Bleeding Per Rectum In Children By Prof. Sushmita N. Bhatnagar MBBS, M.S., M.Ch,M.PHIL(Hospital Management) HEAD, PEDIATRIC SURGERY B.J WADIA CHILDREN’S HOSPITAL, MUMBAI CONSULTANT PEDIATRIC SURGEON BOMBAY HOSPITAL JOINT SECRETARY ASSOCIATION OF MEDICAL CONSULTANTS For info log on to www.healthlibrary.com.

1. BLEEDING PER RECTUM IN
CHILDREN
Prof. Sushmita N. Bhatnagar
MBBS, M.S., M.Ch,M.PHIL(Hospital Management)
HEAD, PEDIATRIC SURGERY
B.J WADIA CHILDREN’S HOSPITAL, MUMBAI
CONSULTANT PEDIATRIC SURGEON
BOMBAY HOSPITAL
JOINT SECRETARY
ASSOCIATION OF MEDICAL CONSULTANTS

2. INTRODUCTION
UPPER
GIT LOWER
GIT
Hematochezia
Malena Occult

3. COMMON CAUSES OF BPR
NEWBORNS
RED BLACK
UPPER GIT
(Esophagus,
stomach, small
bowel)
.Volvulus of midgut
.Bacterial enteritis
.Drug induced
.Congenital or acquired
coagulopathies
. Hemorrhagic disease of
newborn
.Intussusception
.Erosions in
stomach,
esophagus,
duodenum
.Peptic ulcer
disease
LOWER GIT
( Colon, rectum,
anus)
.Anal fissure
.Arterio-venous malformations

4. INFANTS/TODDLERS
RED BLACK
UPPER
GIT
. Volvulus of midgut
. Bacterial enteritis
. Drug induced
. Congenital/acquired coagulopathies
. Gangrenous bowel-other causes
. Band obstruction
. Intussuception
. Meckel’s diverticulum
. Benign hamartomas
. Tumors - Lymphoma/Carcinoid
. GER
.
Gastritis/H.Pylori
/Sress/Drugs/Syst
emic illness/
. Peptic ulcer
disease
LOWER
GIT
. Rectal polyp
. Anal fissure
. Arterio-venous malformations
. Colonic polyps

5. OLDER CHILDREN
RED BLACK
UPPER GIT
(Esophagus,
stomach,
small bowel)
. Esophageal varices – Portal HTN
. Gastric varices
. Volvulus of midgut
. Bacterial enteritis
. Drug induced
. Congenital/acquired coagulopathies
. Hemorrhagic disease of newborn
. Intussusception
. Esophageal
varices – Portal
hypertension
. Peptic ulcer
disease
LOWER
GIT
( Colon,
rectum, anus)
. Anal fissure
. Inflammatory bowel disease
. Infectious diarrhoea
.Arterio-venous malformations

6. Quantification
MASSIVE – Evaluation & Rx of shock, control
of bleed + evaluation of cause of bleed
MODERATE – hospitalisation, rapid
evaluation of source of bleed, control of bleed
MILD – evaluation of cause on outpatient basis,
Rx as per the source of bleed

7. Clinical scenarios
Clinical picture Diagnosis
Blood mixed with stools Infective – enteritis/colitis, Hemolytic Uremic
syndrome, NEC, Eosinophilic enterocolitis, IBD
Blood streaks on stool Anal fissure/rectal mucosal ulceration
Constipation
Rectal prolapse
Blood after defecation in
drops with normal stools
Rectal polyp
Vascular anomalies of lower GIT
Blood with mucus in stools Infective
Intussusception
Frank blood Volvulus of midgut
Arteriovenous malformations
NEC
Occult bleeding PR Worm infestation
Acid peptic disease of upper GIT
Celiac disease
IBD
Polyposis

8. How could the clinician determine
the severity of GI bleed?
• Physical appearance
• Pallor
• Hemodynamic status
• Estimated volume of blood lost
• Color of lost blood
Worrisome S/S
Pallor
Diaphoresis
Restlessness
Lethargy
Abdominal pain
DANGER SIGNALS
Orthostatic changes in HR
& BP

9. Clinical approach
• Look at the child – well or ill
• Look at vital parameters – hemodynamically stable or not
• Look at the abdomen – distended or normal, lump
palpable, tenderness anywhere,
• Look at the rectum – do a per rectal examination – anal
fissure, polyps
• Look at the type of blood in the stools

10. Can the child suspected with bleeding PR
be normal?
Substances that deceive
• Red discoloration
• candy, fruit punch, Jell-o, beets, watermelon, laxatives,
phenytoin, rifampin
• Black discoloration
• bismuth, activated charcoal, iron, spinach, blueberries,
licorice

11. Surgeon’s role