A CHILD WITH BLOODY DIARRHOEA
History
Bobby is a 7-month-old child who is referred to the paediatric rapid referral clinic with a 2-day history of diarrhoea with blood and mucus in the stool. His mother states that he has periods of inconsolable crying which are getting worse and more frequent. In the last few hours, he had started to vomit and the last vomit was bile-stained. There is no history of contact with gastroenteritis, of travel or of bleeding disorders. He had neonatal meningitis and subsequently developed epilepsy, which is treated with sodium valproate. He has had no fits in the past month. His mother is in good health but his father has type 1 diabetes.
Examination
He has a temperature of 37.9C. His pulse rate is 186 beats/min, blood pressure is 80/44 mmHg and capillary refill is 4 s. He is difficult to examine due to frequent crying, but when examined during a quiet period, a mass is felt on the right side of the abdomen. The anus appears normal and there are no other sig
INVESTIGATIONS
Normal
Haemoglobin 12.8 g/dL 10.5–13.5 g/dL
White cell count 7.0 109/L 4.0–11.0 109/L
Platelets 457 109/L 150–400 109/L
Sodium 138 mmol/L 135–145 mmol/L
Potassium 3.9 mmol/L 3.5–5.0 mmol/L
Urea 9.5 mmol/L 1.8–6.4 mmol/L
Creatinine 60 µmol/L 20–80 µmol/L
C-reactive protein 12 mg/L 6 mg/L
Questions
• What is the diagnosis?
• What is the key investigation?
• What is the treatment?
Medicine
The commonest causes of passing blood per rectum are gastroenteritis and an anal fissure. Gastroenteritis is a possibility in this case, but the lack of contact with gastroenteritis and of recent travel makes it somewhat less likely. The normality of the anus makes an anal fissure unlikely. The age of the child, the rectal bleeding and the mass (a late feature of intussusception) make an intussusception the most likely diagnosis. The typical age in intussusception is 3 months to 3 years. It is due to a part of the bowel telescoping into the adjacent distal bowel. Most intussusceptions are ileocolic. They result in stretching of the mesenteric vasculature that can potentially lead to bowel ischaemia or infarction. For this reason, investigation and treatment need to be instituted urgently. Typically the child has paroxysmal pain during which he or she becomes very pale; stool containing a mixture of blood and mucus (hence the name redcurrant jelly stool); and a sausage-shaped mass (the intussusception itself ) in the upper right quadrant of the abdomen. As the disease progresses, bowel obstruction, peritonitis and septicaemia may develop. The diagnostic investigation is an ultrasound.
Causes of rectal bleeding
• Gastroenteritis
• Anal fissure
• Intussusception
• Cow’s milk protein allergy
• Meckel’s diverticulum
• Inflammatory bowel disease
• Polyp
• Clotting abnormality
• Sexual abuse
This infant has clinical signs (tachycardia and prolonged capillary refill) and biochemical evidence (raised urea) of dehydration, and initial treatment consists of intravenous fluid resuscitation and intravenous antibiotics, such as penicillin, gentamicin and metronidazole. A nasogastric tube should be inserted and the stomach emptied. In the majority of cases, reduction can be achieved by a radiologist with an air enema. The antibiotics are given because of the possibility of sepsis and the small risk of a perforation during the reduction. If this procedure fails, or if the child is unstable or has signs of peritonitis or a perforation, then surgery is indicated. There is a recurrence rate of 10 per cent following an air enema reduction, and of 2–5 per cent following a surgical reduction.
KEY POINTS
• Intussusception should be considered in any child aged 3 months to 3 years with bloody stool.
• There should be a low threshold for carrying out an ultrasound.
• An air enema reduction is successful in the majority of cases.
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