Rectal bleeding in children

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— Rectal bleeding is quite common in children. Often the bleeding is self-limiting. Rectal polyps are very important cause of rectal bleeding. Infections like shigellosis are important causes and should be kept in mind for differential diagnosis.
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   International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-4, Issue-12, Dec- 2017] https://dx.doi.org/10.22161/ijaers.4.12.3 ISSN: 2349-6495(P) | 2456-1908(O) www.ijaers.com Page  | 20   Rectal bleeding in children Tamal K. Choudhury 1 , Sujit K. Bhattacharya 2 KPC Medical College and hospital and Glocal Healthcare Systems Pvt Ltd Corresponding author: Tamal K. Choudhury Email: Choudhury.tk@gmail.com   Abstract   —     Rectal bleeding is quite common in children. Often the bleeding is self-limiting. Rectal polyps are very important cause of rectal bleeding. Infections like  shigellosis are important causes and should be kept in mind for differential diagnosis. Keywords  —   Bleeding, Rectum, Stool, Dysentery, Rectal  polyp. I.   INTRODUCTION Rectal bleeding in children is quite common and parents  become very anxious due to the sight of blood in stool. So the presentation to doctors is relatively early than in other disease conditions. The positive part is the blessing is often self limiting and mostly benign in nature. Bleeding can be painful or painless, mild to severe & intermittent or continuous. The incidence is about 0.3%.Bleeding may  be streaks on the stool, drops or admixed with loose stool & rarely profuse. II.   AETIOLOGY The commonest cause of rectal bleeding is local in the anal canal 1,2  or rectum. Occasionally it may come from higher locations like colon and small gut. It can srcinate very rarely from stomach or duodenum particularly in  brisk bleeding. Of the local causes anal fissure accounts for the majority of cases. The second most common cause is polyps. Most of the polyps are hamartomatous or hyperplastic. Other polyploidal conditions e.g. PJ syndrome or FAP may be the source of bleeding. Intussusceptions are an important cause to be remembered  particularly during weaning period. Another important cause of bleeding is prolapse rectum. Rarer causes include HD, stercoral ulcer, haemorrhoids, Meckel's diverticulitis, IBD, Diverticulitis, mesenteric ischemia, volvulus etc. Medical conditions which are associated with bleeding  per rectum are dysentery, allergic enteritis, infectious diarrhoea (campylobacter &clostridium dificile), Henock Shonlein purpura etc. Children are brought to hospital or doctor's chamber by  parents mostly on first bleed or quite early unlike in adults who ignore it for a long time. Unless severe in nature children do not have any complaints. Cramping pain may  be experienced by some during the episode & vomiting is very rare. History of constipation and passing hard stool is commonly obtained specially in fissure and HD. Pallor is  present in chronic blood loss or severe haemorrhage. Pigmentation and patechial spots may be detected in PJ syndrome or Henoch Shonlein pupura.A palpable sausage shaped mass in the central abdomen is diagnostic of intussusceptions. Abdominal distension and visible  peristalsis may be found in volvulus or HD. Perianal skin tags, fissures & prolapsed rectum are diagnostic on  perianal examination. Digital rectal examination will confirm the presence of fissure, polyp or ulcer. Proctoscopy & sigmoidoscopy will reveal most of the  pathologies in the anal canal, rectum & sigmoid colon 3 . III.   INVESTIGATION In most of the cases diagnosis is confirmed by clinical examination alone with the help of proctoscopy and sigmoidoscopy and treatment advised. Investigations include CBC, PT, APTT, ESR, C-reactive protein to exclude haemorrhagic disorder and IBD. Stool microscopy and culture is indicated in cases of bleeding with diarrhoea. Colonoscopy 4  & Gastroduodenoscopy are carried out to visualise and document the pathology in  proximal bowel. Technetium scan is the investigation of choice to diagnose Meckel's. Polyps should be sent for  biopsy to ascertain the nature. IV.   TREATMENT Treatment should start as early as possible. Medical causes5 need immediate attention with proper diet, fluid & drugs. In anaemic patients haematinics & blood transfusion may be necessary. Anal Fissure needs conservative management which include bowel training, fluids & laxatives .Rectal polyps are removed digitally or  by snares & they need histopathological examination 6 . Multiple polyposes should be investigated thoroughly regarding their nature and appropriate treatment suggested. Prolapse of rectum is reduced manually, diarrhoea controlled and weight gain encouraged. Operative reposition is occasionally indicated. Bleeding from Meckel's diverticulum dictates surgical excision on an emergency basis. Stress ulcers are becoming common nowadays in ICU children if proper care is not taken. IBD and other colitis are not rare & early diagnosis & treatment in a paediatric setting is recommended.   International Journal of Advanced Engineering Research and Science (IJAERS) [Vol-4, Issue-12, Dec- 2017] https://dx.doi.org/10.22161/ijaers.4.12.3 ISSN: 2349-6495(P) | 2456-1908(O) www.ijaers.com Page  | 21   V.   CONCLUSION In cases of diarrhoea with bleeding conservative management is indicated. Stool microscopy and culture are of paramount importance in such cases. In severe cases hospitalisation is mandatory. Blood dyscrasias causing rectal bleeding needs admitting in Paediatric unit for evaluation & proper treatment. As most of the cases are of benign nature and self limiting explanation, assurance and "safety netting”  is indicated. REFERENCES   [1]   Sáenz, Roque; Valdivieso, Eduardo. "Approach to lower gastrointestinal bleeding" (PDF). p. 2. Archived from the srcinal (PDF) on 2013-12-13. [2]   Jump up^ Katz, Jonathan. "HEMATOPAPYRUS AND OTHER MEDICAL JARGON". Archived from the srcinal on 2016-10-05. [3]   Jump up^ "Colon Cancer Symptoms - What are Colon Cancer Symptoms". Coloncancer.about.com. 2009-01-20. Retrieved 2012-01-31. [4]   Jump up^ "Colon cancer: Symptoms". MayoClinic.com. 2011-08-13. Retrieved 2012-01-31. [5]   "Causes and Symptoms of Shigellosis". Minnesota Department of Health. [6]   Jump up^ Lenz, Heinz-Josef (2009-03-06). "What are Early Symptoms of Colorectal Cancer? Watch out for Small Changes". Alexandria, Virginia, United States: Fight Colorectal Cancer. Archived from the srcinal on 2009-03-10. Retrieved 2013-02-23
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