Rectal Bleeding in Children
Bleeding from anywhere tends to generate a great deal of anxiety. If that bleeding is from the rectum, and the patient is a child, then the stress levels inevitably multiply. So while this is a relatively unusual presentation, it will often present as an ‘urgent’ and typically require much reassurance. GPs have to deal with their own anxiety too – of overlooking the rare serious cause
Differential diagnosis
Common Diagnoses
- Swallowed Maternal Blood (from Cracked Nipples)
- Anal Fissure
- Gastroenteritis
- Cow’s Milk Protein Intolerance (CMPI)
- Rectal Polyp
Occasional Diagnoses
- Trauma (Including Non-Accidental Injury)
- Inflammatory Bowel Disease (IBD)
- Meckel’s Diverticulum
- Intussusception
- Haemorrhoids (in Older Children)
Rare Diagnoses
- Henoch–Schönlein Purpura
- Solitary Rectal Ulcer Syndrome
- Volvulus
- Necrotising Enterocolitis (in Neonates)
- Vascular Lesion/Bleeding Tendency
Ready reckoner
Key distinguishing features of the most common diagnoses
| Swallowed Maternal Blood | Anal Fissure | Gastroenteritis | CMPI | Rectal Polyp | |
|---|---|---|---|---|---|
| Constipated | No | Yes | No | Possible | No |
| Anal Pain | No | Yes | No | No | No |
| Diarrhoea | No | No | Yes | Possible | No |
| Repeated Episodes | No | Possible | No | Yes | Yes |
| Vomiting | No | No | Possible | Possible | No |
Possible investigations
- In most cases, primary care investigations will be unnecessary – the diagnosis will either be obvious and harmless (e.g. anal fissure) or will require admission or referral and investigation in secondary care. So the following are the only investigations likely to be performed in primary care:
- Stool: M, C and S for gastroenteritis
- Faecal calprotectin: If IBD suspected.
- FBC, CRP, ESR: If IBD suspected.
Top Tips
- Remember that red stools do not necessarily imply blood – discolouration can be caused by food, drink and medication.
- Rectal bleeding caused by an anal fissure should be obvious through the history – it should not be necessary to traumatise the child further via a digital examination.
- As in adults, the nature of the bleeding will help locate its origin, with bright blood usually from distal, and altered blood from more proximal, sites.
- If gastroenteritis is suspected, then Campylobacter or Shigella are likely
Red Flags
- Always be alert to the rare possibility that rectal bleeding might be the result of nonaccidental injury.
- The classic redcurrant jelly stool is a fairly late feature of intussusception. Consider this especially in young children (usually under two) with episodes of severe distress/abdominal pain associated with pallor
- Many symptoms are attributed to possible CMPI. It certainly can cause rectal bleeding, but remember other possible causes if a trial of cow’s milk protein-free feeds does not resolve the problem, and ensure investigation.