Lower gastrointestinal (LGI) bleeding in the pediatric patient 5 years of age or younger is an uncommon ED presentation that causes anxiety and concern both in the child’s family and in the clinician. A report from Boston Children’s Hospital in the early 1990s showed that rectal bleeding was a presenting complaint in 0.3% of pediatric patients who visited the emergency department (ED) within a 1-year period. The emergency clinician may find this presentation daunting, since the differential diagnosis of LGI bleeding includes numerous age-specific disorders not found in the adult population, ranging from self-limited anal fissures to surgical emergencies. The time to diagnosis and reduction will influence morbidity and mortality in these patients; hence, the emergency clinician should have a high index of suspicion as well as knowledge of current evidence for diagnosis and treatment. This issue of Pediatric Emergency Medicine Practice reviews the common differential diagnoses of LGI bleeding in children younger than 5 years of age, relying on the best available evidence from the literature. Readers will be able to apply clinically appropriate guidelines regarding diagnosis and treatment in an effective and patient-specific manner. In particular, this article focuses on the challenge of evaluating and managing the pediatric patient with intussusception.
A 3-year-old female presents to your ED with the chief complaint of diffuse abdominal pain and nonbloody, nonbilious vomiting over the past 2 days. Her mother tells you that, after vomiting, the child becomes “lethargic and lies still in pain.” These events are self-limited, lasting a few minutes. The patient is otherwise healthy and has been afebrile without diarrhea. On physical examination, the child appears well and is interactive but is somewhat listless. She has no fever and, except for a heart rate of up to 115 beats per minute, her vital signs are within normal limits. Auscultation of her abdomen indicates normo-active bowel sounds. Her abdomen is soft and distended, with mild diffuse tenderness. A fecal occult blood test comes back positive. Her intermittent abdominal pain raises your suspicion for possible intussusception, which is suggested by the presence of occult blood in the stool. With many imaging modalities available, as well as consultants on hand, you suspect you’ll be able to confirm or confidently rule out this diagnosis.
The possibility of bleeding from the LGI tract in a young child causes anxiety for the child’s family. The general emergency clinician may find this presentation daunting, since the differential diagnosis of LGI bleeding includes numerous age-specific disorders not found in the adult population. Many emergency clinicians do not feel comfortable discharging the pediatric patient with recent LGI bleeding, and disposition can present a challenge. By assessing for age-specific pathologies and obtaining a thorough clinical history and examination, the emergency clinician will narrow diagnostic choices, thereby optimizing management and further care of the pediatric patient with LGI bleeding.
This issue of Pediatric Emergency Medicine Practice will review the common differential diagnoses of LGI bleeding in children younger than 5 years of age, relying on the best available evidence from the literature. In particular, it will focus on the challenge of evaluating and managing the pediatric patient with intussusception. The emergency clinician will be able to apply clinically appropriate guidelines regarding diagnosis and treatment in an effective and patient-specific manner.
A large number of articles have been published regarding outcomes in patients with intussusception who were treated with various modalities; specifically, hydrostatic and pneumostatic reduction and surgery. Much of this research involved retrospective cohort studies. This review focuses on these findings in detail.
An extensive search of the literature on pediatric LGI bleeding and intussusception between 1970 and 2011 using Ovid MEDLINE® and PubMed was conducted. Keywords included pediatric GI bleeding, intussusception, Meckel diverticulum, bowel malrotation, milk-protein sensitivity, milk-protein allergy, pediatric GI hemorrhage, blood per rectum, inflammatory bowel disease, necrotizing enterocolitis, GI arteriovenous malformation, and pediatric rectal/anal trauma. The search was limited to studies involving persons between 0 and 18 years of age.
Intussusception classically presents with colicky abdominal pain, and the patient may appear well between painful episodes. A positive fecal occult blood test can support a suspicion of intussusception, although it may also be positive in the child with milk-protein allergy. History is an important tool in narrowing the differential diagnosis. Milk-protein allergy is not likely to begin acutely in this older patient. Ultrasound should be used to diagnose intussusception. Observation in the ED may also be warranted if ultrasound is unavailable, and it may be helpful in deciding whether to obtain a CT scan, which would expose the patient to radiation.
Although intussusception is most common in younger patients, it can occur at any age. The incidence of intussusception associated with a pathologic lead point increases with age.
Hospital admission is not indicated in the easily and successfully reduced case of idiopathic intussusception if, after a period of observation in the ED, the patient returns to baseline status and tolerates oral intake without vomiting or pain. Hospital admission to monitor for recurrence after a simple reduction in the well-appearing patient is not warranted and imposes significant costs on the healthcare system. Family counseling must be given, as well as clear discharge instructions regarding returning to the ED in the event of abdominal pain, vomiting, or bloody stools.
Although it is considered the “classic” presentation, intussusception does not commonly present with redcurrant jelly stools. Frank hematochezia is a presenting sign in about 60% of cases of intussusception.
Many food products and medications may give the false appearance of bloody stools. The presence of blood should be confirmed with a fecal occult blood test prior to initiating further evaluation in the stable patient.
Ultrasonography is a sensitive and specific imaging modality for intussusception. If available, an ultrasound examination will spare the patient exposure to the radiation from a CT scan. If the ultrasound result is negative or inconclusive, CT would be the next option.
Ultrasonography is the best imaging choice for diagnosing intussusception and will avoid unnecessary radiation exposure from CT. However, a delay in diagnosis and therapeutic reduction can increase the risk for complications. If ultrasound is unavailable and you suspect intussusception, a CT scan should be obtained.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Angela K. Lumba; Heather Conrad
January 1, 2012