Patient Presentation
A 3-year-old male came to clinic because of rectal bleeding. He was toilet training and had had some constipation. His parents noted that morning that he had some streaked blood on the toilet tissue and were concerned. They said they had not seen any blood in the toilet or on the stools. They denied any mucous in the stool, but said that it was hard. The past medical history was non-contributory. The pertinent physical exam showed a well-appearing male in no distress with normal vital signs and growth parameters. His abdomen examination was negative. His genitourinary examination showed a posterior midline fissure of his anus.

The diagnosis of an anal fissure was made. The senior resident physician recommended conservative treatment including Sitz baths if he had more pain. She also gave several suggestions for constipation treatment and toilet training. When staffing the patient, the resident and attending discussed the differential diagnosis of rectal bleeding and at one point asked, “When do hemorrhoids occur in kids?” The attending wasn’t exactly sure but knew that it didn’t occur very often in her clinical practice. They decided to try to find an answer in the medical literature.

Discussion
Common anorectal problems come to the attention of clinicians because of blood, pain or a mass lesion. These include anal fissures, perianal abscess and fistulas and hemorrhoids.

Anal fissures are tears of the distal anus usually in the midposterior line that often occur in toilet training children and those with constipation. Rectal bleeding and pain are common. Treatment is conservative.

Perianal abscess and fistulas present as masses that are firm or fluctuant. Treatment is antibiotics along with various types of incision and drainage. Recurrence is high and may require additional surgery. Crohn’s disease should be considered if a perianal fistula occurs.

Hemorrhoids are swollen vein in the anus. Symptoms include bleeding, pain, prolapse and itching. External hemorrhoids can be noted by external examination but internal hemorrhoids require anoscopy. External hemorrhoids occur below the dentate line (the mucocutaneous junction that occurs at the upper 2/3 and lower 1/3 of the anal canal) and are covered by skin. Thrombosis causes pain because of their cutaneous innervation. Thrombosis generally resolves in 2-3 days with regression around 1-2 weeks. A skin tag may remain. Internal hemorrhoids are covered by columnar epithelium. They generally are painless if thrombosed because of their visceral innervation. Bleeding and prolapse are more common.

Hemorrhoid treatment is conservative with increasing fluids and dietary fiber along with Sitz baths. Cooling packs also provide direct relief for pain. When conservative measures fail rubber band ligation, staple hemorrhoidectomy or surgical hemorroidectomy can provide treatment.

The differential diagnosis of gastrointestinal bleeding can be found here and the differential diagnosis of constipation can be found here.

Learning Point
There are few articles that document the incidence or prevalence of hemorrhoids occur children.

In a review article from 2007, the authors state ‘hemorrhoids are extremely uncommon in children with prevalence increase in adolescents and adults.” They also state that patients with portal hypertension have them more often but are rarely symptomatic.

A 2013 paper used nationwide insurance data to investigate the risk of cancer over time in patients who initially presented with benign anal lesions. They found 3,299 patients from 0-19 years old had hemorrhoids. They had a total patient population of 70,513 patients with hemorrhoids most of which occurred in the 20-59 year old age group. Data from Wikipedia, cites a total population of Taiwan at 23,374,000 persons in 2013. Of these 0-14 year olds comprised 15.65%. If all 3299 patients were attributed to the 0-14 year old age group, then the pediatric population in Taiwan would have a rate of .0022% of hemorrhoids. This rate would obviously be lower if the additional adolescents 15-19 year olds were added. Hemorrhoids in the pediatric population are rare.

Questions for Further Discussion
1. What are pilonidal cysts and how are they treated?
2. What causes rectal prolapse and how is it treated?

Related Cases

Disease: Hemorrhoids | Anal and Rectal Diseases

Symptom/Presentation: Bleeding and Bruising | Constipation and Encopresis

Specialty: Gastroenterology | Surgery

Age: Preschooler

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 this topic: Hemorrhoids

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg. 2007 Feb;16(1):71-8.

Lee PC, Hu YW, Hung MH, et. al. The risk of cancer in patients with benign anal lesions: a nationwide population-based study. Am J Med. 2013 Dec;126(12):1143.e9-18.

Demographics of Taiwan. Wikipedia.
Available from the Internet at http://en.wikipedia.org/wiki/Demographics_of_Taiwan (cited 4/1/15).

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital