Rectal bleeding in a child for long duration

Per rectal bleeding is quite scary for parents. Sometimes they are puzzled and scared. Detailed history, focused examination, careful assessment, and rational investigations could reveal the cause. Most of the cases it is benign in nature but some conditions indicate underlying pathology. Anal fissures and polyps are the two most common causes of rectal bleeding in children. In this topic, we are going to discuss rectal bleeding.

Case Discussion: Miss Y, a 4-year-old immunized girl, the only issue of her non-consanguineous parents, got admitted to BSMMU with complaints of painless, intermittent, fresh per rectal bleeding for the last 1.5 years which was a small amount, initially streaking around the stool and then drop by drop after defecation. She also had a history of constipation for the same duration.

She had no history of fever, abdominal pain, fecal soiling, repeated antibiotic use, blood transfusion, oral ulcer, weight loss, cold intolerance, or close contact with a known TB patient.

On examination, she was conscious, alert, mildly pale, vitally stable, and anthropometrically well thriving. Per-abdominal examination revealed no organomegaly or ascites. DRE revealed staining of the fingertip with fecal matter but no blood and other systemic examinations revealed normal findings.

So what could be the diagnosis?

Plan of investigation

1. CBC with PBF
2. Plain X-ray abdomen in an erect posture
3. Stool R/E
4. Colonoscopy

For colonoscopy:

Blood grouping and cross matching

PT, APTT

HBsAg

All the reports were normal.

This is the x-ray finding: radiolucent area and paucity of air in between and loaded intestine with fecal matter.

Colonoscopy findings

A single pedunculated polyp is seen at the rectum 10 cm from the anal verge. Polypectomy of pedunculated polyp done and sent for histopathology.

Histopathology report

The report was collected on follow-up.

Possible questions from the above scenario:
1. Why did you say no history of blood transfusion and repeated antibiotics use?

A colorectal polyp is associated with small bleeding and no need for a blood transfusion. But in Meckel’s diverticular bleeding, there is profuse bleeding that often requires a blood transfusion. Repeated antibiotic use is associated with pseudomembranous colitis.
2. You said she got lactulose, was it adequate?

No, a dose of lactulose is 1-5ml/kg/dose, 12 hourly until normal stool. Then titrate the dose for 1-2 soft stool per day.
3. What is the importance of dietary history in your patient?

Frequent taking of street food, and junk food, and less water intake is associated with constipation which results in anal fissure and rectal bleeding.
4. Why did you say no family history of the same type of illness?

Familial adenomatous polyposis runs in the family as it is autosomal dominant.
5. What are the other causes of painless PR bleeding?

Meckels diverticular bleeding, vascular malformation, coagulopathy.
6. You said, age suggestive, what is the peak age?

Colorectal polyp peak age is 2-6 years. It is rare after 10 years of age.
7. Is histopathology needed for all patients? What are the chances of malignancy?

There are 2 % chances of malignancy. So histopathology is done to exclude malignancy.
8. Why did you call it juvenile?

Juvenile refers to the histological type of polyp as benign and has no risk of malignancy and not the age of onset of the polyp.

9. What are the complications of polypectomy?

Complications are rare with an expert hand. The most common complications are hemorrhage, intestinal perforation, post-polypectomy syndrome, and Mild GIT symptoms like abdominal pain, bloating, diarrhea, nausea, etc.
10. What advice did you give? Does the patient need follow-up? Can it occur again?

Advice for the relief of constipation is as follows:

• Dietary modifications such as adequate fiber and fluid intake, avoiding junk food, fast food, and cow’s milk.
• Toilet training for >4 years child. Sit on the toilet for 5-10 minutes, 3-4 times after a major meal.
• Increased physical activity.
• Removal of stressful conditions.
• Clean toilet in school.

Most common causes of per rectal bleeding in Bangladesh?

• Infective colitis
• Anal fissure
• Colorectal polyp
• Meckels diverticular bleeding
• Vascular malformation

Polyp is a tissue mass that project from the wall of the bowel into the lumen of the GI tract.

Juvenile polyps: are hamartomatous polyps limited to the colon, usually less than 5 in number with an absence of family history.

Juvenile polyposis syndrome: more than 5 polyps in the colon or rectum, also in other parts of the GI tract, and positive family history.

Familial Adenomatous polyposis: Autosomal dominant variant, more than 100 polyps, asymptomatic, and chance of malignancy.

Thanks, everyone for reading.

Further reading: PDF

Patient education: Blood in bowel movements (rectal bleeding) in babies and children (Beyond the Basics) Uptodate.com [Link]

Per Rectal Bleeding in Children: Experiences in the Department of Paediatric Surgery in BSMMU Link