Lower Gastrointestinal Bleeding

 

Lower gastrointestinal bleeding (LGIB) in infants and children is commonly encountered in clinical practice.  It can appear as blood mixed in the stool, on toilet paper, or in the toilet bowl. The blood can appear as bright red in color to a dark maroon. The color of the blood can help further distinguish where the bleed is coming from.

 

  • Hematochezia: described as the passage of bright red blood per rectum (BRBPR) and will usually suggest a lower GI bleed, typically from the rectum or anus.
  • Melena: describes the passage of stool that appears black, dark maroon or tar-like, which usually suggests an upper GI bleed.
  • Occult blood, unseen blood that is identified by stool testing, is not visible to the patient or physician, but will typically present as iron deficiency anemia.

There are many different causes of lower GI bleeding, but the diagnosis varies depending on age. The following causes of bleeding are the most common causes seen in the United States.

 

NEONATAL: (younger than one month)

In a newborn infant, who presents with LGIB, the rectal blood should be tested to determine whether the blood is coming from the infant or if it represents maternal blood, which may have been swallowed during delivery or ingested during breast feeding from cracked nipples.

  • Swallowed maternal blood: The Apt test (hemoglobin alkaline denaturation test) can detect fetal hemoglobin and will accomplish the distinction between the neonates blood or maternal blood.
  • Anorectal fissures:
    • Most common cause of rectal bleeding in patients less than one year of age. A history of straining, stool holding behaviors, and streaks of bright red blood on the outer surface of the stool or on a wipe are all indications of a possibility of a rectal fissure. Anorectal fissures are highly associated with constipation, therefore upon treating the constipation with stool softeners, lubricants, and a change in diet to allow for softer stool will also treat the progression or anorectal fissures.
      • Note: increased associated risk of fissures with the introduction of solid foods or cows milk into the diet, school entry or potty-training.
    • Necrotizing enterocolitis (NEC):
      • An acute illness of unclear etiology is associated with inflammation of the lining of the intestine followed by intestinal necrosis (dying of the intestinal cells). NEC is suspected in a newborn when they present with a sudden change of feeding tolerance along with nonspecific systemic signs such as high fever, poor feeding, fatigue, abdominal distention and tenderness, bilious vomiting, diarrhea with gross or occult blood, and respiratory failure. Typically these patients are born prematurely and will normally occur in infants who are on enteral feedings. Enteral feedings is a method to provide food through a tube into the gastrointestinal (GI) tract as a means to deliver a person’s caloric needs. The tube can be placed in the nose to the stomach or can be placed through the skin into the stomach.
      • Abdominal imaging: The finding of pneumatosis intestinalis, bubbles of gas within the walls of the small intestine, is diagnostic of NEC. An abnormal gas pattern with dilated loops of bowel may also be seen in NEC. A normal abdominal X-ray cannot rule out NEC.
      • Management: as soon as NEC is suspected in an infant, prompt medical management needs to be initiated. This includes supportive care, antibiotic therapy, and regularly scheduled examinations with close laboratory and radiologic monitoring.
        • Supportive care: discontinuation of enteral feedings with bowel rest, gastric decompression with nasogastric suction (a tube is placed from the nose to the stomach to prevent gas buildup in the stomach), starting total parenteral nutrition, and correction of fluid/electrolytes. Total parenteral nutrition (TPN) is a method to supply all of the nutritional needs of the body by directly dripping nutrient rich solution into a vein and bypassing the GI tract.
        • Surgical intervention: A surgeon is consulted when NEC is suspected to help in the evaluation and management of the neonate. Surgery is only indicated when a pneumoperitoneum (presence of air in the peritoneal cavity) is detected by abdominal imaging. Pneumoperitoneum indicates that a hole has been formed within the walls of the intestines into the abdominal cavity due to the death of the intestinal cells. Surgery can also be indicated in a neonate who does not have pneumoperitonitis, but is showing signs of clinical deterioration despite maximal medial support.
      • Malrotation with midgut volvulus
        • Intestinal malrotation is a defect that occurs during development; during the 10th week of gestation, the intestines to not correctly migrate back into the abdominal cavity, causing a defect known as intestinal malrotation. In intestinal malrotation, the large intestine is to the left of the abdomen and the small intestine is on the right side of the abdomen. The cecum and appendix, which are usually held down in the right lower quadrant, are now unattached and held loosely in the upper abdomen. In addition, there is usually abnormal tissue present, Ladd’s bands, that attach the cecum (beginning of the large intestine) to the duodenum (beginning of the small intestine), which can later cause an intestinal obstruction. Due to this malrotation, the blood supply to the intestines are through a narrow structure called the mesentery and since the bowel is not properly attached, it can twist on its own blood supply, termed mid-gut volvulus. As the blood supply gets cut off to the bowel, the intestines will start to necrose, death of the intestinal cells.
        • Signs and symptoms: Infants will typically present with abdominal distention, vomiting with or without bile, abdominal obstruction, melena or hematochezia. This is considered a life-threatening surgical emergency until proven otherwise.
        • Support: Children are started on intravenous (IV) fluid to prevent dehydration and are also started on antibiotics to prevent infection.
        • Diagnosis: can be suggested by a plain abdominal X-Ray, which may show mild intestinal dilation, but more importantly it can show the “double-bubble” sign, indicating a duodenal obstruction. Abdominal X-ray’s are typically first done to rule out intestinal perforation. Once that is ruled out, the BEST test is an upper gastrointestinal contrast series that will allow direct visualization of the position of the small intestines. Barium contrast studies may reveal a corkscrew appearance of the small bowel, or a “birds beak” if complete obstruction is present.
        • Treatment: via surgery the intestines are untwisted and normal circulation is typically restored after untwisting. If the bowel remains healthy, the Ladd Procedure is performed to repair the malrotation and prevent future occurrences.
      • Hirschsprung Disease (HD) ***ADD UNDER CAUSES OF CONSTIPATION***
        • HD is a motor disorder of the gut due to the failure of the enteric ganglion cells to migrate completely to the large intestine during development of the intestines during fetal life. The resulting aganglionic segment of the colon fails to relax, causing a functional obstruction. HD typically affects the rectosigmoid colon.
        • Signs and symptoms: newborns will present with delayed passage of meconium (stool) greater than 48 hours after birth. Some infants present with an acute obstruction, where they develop abdominal distention and vomiting, may or may not be bilious. Other infants will present a few weeks after birth with constipation and diarrhea with abdominal distention. Typically 25% of the population who has HD will present with blood in the stool.
        • Diagnosis: is strongly suggested after a digital rectal examination, after which the infant will have explosive expulsion of gas and stool. In a stable patient, a contrast enema can be used as the initial test, which will show marked dilation of the unaffected colon before the aganglionic segment of the colon, which will appear smaller in comparison. If needed, the confirmatory test is done with the anorectal suction biopsy or anorectal manometry, which can show complete absence of the ganglion cells of the Meissner and Auerbach plexus on biopsy of the intestinal mucosa and submucosa.
        • Treatment is usually surgical resection of the aganglionic segment.
      • Coagulopathy
        • Vitamin K deficient bleeding: this disorder usually presents in the infants who did not receive the vitamin K injection at birth. The infant will present with LGIB, intracranial bleeding in neonates, cutaneious symptoms that develop within the first week of life.
        • Underlying liver disease with a defect in blood coagulation
          • In severe disease, the liver is unable to make clotting factors for the body. A defect in the coagulation system can lead to the inability to stop a bleed within the GI system. The patient may present with a serious LGIB with labs that show an increased Prothrombin time (PT), Partial thromboplastin time (PRR), and International normalized ratio (INR). These are evaluate proper coagulation times.
        • Congenital hemochromatosis:
          • This is a disorder affecting newborns. It is characterized by absorbing too much iron from the gastrointestinal tract. The body does not have a way of getting rid of the excess iron, so instead it stores in the major organs of the body, such as the liver, heart, brain, pancreas, and the joints. Over time, the increasing levels of iron become toxic to the body and can damage and destroy these organs, most commonly the liver. The liver becomes cirrhotic (scarring of the liver tissue) and will be unable to make clotting factors. Patients may present with abdominal pain, typically RUQ, and possibly lower GI bleed due to the inability to make clotting factors from the severe liver disease.
        • Tyrosinemia Type 1:
          • A rare autosomal recessive genetic metabolic disorder due to the lack of an enzyme, Fumarylacetoacetate hydrolase (FAH). FAH is the enzyme needed in the final break down tyrosine, an amino acid. Therefore, tyrosine and its metabolic metabolites accumulate in the body, which can lead to liver disease. Patients, within the first month of life, will present with symptoms that most commonly include failure to thrive (inability to gain weight and grow at the expected rate for their age), fever, diarrhea that is bloody (melena), vomiting, hepatomegaly (enlarged liver), and jaundice (yellowing of the whites of the eyes and the skin). Severe complications can lead to liver cirrhosis (scarring of the liver tissue). Due to liver disease and the inability to make clotting factors, the patient may also present with easy bruising and bleeding.

 

Infants and Toddlers: one month to two years

  • Anal fissures: as discussed above
  • Milk or soy induced colitis:
    • This is a type of inflammatory reaction of the gut caused by ingestion of cows milk or soy proteins in both formula-fed and breast-fed infants, via the mother’s diet. This type of induced colitis will present as bloody stools, often with occult or gross blood, but are otherwise healthy infants.
    • Treatment includes elimination of the causative protein from the mothers’ diet and from the formula being used. Typically, by 18 months, this sensitivity will resolve on its own, at which time the milk protein can slowly be added back to the infants diet.
  • Intussusception:
    • Intussusception is the telescoping of part of the intestine into itself. It is the most common intestinal emergency and intestinal obstruction in infants between 6 to 36 months of age. Intussusception is typically idiopathic (the cause is unknown and occurs spontaneously) and occurs in the ileocecal region (where the small intestine turns into the large intestine), in contrast to older children in which a polyp or Meckel’s diverticulum will serve as the lead point.
    • Signs and Symptoms: The child will be very irritable and present with severe abdominal pain and vomiting. The infant may pass stool and improve temporarily before the cycle repeats, eventually patients become severely irritable and may pass a bloody, “currant-jelly” type of stool. Currant-jelly stool refers to stool that is dark red and gelatinous like that contains blood and mucus. The stool may have gross or occult blood. On physical examination, there will be a “sausage-shaped” mass in the region of the colon, typically in the right upper quadrant.
    • Diagnosis: typically done with ultrasonography showing a “donut” or “target sign” sign; represents layers of intestine within the intestine. An ultrasound test is better able to find the lead point that caused the intussusception. The diagnosis can also be done with air or water-soluble contrast enema.
  • Meckel’s Diverticulum:
    • The most common congenital abnormality of the GI tract, resulting from the incomplete obliteration of the vitelline duct during fetal development. The remaining vitelline duct forms a true outpouching (diverticulum) of the small intestine that is present at birth. The outpouching is composed of the stomachs mucosa instead of small bowel mucosa, therefore produces acid. This acid production can lead to ulcer formation, which can eventually lead to a hole within the small intestine causing a serious infection. When an ulcer forms, it normally bleeds, leading to melena. Meckel’s diverticula are uncommon and typically occur in about 2% of all infants.
    • Signs and symptoms: Patients’ will typically present with abdominal pain, GI bleeding and/or bowel obstruction.
    • Diagnosis: the definitive diagnosis is made with a Meckel’s scan and, if positive and symptomatic, treatment is resection.
  • Lymphonodular hyperplasia:
    • Lymphonodular hyperplasia is routinely round incidentally during endoscopy or colonoscopy. It has been said that it may be a normal finding or it may be due to an immunological response to a variety of stimulants including allergies, medications or infection. The true etiology is unknown.
    • In lymphonodular hyperplasia, there is disruption of the normal mucosa leading to mucosal thinning and an increased chance of ulceration, which can then lead to intestinal bleeding and ultimately hematochezia. This is a type of painless lower GI bleeding and will typically resolve on its own.

 

Pre-School aged children:

  • Anal fissures: see above
    • Especially during potty-training periods
  • Intussusception: see above
  • Meckel’s Diverticulum: see above
  • Infectious colitis
    • Many different pathogens can cause LGIB in preschool children. The most common pathogens in the U.S. are Salmonella, Shigella, Campylobacter, E. Coli O157:H7, and Clostridium difficle. The diagnosis of the specific bacteria is done via a stool culture where the organism is isolated and identified. Along with a stool sample, other tests that are typically performed are occult blood, fecal leukocytes, fecal calprotectin, or fecal lactoferrin—these are nonspecific tests but can help with diagnosis of infection and/or inflammation of the gut.
      • Salmonella: most commonly in children younger than 5 years of age, with the highest incidence being below one year of age.
        • Salmonella is a type of bacteria that is responsible for causing salmonellosis, a foodborne illness caused by infection of the salmonella bacteria. Salmonella is spread to people through contaminated food, usually meat, poultry, eggs or milk. This infection is contagious and can spread from several days to several weeks after they have been infected. The infection can take up to 72 hours to starts after ingestion of the bacteria. The symptoms may last from 4-7days.
        • Signs and symptoms: nausea and vomiting, abdominal cramps, diarrhea with or without blood, fever and headache.
        • Diagnosis: stool sample to confirm the actual bacteria.
        • Treatment: the infection typically clears on its own without intervention, but if your child has a fever you may want to give acetaminophen to lower the temperature and abdominal cramping. In infants less than one year of age, antibiotics are typically given to help clear the infection. Avoid dehydration with oral rehydration solution!
        • How to prevent Salmonella infection?
          • Cook food thoroughly, handle raw eggs carefully, avoid foods that might contain raw ingredients, and keep food chilled.
        • Shigella:
          • Shigella bacteria produces a type of toxin that can attack the lining of the large intestine causing swelling, ulcers, bloody diarrhea, and can lead to an infection called shigellosis. This infection most commonly affects children aged 1-4 years old.
          • Shigellosis is extremely contagious. Shigella is spread from contact with something contaminated by stool from an infected person. This can be anything like surfaces of toys, tables, bathrooms, and even water supplies in areas with poor sanitation. It does not take many of the Shigella bacteria to cause disease, therefore it’s spread very very easily.
          • Signs and symptoms: fever, crampy abdominal pain, nausea, vomiting, and watery diarrhea that later becomes bloody.
          • Diagnosis: stool sample to confirm the actual bacteria.
          • Treatment: some cases do not require treatment but this bacteria can actually be treated with antibiotics, unlike many other bacteria that cause diarrhea. Without treatment, the disease typically lasts 7-10 days and your child may still carry the bacteria for several weeks after the diarrhea stops. Avoid antidiarrheal medications because that will slow your gut motility and you want the bacteria to leave the intestines as quickly as possible. Acetaminophen can be given for fever and pain. Prevent dehydration with oral rehydration solution.
          • Prevention:
            • Careful and frequent hand washing with soap, especially after using the bathroom and before eating!
            • Proper handling, storage, and preparation of food.
          • Campylobacter:
            • Campylobacter bacteria is a type of bacteria that is found in the intestines of many wild and domestic animals. This bacteria can pass to humans when various types of food, meats, water (stream or rivers), and unpasteurized (raw) milk are contaminated with animal feces that are infected.
            • The bacterium can attack the lining of the small and large intestines. Campylobacteriosis is contagious and can spread from person to person when someone comes in contact with fecal matter from an infected person. Symptoms typically occur 2-5 days after ingestion of the contaminated food. The symptoms may last up to 10 days.
            • Signs and symptoms: fever, abdominal cramps, nausea and vomiting, and mild to severe diarrhea. The diarrhea typically begins watery but can progress to include blood and mucous. Severe diarrhea can lead to dehydration.
            • Treatment: Normally self resolves without need for treatment. Rarely are antibiotics prescribed, unless the child is very young or the symptoms persist. Do not use antidiarrheal medications.
            • Prevention:
              • Use drinking water that has been tested and approved
              • Choose pasteurized milk and juice
              • Wash hands before preparing food and after touching raw meats, especially chicken
              • Cook meat and eggs thoroughly
              • Wash hands after using the bathroom, cooking with raw meats, or contact with pets and farm animals!
            • Clostridium difficle (C. difficle):
              • difficile is a toxin producing bacteria that naturally lives in our large intestine to help break down the food we eat. Occasionally, this bacteria will produce toxins that can affect the lining of our gut and cause C. Difficle enteritis. This infection typically occurs after recent antibiotic use for a longer period of time. Kids are also at an increased risk of C. Difficle infections if they have been in a hospital setting for a long period of time or have a decreased immune system.
              • Signs and Symptoms:
                • Mild to moderate symptoms: watery diarrhea, abdominal pain, and cramping
                • Severe cases: watery diarrhea up to 15 times per day, fever, nausea, dehydration, abdominal pain, and tenderness
              • Diagnosis: stool sample to verify the bacteria.
              • Treatment: the predisposing antibiotic needs to be stopped first and typically the C. difficle will go away on its own. In some cases, another antibiotic, Flagyl, Oral Vancomycin, or Alinia, will be prescribed to keep the bacteria from growing.
            • Coli O157:H7:
              • Coli is a type of bacteria that normally lives in the gut flora of our large intestine and helps break down and digest the food we eat. There are certain types of E. Coli that are infectious and can spread through contaminated food, water, or other infected individuals. E. Coli O157:H7 is a specific type of bacteria that can produce a toxin that destroys the mucosa of the small intestine.
              • Signs and symptoms: abdominal cramps, diarrhea mostly with blood, and vomiting. Symptoms start about 3-4 days after ingestion of the bacteria and symptoms typically last around a week.
              • Treatment: symptomatic control. Antibiotics can actually be harmful for this type of bacteria. Anti-diarrheal should be avoided as the child needs to rid the stool to get rid of the bacteria. Make sure to maintain hydration.
              • Prevention:Coli outbreaks have been associated with hamburgers, fresh spinach, shredded lettuce, and prepackaged cookie dough. The best way to prevent contamination is safe food preparation: cook meat thoroughly, clean anything that has had contact with raw meats, choose pasteurized juices and dairy products, clean raw produce very well before eating.
              • Teach Kids about regular and thorough hand washing, especially after going to the bathroom or petting animals!!!
            • Hemolytic-uremic syndrome (HUS)
              • HUS is described by the simultaneous occurrence of microangiopathic hemolytic anemia (loss of red blood cells through destruction), thrombocytopenia (low platelets), and acute renal injury. The most common cause of HUS is Shiga toxin-producing Escherichia coli (STEC) and less commonly from Shigella dysenteriae Type 1 infection. In this section we are going to focus on the diarrhea producing forms of HUS.
              • Children with STEC-HUS will generally first present with abdominal pain, vomiting, and diarrhea before the actual development of HUS by 5 to 10 days. It is important to note that the signs and symptoms of the gastrointestinal complains of HUS mimic Ulcerative colitis, other enteric infections, and can even present like appendicitis.
              • Signs and symptoms that define HUS: (sudden onset)
                • Hemolytic uremic syndrome: the destruction of our red blood cells (RBC). Classified as a hemoglobin level usually less than 8g/dL. Under a microscope, there will be a large percentage of schistocytes and helmet cells (RBCs that have a deformed shape due to their destruction). The child may have a recent onset of paleness and increased tiredness.
                • Thrombocytopenia: low platelet count, below 140,000/mm3. Usually you do not have active bleeding but may have easy bruising.
                • Acute kidney injury: may have blood and protein in the urine, decreased urinary output, and ultimately dehydration.
              • Diagnosis: Typically based off of the history of recent diarrhea (possibly with blood) and signs of multisystem disorders. Evaluation includes a complete blood count, kidney function tests, a smear to look at the RBC’s, and a screening for the Shiga toxin producing bacteria.
              • Treatment: This can be a life-threatening condition and may require hospitalization. The management is typically supportive care because there is no actual proven safe or beneficial intervention. It is important to watch for dehydration and maintain fluid and electrolyte balance, occasionally intravenous (IV) fluids will be indicated. Anemia may require a blood transfusion. In extreme cases, temporary dialysis may be necessary to help with the acute kidney injury.
            • Immunoglobulin A vasculitis (IgAV), also known as Henoch-Schönlein Purpura (HSP):
              • IgAV is an immune-related vasculitis associated with IgA deposition. The underlying cause of IgAV is unknown but it is said that immunologic, genetic, and environmental factors all play a role. Typically occurs in children aged 3-15 years old.
              • Signs and symptoms: abdominal pain, palpable bruises with normal platelet count, joint pain, and/or kidney disease. The GI symptoms occur in about one-half of the patients with IgAV and can range from mild nausea, vomiting, abdominal pain to more severe findings such as GI hemorrhage, bowel death due to decreased blood supply, and bowel perforation.
              • Treatment: Majority of patients will recover spontaneously, therefore treatment is supportive with hydration, rest, and symptomatic pain relief.
            • Polyps:
              • A polyp is an abnormal growth of tissue formed from the lining of the intestines. Polyps all vary in size and can be classified as sessile (short and flat) or can be pedunculated (large and protruding). They can be found anywhere throughout the GI tract, but most commonly found in the large intestine. Typically occur between the ages of 2 and 10 years of age. Polyps usually bleed after the stool has pushed against it causing bright red blood per rectum. There are many different types of polyps, we will discuss a few below.
              • Hyperplastic/Inflammatory polyps are the most commonly seen polyps in children. They are benign polyps and are typically pedunculated.
              • Juvenile polyp is most commonly a benign hamartoma, which is a noncancerous growth made up of a mixture of cells and tissues that are normally found in that region of the body but are growing in an unorganized fashion forming a mass like growth. Hamartomas are normally pedunculated.
              • Most children have one to two juvenile polyps, but if a child presents with greater than 10 polyps and a family history of polyps, they may have a genetic condition called Familial Polyposis Syndrome (FAP). FAP is an autosomal dominant disease caused by mutations in the Adenomatous Polyposis Coli gene. “Classic” FAP is described as a child having over 100 or more adenomatous colorectal polyps. Patients with FAP should undergo genetic testing and should also have a colonoscopy and biopsy ever two to three years to screen for colorectal cancer. Although these polyps are typically benign, children with this syndrome are said to have an increased risk of developing colorectal malignancies.
              • Signs and symptoms: Painless rectal bleeding with or without mucus and abdominal pain.
              • Diagnosis and Treatment: the diagnostic tests are upper and lower endoscopies to directly visualize and remove the polyp. The polyp is then sent to the lab to check for cancerous cells. Polyps in children are typically benign.
            • Hemorrhoids:
              • Hemorrhoids are swollen veins in the lower rectum or anus. Hemorrhoids are very common in a wide age range and can present in infants all the way up to adulthood. Hemorrhoids can be classified in two different ways: they can be internal or external.
              • Internal:
                • Internal hemorrhoids can be found inside of the anus and at the beginning of the rectum, but they may stretch and bulge out of the anus. They are considered to be painless.
              • External:
                • External hemorrhoids are outside of the body and can be felt as a painful buldge at the anal opening. These can become irritated and cause itching and potential bleeding. Blood clots form causing severe pain, swelling and inflammation.
              • Diagnosis: The doctor can typically see the hemorrhoids on physical examination or they can perform an internal anal and rectal exam if not easily seen. Occasionally, for internal hemorrhoids a proctoscope or sigmoidoscope may be used to better visualize the hemorrhoid.
              • Treatment: most hemorrhoids can be treated at home with over the counter hemorrhoid creams, sitz baths, and witch hazel.
              • Prevention: the best way to prevent hemorrhoids is to prevent constipation. Being constipation can worsen hemorrhoids due to the straining. Eat lots of fruits and vegetables to increase fiber intake, can take fiber power, or stool softeners.
            • Arteriovenous Malformation (AVM):
              • AVM is a rare disorder that occurs during the developmental stage of the vascular system, therefore they develop before birth but can enlarge as the child ages. AVM malformations are most common intracranially (within and around the brain) but can also occur within the GI tract.
              • An AVM is an abnormal connection between an artery (vessel that carries oxygenated blood from the heart to the body) and a vein (vessel that carries blood from the body back to the heart for oxygenation). Capillaries connect the high pressure arteries to the lower pressure veins. When an AVM occurs, the capillaries are missing and the arteries connect directly to the veins. These abnormal connections in the bowel can lead to a severe lower GI bleeding. The child may also present with anemia and fatigue.
              • Diagnosis: an imaging test, such as an ultrasound, MRI, CT or angiography, is done for confirmation.
              • Treatment: depending on the size and location of the AVM as well as the child’s symptoms.

 

School-aged children and adolescents:

  • Anal Fissures: see above
  • IgAV (HSP): see above
  • Meckel’s Diverticulum: see above
  • Infectious colitis: see above
  • Juvenile Polyps: see above
  • Hemorrhoids: see above
  • Arteriovenous Malformations: see above
  • Inflammatory bowel disease (IBD):
    • IBD may present in preschool children and even in infancy, but it is much more common in school-aged children and adolescents. The peak incidence of IBD is in late adolescents and early adulthood, 15-30 years of age. IBD is composed of two major disorders: Ulcerative Colitis (UC) and Crohn’s Disease (CD). The most common symptoms of IBD are abdominal pain, fever, and diarrhea (with or without blood and mucus), and weight loss.
    • Ulcerative Colitis (UC): UC is a chronic inflammatory disorder that affects the lining of the large intestine, specifically starting at the rectum (the end part of the colon) and spreading back into of the colon. Children typically present with diarrhea, with or without blood and mucus, abdominal pain, nausea and vomiting.
    • Crohn’s Disease (CD): CD is an immune-mediated inflammatory disorder of the gastrointestinal (GI) tract affecting anywhere from the mouth to the anus. CD typically affects the terminal ileum (the end of the small intestine) and the cecum (the beginning of the large intestine), but can affect the entire colon and anywhere along the GI tract. Children with CD will typically present with persistent diarrhea, sometimes with blood and mucus, abdominal pain and cramping, weight loss, mouth sores, arthritis, and/or fever.
  • Solitary rectal ulcer syndrome (SRUS):
    • SRUS is a very rare benign syndrome but can potentially cause a chronic ulcerative disease of the rectum. The cause is unknown. SRUS is typically found incidentally during the workup of the patients’ complain of a LGIB.
    • Symptoms: bleeding from the rectum typically with mucus, straining with defecation, and a feeling of fullness in the rectum after defecation.
    • Diagnosis: during a colonoscopy the ulcer will be visualized in the rectum
    • Treatment: in a child with constipation, treat the constipation first to avoid straining and further injury to the ulcer.

 

 

 

  1. Tanya Mohseni, OMS-IV

 

2100 Clinch Ave #510,
Knoxville, TN 37916

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2100 Clinch Ave #510,
Knoxville, TN 37916

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