Patient Presentation
A 19-year-old male came to clinic with multiple symptomatic complaints for 2-3 weeks including rhinitis, cough, fatigue, body aches and a tactile temperature. He has been very stressed because of school demands and extra-curricular activities during his senior year in high school, and has been taking large amounts of ibuprofen medication. The symptoms have been slightly improved the past few days. After his mother left he confided that he was actually most worried about some blood that he had noticed in his stool which he described as streaks on the outside of the stool. This has occurred several times in the past few days and his anus has some pain when passing a stool. He says that his stools have been harder and less frequent since his illness. He also says he hasn’t been drinking as much as usual. He denied sexual activity. He has a past medical history of constipation which he does not actively treat.
The pertinent physical exam shows a healthy appearing male who appears stressed about his daily routine. He has not gained nor lost weight since a visit 3 months previously. HEENT shows mild clear rhinitis and his lungs are clear. Abdomen is soft, non-tender without masses. Rectum shows no fissures or tags and rectal examination has hard stool present in a dilated vault without pain. Guaiac is negative.
The diagnosis of constipation causing rectal bleeding was made. Additionally the patient had concomitant non-steroidal anti-inflammatory medication (i.e. NSAIDS) use which may be playing a minor role. He was reassured that he most likely had a viral syndrome that was now improving and counseled to decrease the ibuprofen use and if needed to use acetaminophen. Constipation counseling was also done including use of Miralax®, increasing fiber and regular toileting habits. Stress was also addressed. He agreed to having his problem discussed with his mother, who wanted him to also see a gastroenterologist. One month later at the gastroenterologist he was having normal stools and reported no blood since he has increased the fiber in his diet.
Discussion
Blood mixed in the stool is usually from higher in gastrointestinal tract, while blood coating the stool is usually from the anal canal or rectum. Brisk hemorrhage (i.e. hematochezia) with fresh blood and clots is distal to the Ligament of Trietz. Fresh blood is often from the left colon or maroon-colored if from the right colon. Melena is passage of dark, tarry stools. Melana is usually from the esophagus, stomach or duodenum but all areas of the small bowel may be affected. Tarry stools can also be caused by bismuth, iron or licorice ingestion. There is an artificial dividing line between upper and lower disease processes, because rapid transit of blood from the upper GI tract can produce hematochezia and slow transit of blood in the lower tract can cause melena.
Neonates and young children often will present with congenital anomalies or causes of bleeding seen only in this period, i.e. necrotizing enterocolitis. Adolescents present the opposite problem. While they most likely have common problems such as constipation or infectious diseases as the cause of their bleeding, they also may have adult problems such as Mallory-Weiss tears from binge drinking, proctitis from anal intercourse or even adult cancers such as adenocarcinoma. As always, careful history, evaluation and follow-up are always key.
Learning Point
The differential diagnosis of gastrointestinal bleeding includes:
- Upper GI bleeding
- Esophagitis
- Gastritis
- Peptic ulcer
- Mallory – Weiss tear
- Allergy – cow’s milk, other
- Blood dyscrasia – disseminated intravascular coagulation, thrombocytopenic states
- Drugs – NSAIDS
- Factitious
- Foreign body
- Nasopharyngeal bleeding
- Swallowed blood – particularly neonates
- Trauma
- Tumors – intestinal hemangioma, leukemia, leiomyoma
- Varices
- Vasculitis – Henoch-Schonlein purpura
- Uremia
Lower GI bleeding
- Anal fissures secondary to constipation, trauma
- Hemorrhoids
- Proctitis
- Rectal prolapse
- Trauma – foreign body
- Diverticula
- Duplication
- Infection – viral gastroenteritis, Shigella, Salmonella, Campylobacter, Yersinia, parasites, pseudomembraneous colitis
- Intussception
- Hirschsprung disease
- Malrotation and volvulus
- Meckel’s diverticulum
- Necrotizing enterocolitis
- Nodular lymphoid hyperplasia
- Tumor – polyps, adenocarcinoma, lymphoma, leukemia
- Ulcerative colitis and Croh’s disease
- Vascular malformations
- Allergy – cow’s milk or other
- Artifactual – menses and vaginal bleeding, hematest is false positive
- Blood dyscrasia – disseminated intravascular coagulation, thrombocytopenic states
- Factitious
- Long distance running
- Turner Syndrome
Questions for Further Discussion
1. How is the Apt-Downey test performed to determine if blood is fetal or maternal in origin?
2. What diagnostic and therapeutic treatment options are available for hematochezia?
3. What imaging studies can be helpful for diagnosis of gastointestinal bleeding?
Related Cases
- Disease: Constipation | Gastrointestinal Bleeding
- Symptom/Presentation: Bleeding and Bruising | Constipation and Encopresis | Bloody Stool
- Specialty: Adolescent Medicine | Gastroenterology
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Gastrointestinal Bleeding and Constipation.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:95-97.
Di Lorenzo C, Vasiliquskas E. Gastrointestinal Bleeding. In Pediatrics A Primary Cre Approach, Berkowitz C. ed. W. B. Saunders Co. Philadelphia PA. 1996;339-342.
Hsia RY. Halpern J, Loret de Mola O. Gastrointestinal Bleeding Pediatrics. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/802064-overview (rev. 12/8/2009, cited 3/24/2010).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 