Hematochezia

Hematochezia refers to bright red blood per rectum (BRBPR). When the blood is maroon, the bleeding source is usually colonic. Massive upper GI bleed may rarely present with BRBPR because blood is a cathartic and children have a short intestinal transit time. Milk protein allergy is the commonest etiological factor, followed by anorectal fissure in infants. In the neonatal period, NEC must be ruled out. Infectious colitis, followed by anorectal fissures, are the most common in childhood. IBD should be considered in the older child and adolescent.

Differential Diagnosis

• Milk or soy protein allergy (colitis)
• Anorectal fissure: passage of hard stool causing rectal trauma
• Nectrotizing enterocolitis (NEC): Vast majority occur in premature infants

• Infectious colitis
  –Bacterial: Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile, and E. coli (O157:H7) –Parasitic: Entamoeba histolytica

• Immunocompromised host
  –CMV enterocolitis
  –Disseminated aspergillosis
  –Mycobacterium avium complex
  –Typhlitis: Polymicrobial inflammation of the cecum associated with neutropenia
• AIDS
  –Aphthous ulcerations of the intestine
• Juvenile polyps
  –Most common source of significant rectal bleeding in childhood
  –Pathologically benign inflammatory polyps
• Inflammatory bowel disease
• Meckel diverticulum: Ectopic gastric mucosa, 2% of population
• Intestinal duplication
• Henoch-Schönlein purpura (HSP)
• Lymphonodular hyperplasia
• Solitary rectal ulcer
• Ischemic injury
  –Malrotation with volvulus
  –Intussusception
  –Postoperative (colonic watershed regions)
  –Acute drug-induced ischemia (cocaine)
• Hirschprung enterocolitis
• Foreign body injury: Ingested glass, broken glass thermometer, other sharp objects
• Munchausen syndrome by proxy
• Vascular lesions
  –Hemangiomas (rare)
  –Arteriovenous, venous malformation
  –Klippel-Trenaunay syndrome
  –Blue rubber bleb nevus syndrome
  –Hereditary hemorrhagic telangiectasia
• Hemorrhoids and colorectal varices from portal hypertension
  –Hemorrhoids rarely bleed in children

Workup and Diagnosis

• History and physical exam
  –Painless rectal bleeding is typical of juvenile polyp, vascular lesions, Meckel, or ulcerated duplication
  –Crampy abdominal pain, bloody/mucoid stool, with or without fever suggest infectious, inflammatory, or ischemic process in the colon
  –History of constipation and blood streaked stool points toward anorectal fissure
  –Skin examination for vascular lesions
  –Anal inspection and rectal examination may reveal markers of IBD, such as a skin tag, fistula, or fissures

• Stool examination: Currant-jelly stool is a late sign in intussuception; maroon-colored stool may represent blood from a distal small bowel lesion (e.g., Meckel); bacterial culture, C. difficile toxin assay, O&P
• CBC, blood smear, urinalysis, BUN, and Cr to evaluate for HUS
• Endoscopy
  –Colonoscopy is the most valuable tool after infections have been ruled out
  –May offer both diagnosis and therapy (polypectomy)
• X-rays: Obstructive series useful when pain or vomiting is present; thumb printing seen with bowel wall edema; pneumoperitoneum with perforation
• Ultrasound: Can detect intussuception
• Meckel scan (Tc-petichnitate)
• Angiography, scintigraphy, push enteroscopy, or capsule endoscopy for vascular lesions

Treatment

• Treatment is directed at the underlying cause
• Correct hemodynamic instability with volume expansion, pressure support, and blood transfusion
• Milk protein allergy: Protein hydrolysate formulas
• NEC: Antibiotics and supportive therapy, surgery for perforation
• IBD: Anti-inflammatory (e.g. steroids, 6MP, 5ASA)
• Hemangiomas: Corticosteroids or alpha-interferon
• Infectious colitis: Antibiotics for Shigella, Campylobacter,
• difficile, and amebiasis; treat Salmonella only in very young or febrile infants
• Endoscopic therapy: Polypectomy for juvenile polyp, elastic band ligation, sclerotherapy, and/or electrotherapy for vascular anomalies.
• Surgery: Indicated for failure of radiographic reduction of intussuception, volvulus, or other ischemic injuries; Meckel diverticulum, and vascular anomalies
• Stool softeners for anorectal fissures

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Stool color: Introduction (review 325 causes)
• Next Book Extract About Stool color: CONSTIPATION (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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