ORIGINAL ARTICLE Year : 2023  |  Volume : 14  |  Issue : 2  |  Page : 69-72

Lower gastrointestinal bleeding in children: Clinical profile and outcome

Narender Kumar1, Manish Narang1, Anju Aggarwal1, Naveen Sharma2
1 Department of Pediatrics, University College of Medical Sciences (University of Delhi) and Guru Teg Bahadur Hospital, New Delhi, India
2 Department of Surgery, University College of Medical Sciences (University of Delhi) and Guru Teg Bahadur Hospital, New Delhi, India

Date of Submission25-Dec-2022Date of Decision26-Dec-2022Date of Acceptance26-Dec-2022Date of Web Publication04-Jul-2023

Correspondence Address:
Dr. Manish Narang
Department of Pediatrics, University College of Medical Sciences (University of Delhi) and Guru Teg Bahadur Hospital, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_144_22

Background: Bleeding per rectum is a fairly common clinical problem in children. Gastrointestinal infections, anal fissures, and polyps are the most common causes. However, many cases remain undiagnosed due to the nonavailability of diagnostic modalities. This prospective hospital-based study was designed to study clinical profiles and outcomes in children with lower gastrointestinal bleeding. Materials and Methods: Fifty-six children (1–12 years) presenting with bleeding per rectum were enrolled in the study. History and detailed examination were recorded. Investigations were done on basis of the clinical scenario. Children with bleeding per rectum were analyzed for demographic profile, clinical presentation, etiology, diagnostic investigations, and outcome in bleeding per rectum. Results and Observations: Anal fissure (67.3%) was the most common cause followed by colorectal polyp (16.4%), nonspecific colitis (7.3%), invasive amoebiasis (1.8%), intussusception (1.8%), and rectal mucosal prolapse (1.8%). Colonoscopy was diagnostic in 73% of children. Conclusion: Anal fissures and colorectal polyps are the most common noninfective cause of bleeding per rectum. Undiagnosed chronic cases of bleeding per rectum can result in complications such as anemia and malnutrition. The availability of diagnostic modalities can help in early diagnosis and treatment for better outcomes.

Keywords: Anal fissure, bleeding, colonic polyp, colonoscopy, gastrointestinal hemorrhage

How to cite this article:
Kumar N, Narang M, Aggarwal A, Sharma N. Lower gastrointestinal bleeding in children: Clinical profile and outcome. Indian J Med Spec 2023;14:69-72
How to cite this URL:
Kumar N, Narang M, Aggarwal A, Sharma N. Lower gastrointestinal bleeding in children: Clinical profile and outcome. Indian J Med Spec [serial online] 2023 [cited 2023 Jul 4];14:69-72. Available from: http://www.ijms.in/text.asp?2023/14/2/69/380391   Introduction 

Bleeding per rectum in children is commonly encountered in clinical practice, although its epidemiology has not been well evaluated.[1] The current available data on lower gastrointestinal infection (GI) bleeding in children from developing countries are limited;[2] however, a study from Boston reported the incidence of bleeding per rectum as 0.3%.[3] Gastroenteritis and GIs are the most common causes of rectal bleeding.[4] Rectal polyps, anal fissures, nonspecific colitis, intussusception, Meckel's diverticulum, and inflammatory bowel disease are the most common noninfective causes of lower gastrointestinal bleeding in children.[1],[3],[5] Although bleeding per rectum is nonsevere and requires only conservative management in most of the cases, the empirical approach can result in missing of severe life-threatening conditions like intussusception.[6] Further, if undiagnosed, chronic cases of bleeding per rectum like colorectal polyp can result in complications like anemia.[6],[7] Application of diagnostic modalities like colonoscopy has resulted in reduction in undiagnosed cases.[2] Due to the limited availability and use of modalities like colonoscopy in India, cases go undiagnosed in India.[6],[8] Hence, this study was focused on establishing the clinical profile and outcome in children with bleeding per rectum.

  Materials and Methods 

We conducted a prospective study in children with bleeding per rectum in a tertiary care center of North India from November 2017 to April 2019 after approval from the institutional ethical committee. Written informed consent was obtained from parents of the children and assent was taken from children ≥7 years of age. Children aged 1–12 years with bleeding per rectum were screened from the outpatient department. Children with bleeding per rectum and those with dysentery who failed to respond to 2 weeks of antibiotic treatment were enrolled in the study. Emergency cases requiring urgent surgical intervention and children with comorbid systemic conditions such as cardiac disease or other systemic diseases were excluded from the study.

A detailed history and examination were done in all eligible children and recorded in the case record form. Laboratory investigations planned in the enrolled children included complete blood count, serum electrolytes, liver function test, erythrocyte sedimentation rate, C-reactive protein, coagulation profile, stool microscopy, stool culture, amoebic serology, and blood culture sensitivity. Colonoscopy, abdominal X-ray, and abdominal ultrasound were done wherever indicated.

Cases of bleeding per rectum were treated according to the latest guidelines.[9] An anal fissure was managed conservatively with dietary modification, lactulose (or other stool-softening agents), local 2% lignocaine, and local diltiazem cream. Patients diagnosed with colorectal polyps were treated by polypectomy. Excised tissue was sent for histopathology. Patients with other surgical conditions such as intussusception and rectal prolapse were referred to the surgery department for surgical management. Patients were followed up till remission. Data for demographic profile, clinical presentation, etiology, and diagnostic modalities and outcomes were recorded. Qualitative data and quantitative data were expressed in the form of percentages and mean (± standard deviation). The Chi-square test was used to determine the association between two categorical variables. Statistical data analysis was done using SPSS v20.0 (IBM, SPSS statistics for windows, Armonk, NY:IBM Corp, USA).

  Results 

The study flowchart is shown in [Figure 1]. The demographic characteristics of the patients are shown in [Table 1].

Table 1: Demographic characteristics of children with bleeding per rectum

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In a total of 55 children, 37 (67.3%) children were diagnosed with anal fissure and was the most common cause of bleeding per rectum followed by colorectal polyps diagnosed in 9 (16.4%) children. Four (7.3%) children were diagnosed with nonspecific colitis. Invasive amoebiasis, intussusception, and rectal mucosal prolapse were diagnosed in 1 (1.8%) child each. No cause could be identified in two (3.6%) children. Bleeding per rectum was painful in 41 (74.5%) children. Among all cases of painful bleeding, anal fissure was the most common with 37 cases (90.2%). Out of a total of 14 cases of painless bleeding, 9 (64.2%) cases were of colorectal polyp, 4 (28.5%) cases of nonspecific colitis, and 1 (7.1%) cases of invasive amoebiasis. Constipation was the most common associated feature found in 40 (72.7%) children with bleeding per rectum [Table 2]. Thirty-five (94.5%) cases out of 37 cases of anal fissure were associated with constipation (P < 0.05), whereas 2 (5.4%) cases were associated with cerebral palsy. The only cases of rectal prolapse were associated with severe malnutrition and constipation in the child. Anorexia was present in 23 (41.8%) cases and abdominal pain in 17 (30.9%) children. Eighteen (32.7%) cases had anemia [Table 2]. One case of severe anemia required blood transfusion. Cases of anal fissures were diagnosed by clinical examination only. Intussusception was diagnosed by finding in ultrasonography of the abdomen. A polyp or a mass was found on digital rectal examination only in 4 (44.4%) cases out of nine cases. Five (55.5%) out of nine cases of colorectal polyp were only diagnosed after colonoscopy. Colonoscopy was performed in 15 children and was had abnormal findings in 11 (73.4%) cases out of 15 children. The most common finding in colonoscopy was colorectal polyp (60%). All nine children with colorectal polyps were treated by polypectomy without any complications. Among 37 children with anal fissures, 26 children were successfully treated with dietary modification, toilet training, osmotic laxatives (lactulose or polyethylene glycol), and local lignocaine gel. Eleven children responded with a combination of osmotic laxatives, local diltiazem cream, and local lignocaine gel. The child with rectal mucosal prolapse was managed conservatively with digital reposition, laxatives, and nutritional rehabilitation.

In our study, 10 (18.1%) children out of 55 children were having bleeding per rectum for the past 1 or more than 1 year at presentation. All these 10 children were free of symptoms within 4 weeks of treatment. In 38 (69%) children out of 55 children, bleeding was resolved within 4 weeks of treatment.

  Discussion 

Bleeding per rectum is a commonly encountered entity in children. Rectal bleeding is usually benign in children.[10] Bleeding per rectum in children is mostly due to GIs and in most of the cases resolves with antibiotic treatment alone.[4] In this study, an anal fissure was the common noninfective cause of bleeding per rectum found in 37 (67.2%) children out of total of 55 enrolled children followed by colorectal polyp with 9 (16.3%) cases. Most of the studies report colorectal polyps and anal fissures as the most common causes.[1],[3],[5]

Kakar et al. and Gimiga et al. had results similar to our study with anal fissure as the most common cause followed by rectal polyp.[11],[12] Yachha et al. and Khurana et al. reported colorectal polyp as the most common cause.[2],[13] Hamad et al. also found colorectal polyp as the most common cause of bleeding per rectum in children.[1] In our study, an anal fissure was the most common cause of painful bleeding and could be diagnosed by clinical history and examination only. Colorectal polyp was the most common of painless bleeding followed by nonspecific colitis. Out of 14 cases of painless bleeding, only 4 (28.5%) cases could be diagnosed clinically. Ten (78.5%) cases were diagnosed only after colonoscopy. Hence, colonoscopy was high diagnostic yield in our study. Similar results were shown by Wu et al. that colonoscopy was highly diagnostic in cases of lower GI bleeding.[8] Previous pediatric studies reported adenomatous changes in polyps that are known to be precursors of colorectal cancer.[14],[15],[16] In our study, no polyp had adenomatous changes and all cases were benign. Constipation was the most commonly associated clinical problem in children with bleeding per rectum. Constipation was associated with anal fissures and rectal prolapse in children. Most of the cases of bleeding per rectum were managed conservatively except for polyps which were removed by polypectomy without any complication.

In our study, 10 children had bleeding per rectum for the past 1 or more years at presentation. All these 10 children were free of symptoms within 4 weeks or less. It was found that these children were not adequately investigated either nonavailability of diagnostic modalities such as colonoscopy or unaffordability. When these children were thoroughly investigated and treated accordingly, their symptoms subsided within a few weeks. Anemia (29.1%) and malnutrition (29.1%) are a common associated features in children with bleeding per rectum.

The major limitation of this study is that being a hospital-based study results obtained in this study might not be representative of the whole population. Noninclusion of emergency cases requiring urgent surgical intervention was also a limitation of this study. Prospective study design in children, no loss to follow-up, and use of colonoscopy and biopsy were the strengths of our study.

  Conclusion 

We conclude that in children presenting with bleeding per rectum, anal fissure and colorectal polyp should be kept in mind while making diagnosis. Children having bleeding per rectum should be screened for such benign conditions such as polyp or nonspecific colitis that may remain undiagnosed with proper investigation and can result in anemia and malnutrition. Colonoscopy availability as a diagnostic modality in the health-care system can increase the chance of diagnosis as well as early treatment in children with bleeding per rectum. Most of the cases can be managed conservatively if clinicians able to diagnose such conditions with better diagnostic modalities.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 

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  [Figure 1]
 
 
  [Table 1], [Table 2]