Key clinical features of diagnoses

Key clinical features of diagnoses

Swallowed maternal blood

• Occurs secondary to cracked/sore nipples in breast fed babies

Necrotising enterocolitis (NEC)

• Bowel ischaemia and necrosis causing LGIB
• Aetiology poorly understood but more common in preterm/low birth weight babies
• Can present with various symptoms – poor feeding, bilious vomiting, abdominal distension

Hirschsprung’s disease with enterocolitis

• Hirschsprung’s disease is a congenital malformation resulting in aganglionic portions of bowel which are unable to undergo peristalsis
• Hirschsprung associated enterocolitis is a form of toxic megacolon, which is a medical emergency, and can present with lower GI bleeding

Malrotation with midgut volvulus

• During gestation the midgut rotates within the abdominal cavity, in malrotation this does not occur in the normal way, giving rise to the potential for the midgut to form a volvulus.
• The volvulus can cause an obstruction which can lead to bowel ischaemia and therefore bleeding

Coagulopathy

• These include:
  • Vitamin K deficiency
  • Von Willebrand disease
  • Haemophilia

Learning bite

There are multiple causes of coagulopathy which typically present with other symptoms in the neonate (cephalhaematoma at birth, oozing from the umbilicus), but can also cause lower GI bleeding.

Anal fissures

• Can occur at any age, starting in the neonatal period
• Associated with difficult defaecation or straining
• Commonly suggests underlying constipation

Allergic colitis

• Occurs in 5-15% babies
• Can be triggered by a cow’s milk protein, or soy protein allergy which results in an inflammatory colitis which can present with diarrhoea, faltering growth and LGIB
• Occurs in bottle fed and breast-fed babies, due to dairy or soy milk which can be found in the breast-feeding adult’s diet
• Frequently resolves around 18 months of age and dairy/soy can be gradually reintroduced into the baby’s diet

Learning bite

When reintroducing dairy into a child’s diet, the ‘milk ladder’ can be used, gradually increasing the amount of dairy a child is exposed to.

GI duplication cysts

• Congenital malformations commonly found in the jejunum and ileum
• Case study reports suggest they can contain ectopic GI mucosa which can cause LGIB
• More frequently present with obstruction, can be a lead point for intussusception

Vascular Malformations

• Congenital telangiectasias can occur in children with certain congenital diseases e.g.
  • Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu)
  • Klippel-Trenaunay Syndrome
  • Turner’s Syndrome
• These can all produce GI telangiectasias which can produce significant lower GI bleeding

Meckel’s Diverticulum

• See ‘pathophysiology’ for embryological origin of Meckel’s diverticulum
• Bleeding can result from acid production by ectopic mucosa found within the diverticulum
• The severity and chronicity of the bleeding can vary
• 60% of patients who present with LGIB secondary to Meckel’s diverticulum are younger than 2 years old

Intussusception

• This occurs when a portion of bowel ‘telescopes’ within itself
• In children under 2 it is commonly idiopathic but in older children the lead point is more commonly a duplication cyst or a Meckel’s diverticulum
• Presents with paroxysmal abdominal pain which can transiently improve following a vomit or a bowel movement
• The child sometimes has a sausage shaped abdominal mass and is occasionally described as having ‘redcurrent jelly’ stools

Very early onset inflammatory bowel disease

• Presents before 6 years old
• Progresses more rapidly than when IBD occurs in older children and is less likely to respond to standard therapies

Infectious colitis

• Consider if there is a history of a diarrhoeal outbreak for example in a school or nursery
• Commonly shigella, salmonella, campylobacter and Escherichia (E.coli 0157 will be discussed later)
• Giardia and Entamoeba histolytica if there is a travel history

Learning bite

If there is a history of antibiotic use consider Clostridium difficile as a cause of colitis.

Juvenile polyps

• These are submucosal growths with a prevalence of 7-12%, most commonly found in boys below 10 years old
• Produce haematochezia and occasional abdominal pain
• Rarely malignant, more commonly an inflammatory process

Foreign body

• This could have been swallowed or inserted into the rectum
• Beware button batteries or “super strong” magnets which can erode through gut mucosa causing bleeding, or objects with sharp edges which can cause trauma

Immunoglobulin A deficiency, or Henoch Schonlein Purpura (HSP)

• A systemic vasculitis which most commonly presents between the ages of 3-15
• Presents with cutaneous purpura, arthralgia and abdominal pain
• Can also produce LGIB

Haemolytic Uraemic Syndrome

• A complication of E.coli 0157:H7 which produces a toxin that can result in HUS
• A triad of microangiopathic haemolytic anaemia, thrombocytopaenia and acute renal injury
• Develops 5-10 days after the onset of diarrhoea

Solitary rectal ulcer syndrome

• Ulceration within the rectum which can be chronic resulting in bright red blood in the stool and pain on defaecation

Inflammatory bowel disease

• Can be divided into ulcerative colitis which affects only the colon, and Crohn’s disease which only affects the GI tract.
• Presents with abdominal pain and diarrhoea – with or without blood

Haemorrhoids

• More common in older adolescents
• Frequently associated with constipation