A. Necrotizing Enterocolitis. It is important to exclude this diagnosis in infants. Condition is most commonly seen in preterm infants with rectal bleeding, feeding intolerance, and systemic instability, but 10% of cases occur in full-term infants. Antenatal exposure to maternal cocaine and formula feeding are risk factors.
B. Obstructive Lesions. Include Hirschsprung disease, intestinal volvulus and malrotation, and ileocolic intussusception. Pain or irritability can indicate ischemia. Children with Hirschsprung disease present with abdominal distention and difficulty stooling and are occasionally septic looking. Patients with intestinal volvulus and malrotation may have a history of bilious emesis, irritability, and blood streaks in stool. Ileocolic intussusception classically presents with cyclic abdominal pain, lethargy, and current-jelly stools, but patient may have only altered mental status (ie, withdrawal, disinterestedness) and occult blood in the stool.
C. Milk-Protein Allergy. Affects approximately 2% of infants younger than 2 years of age. Clinical spectrum ranges from immediate-type reactions, including urticaria and angioedema, to intermediate and late-onset reactions, such as atopic dermatitis, gastroesophageal reflux, enterocolitis, and proctitis.
D. Anorectal Fissure. The most common proctologic disorder during infancy and childhood. Most cases occur in infants younger than 1 year of age. May be associated with diarrhea, causing per-ineal irritation, but more commonly is associated with constipation. Recurrent fissures or perianal excoriation are associated with perianal ^-hemolytic Streptococcus and pinworm infections.
E. Infectious Enterocolitis. Bacterial causes include Salmonella, Shigella, Campylobacter, Yersinia enterocolitica, C difficile, and Escherichia coli. Entamoeba histolytica and Giardia are important parasitic pathogens. Opportunistic infections in immune-compromised hosts include cytomegalovirus, Mycobacterium avium complex, and disseminated aspergillosis.
F. Vasculitis. Henoch-Schonlein purpura (HSP) and hemolytic uremic syndrome (HUS) are common vasculitides in children. HSP typically consists of purpuric rash of buttocks and lower extremities, arthralgias, angioedema, and acute abdominal pain. GI symptoms, including abdominal pain, occult bleeding, massive bleeding, and intussusception, may precede dermatologic findings. Hematuria also can be present. HUS classically presents with a triad of microangiopathic hemolytic anemia, thrombocytopenia, and oliguric renal failure. One of the many complications of HUS is colitis causing melena and possibly perforation. The cause is unknown.
Inflammatory Bowel Disease. Ulcerative colitis or Crohn disease must be considered in older children or adolescents who present with rectal bleeding. Search for extraintestinal manifestations, as noted earlier.
Structural Anomaly, Intestinal Duplication, or Meckel Diverticulum. Often presents with painless rectal bleeding. Occasionally can be lead point of intussusception. Vascular Lesions. Include angiodysplasia, hemorrhoids, hemangiomas, and arteriovenous malformations. Such lesions are rare causes of bleeding in children.
Polyps. The most common forms are hamartomatous and adenomatous polyps. Hamartomatous polyps are benign and are associated with juvenile polyps, juvenile polyposis coli, and Peutz-Jeghers syndrome. Adenomatous polyps are potentially prema-lignant and are associated with familial adenomatous polyposis and Gardner syndrome.
Coagulopathy. Consider hemorrhagic disease of newborn, a coagulation defect, or disseminated intravascular coagulation as a possible cause of bleeding. Bleeding caused by a coagulopathy is not limited to the GI tract.
Tumors. Occur rarely in children, although leiomyoma and histiocytosis have been described.
Ingestions. Foreign body ingestions are common in toddlers; considerations include glass or rectal thermometers. Ingested medications (antibiotics, bismuth, or iron) and foods (commercial dyes and certain vegetables) can mimic the appearance of blood.
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