haemorrhage. Meckel's diverticulum should always be excluded in a child presenting with massive painless rectal bleeding.

• Inflammatory bowel disease (IBD)⁶ :
  

  • This starts to become more common over the age of 2 years.

  • Bleeding occurs less often with Crohn's disease than with ulcerative colitis but both can cause bloody diarrhoea.

  • Rectal bleeding usually occurs in children known to have IBD rather than as a presenting feature of the IBD.

• Infectious diarrhoea:
  

  • Includes that caused by Clostridium difficile and causes bleeding associated with profuse diarrhoea.

  • Gastroenteritis in many varieties (more commonly Campylobacter spp.).

Rarer causes of rectal bleeding in children

Rare causes need to be considered. Again, how rare a particular cause is can vary with age. It is sometimes necessary to consider upper gastrointestinal bleeding (including all causes such as drugs, gastro-oesophageal reflux, stress ulcers, etc) as a cause for rectal bleeding, as for adults. The shorter transit time in children makes this particularly worthy of consideration where a lower gastrointestinal cause is not obvious and in ill children with massive bleeding.

• Necrotising enterocolitis:
  

  • Occurs in neonates, usually at 3-10 days of age.

  • Recurrent bleeding in an infant recovering from this condition may indicate recurrence or stricture.

• Sexual abuse may present with rectal bleeding. A high index of suspicion in the clinician will be alerted by unusual features in the history or examination.

• Hirschsprung's enterocolitis⁷ .

• Solitary rectal ulcer syndrome:
  

  • Usually presents in older children (≥8 years old)⁸ .

  • Mucorrhoea, constipation, tenesmus and rectal prolapse are often seen.

• Vascular lesions:
  

  • Include a range of haemangiomas, arteriovenous malformations and angiodysplasias which can be difficult to detect by colonoscopy or arteriography⁹ . However, capsule endoscopy is sometimes more effective and has been shown to be safe for use in children^{10 11} .

• Henoch-Schönlein purpura.

• Haemolytic uraemic syndrome.

• Acquired thrombocytopenia.

Older children/adolescents

In adolescents, the pattern of disease and the possible causes begin more to resemble the pattern in adults. Lower gastrointestinal bleeding is most often caused by:

• Anal fissures and haemorrhoids.

• Colonic polyps.

• Gastroenteritis.

• IBD.

Investigations

Most cases of rectal bleeding in children are benign and self-limiting. The majority of cases will not require any investigation. When bleeding is substantial or recurrent consider:

• FBC - anaemia or thrombocytopenia.

• Clotting studies - clotting disorder is suspected.

• LFTs - liver disease.

• Imaging - this is not usually necessary or helpful but may be necessary where more unusual causes of bleeding need to be excluded (in ill children or children with substantial or recurrent bleeding).

• Endoscopic examination in children is usually done under general anaesthesia and by specialist paediatric gastroenterologists¹² .

Management

The management will depend on the cause and extent of bleeding. As most cases will be simple, self-limiting and benign, management will focus on explanation, reassurance and 'safety-netting'. When bleeding is profuse or recurrent then management will focus on resuscitation, investigation and then treatment of the cause.