|Year : 2016 | Volume
| Issue : 2 | Page : 247-251
Colonoscopic findings in children with lower gastrointestinal bleeding
Mohsen M Deeb1, Rania S El-Zayat1, Heba A. Abd Elghany Abo El-Khair2
1 Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Kafer Elsheikh Medical Center, Kafer Elsheikh, Egypt
|Date of Web Publication||18-Oct-2016|
Heba A. Abd Elghany Abo El-Khair
Kafer Elsheikh Medical Center, Kafer Elsheikh, 33511
Source of Support: None, Conflict of Interest: None
The aim of our work was to assess the clinical manifestations and to determine the colonoscopic findings of children with lower gastrointestinal bleeding (LGIB) attending to hospital.
Colonoscopy is used for both diagnostic and therapeutic purposes in patients with lower gastrointestinal symptoms. LGIB in children has many different etiologies and is a serious problem that warrants careful diagnostic work-up.
Patients and methods:
This study was conducted on 75 patients (51 male and 24 female with age ranging from 3 to 12 years) presented with LGIB. We divided the patients into three age groups to find the relationship between the age and the causes of rectal bleeding in the studied patients. These groups were: group 1, which included patients from 3 to 6 years; group 2, which included patients from 6 to 9 years; and group 3, which included patients from 9 to 12 years.
Colon polyps were the most common colonoscopic finding among children (44%), followed by linear ulcerations and edema (25.3%), diffuse nonspecific inflammation (24%), and normal cases (6.6%). Juvenile polyps were the most common pathological finding among children. We found polyps common in patients between 3 and 6 years of age.
Colonoscopy was performed for children with LGIB; we found that the most common causes of bleeding were polyps, ulcerative colitis, nonspecific colitis, and infectious colitis.
Keywords: inflammatory bowel disease, lower gastrointestinal bleeding, ulcerative colitis
|How to cite this article:|
Deeb MM, El-Zayat RS, El-Khair HA. Colonoscopic findings in children with lower gastrointestinal bleeding. Menoufia Med J 2016;29:247-51
|How to cite this URL:|
Deeb MM, El-Zayat RS, El-Khair HA. Colonoscopic findings in children with lower gastrointestinal bleeding. Menoufia Med J [serial online] 2016 [cited 2022 May 27];29:247-51. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/247/192425
Lower gastrointestinal bleeding (LGIB) means bleeding from sites distal to the ligament of Treitz and presents as rectal bleeding .
LGIB can be presented in four forms:
| Introduction|| |
The etiology of LGIB is different in children from that in adults. The causes are usually simple and require little or no treatment, for example, anal fissure, juvenile polyps, but sometimes these symptoms may indicate more severe and life-threatening conditions such as intussusception, Meckel's diverticulum, midgut volvulus, and peptic ulcer disease .
Chronic cases of minor LGIB produce significant anemia; thus, localization of the source of bleeding is important in the management of these children .
A careful history, inspection of the perianal area, digital rectal examination, and a stool test confirm the common causes of per rectal bleeding in children. Other techniques such as endoscopy, radiology, technetium-labeled red blood cells scans, and angiography are available for diagnostic evaluation .
Once the bleeding is suspected to be coming from a lower GI source, it warrants an evaluation in all cases by proctosigmoidoscopy followed by colonoscopy, which is the examination of choice for diagnosis and treatment; it is also the most accurate method of imaging the lower GI tract .
The safety and effectiveness of colonoscopy in the investigation of lower GI tract pathology in children has been established for more than two decades .
Colonoscopy has several advantages and is generally regarded as the preferred initial test in the majority of cases. The advantages are as follows:
- Hematochezia, which is passage of bright red blood from the rectum. It can be isolated or mixed with stools. Its origin usually is from the large intestine but massive bleeding from upper gastrointestinal (GI) is also presented as LGIB.
- Melena, which is passage of tarry, foul-smelling stool. It suggests bleeding above the ileocecal valve and can also occur in the large intestine when the transient time is high.
- Occult bleeding with symptoms of fatigue and pallor. It is usually detected by laboratory tests revealing iron deficiency anemia or positive fecal blood test.
- Symptom of severe blood loss, such as malaise, tachycardia, or even shock .
Disadvantages are as follows:
- Ability to identify bleeding source regardless of the rate or presence of bleeding,
- Multiple therapeutic possibilities,
- Efficiency given diagnostic and therapeutic potential,
- Irrespective of initial testing, colonoscopy is required for definitive diagnosis, and
- Requirement for colon preparation,
- Need for sedation, experienced staff, and endoscopy facilities,
- hemorrhage, and
- Invasive nature .
The procedure of colonoscopy was explained to the parents and consent was taken.
This study was conducted on 75 patients (51 male and 24 female with age ranging from 3 to 12 years) presented with LGIB.
All patients were recruited from Pediatric Gastroenterology Unit at Pediatric Department, Menoufiya University Hospital during the period from 2010 to 2013.
All patients presented with visible rectal bleeding or hematochezia as the chief complain and diagnosed clinically and laboratory as LGIB were included in this study.
All patients not fulfilling these inclusion criteria were excluded.
All patients included in the study underwent complete history taking and full clinical examination including general examination, laboratory investigation, colonoscopy, and histopathology.
Analysis of data was performed by IBM computer using statistical program for the social sciences (SPSS, version 12; SPSS Inc., Chicago, Illinois, USA) as follows:
| Patients and Methods|| |
P value greater than 0.05 was considered insignificant; P value less than 0.05 was considered significant; and P value less than 0.01 was considered highly significant.
- Description of quantitative variables as mean, SD, and range.
- Description of qualitative variables as number and percentage.
- χ2-Test was used to compare qualitative variables between groups.
Four (5.33%) patients presented with fever, 17 (22.66%) presented with diarrhea, one (1.33%) presented with constipation, and 18 (24%) presented with abdominal pain ([Table 1]).
In all, 26 (34.66%) patients showed normal examination and 31 (41.33%) patients showed pallor ([Table 2]).
Colon polyps were the most common colonoscopic finding among children (44%), followed by linear ulcerations and edema (25.3%), diffuse nonspecific inflammation (24%), and normal cases (6.6%) ([Table 3]).
Juvenile polyps were the most common pathological finding among children (44%), followed by ulcerative colitis (25.3%), nonspecific colitis (20%), postinfection colitis (4%), and normal cases (6.6%) ([Table 4]).
The only type of polyps detected on pathological examination was juvenile polyps (100%).
In this Table, we divided the patients into three age groups to find any relationship between the age and the causes of rectal bleeding in patients, and we found that polyps were the most common cause of rectal bleeding in group 1 (3–6 years); there was statistically highly significant difference between the three groups regarding the causes of rectal bleeding according to the age.
The study showed that polyps were the most common cause in 33 (44%) patients followed by ulcerative colitis in 19 (25.33%), whereas nonspecific colitis was the cause in 15 (20%) patients and infectious colitis in three (4%). Five (6.6%) patients were normal. In addition, the study showed that the polyps are common in the younger age group from 3 to 6 years of age ([Table 5] and [Figure 1],[Figure 2],[Figure 3]).
| Results|| |
Rectal bleeding is an alarming symptom and requires additional investigation .
It is a common reason for referral to pediatric gastroenterologists and surgeons .
In this study, colonoscopy was performed for finding the etiologies of LGIB; in 55 (73.3%) patients, rectal bleeding was the only symptom.
In another study, 80% presented with only rectal bleeding .
In this study, anemia, abdominal pain, loose stool, weight loss, and fever were the most common symptoms that accompanied bloody stool.
In another study, they reported that diarrhea, vomiting, abdominal pain, anorexia, and failure to thrive were the most common accompanying symptoms of bloody diarrhea and rectal bleeding .
We found polyp in 44% of patient; this is quite different from another study, which was 10% . Our rate was however very less than the relative frequency of 75% reported by others ; in these studies, the most common cause of LGIB was polyps of colon.
Age is considered an important factor in differentiating the etiologies of LGIB in pediatrics. As shown in previous studies, polyps are considered the most common cause of LGIB in ages following infancy .
The peak age in patients with polyps in this study was between 3 and 6 years; in addition, in Mandhan's  study, it was 6 years.
In this study, juvenile polyps were the most common pathological finding.
In another study, juvenile polyps were the most common types of polyps among children and adolescents .
These polyps are usually hamartomatous and account for 90% of all polyps found in children .
In this study, we found that 61.33% of patients were suffering from anemia.
In another study, between 25 and 35% of patients were presented with anemia from chronic blood loss. The typical age ranged from 3 to 10 years; sporadic juvenile polyps were uncommon before 2 years of age and were rare in the first year of life .
In this study, ulcerative colitis was the second most common cause of rectal bleeding and accounted for 25.3% of all patients.
Previous studies have shown that ∼20% of patients with inflammatory bowel disease are diagnosed before the age of 20 years; among them most are below 15 years of age .
Rectal bleeding is the main presenting symptom in most patients with ulcerative colitis .
GI infections are considered as one of the most common causes of LGIB and dysentery in any age group .
In this study, infections (postinfectious colitis) were the fourth most common cause of bloody diarrhea, whereas in other studies they have been classified as the second most common cause of LGIB in children.
Nonspecific colitis in children is often one of the causes of per rectal bleeding in children. Lesions are restricted to the rectum but may extend proximally to involve the sigmoid colon .
In this study, we experienced 15 (20%) patients diagnosed as nonspecific colitis.
In this study, about 6.6% of colonoscopies were normal.
In another study, they reported 10.6% normal cases .
In this study, polyps were the most common cause in 33 (44%) patients followed by ulcerative colitis in 19 (25.33%), whereas nonspecific colitis was the cause in 15 (20%) patients and infectious colitis in three (4%). Five (6.6%) patients were normal. In addition, the study showed that the polyps were common in the younger age group from 3 to 6 years of age.
A study on 80 children who were managed with LGIB from January 2005 to December 2007 in various hospitals in Karachi has shown the most common causes of LGIB to be rectal polyps, infectious colitis, ulcerative colitis, and nonspecific colitis .
| Discussion|| |
The most common causes of LGIB are rectal polyps, ulcerative colitis, nonspecific colitis, and infectious colitis. Polyps are the most common cause of painless rectal bleeding. Juvenile polyps are the most common intestinal polyps in children. The common age for polyps is from 3 to 6 years.
Conflicts of interest
There are no conflicts of interest.
| Conclusion|| |
| References|| |
Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol 1998; 95:1202-1208.
Turck D, Michaud L. Lower gastrointestinal bleeding. In: Walker WA, Goulet O, Kleinman RE, editors. Pediatric gastrointestinal disease
. 4th ed. Hamilton: BC Deckers; 2004. 266:80.
Dupont C, Badoual J, Le Luyer B, Le Bourgeois C, Barbet JP, Voyer M. Rectosigmoidoscopic findings during isolated rectal bleeding in the neonate. J Pediatr Gastroenterol Nutr 1987; 95:257–264.
Perisic VN. Colorectal polyps: an important cause of rectal bleeding. Arch Dis Child 1987; 95:188–189.
Stevenson RJ. Gastrointestinal bleeding in children. Surg Clin North Am 1985; 95:1455–1480.
Moayyedi P, Ford A. Recent developments in gastroenterology: clinical review. BMJ 2002; 95:1399–1402.
Hassall E, Barclay GN, Ament ME. Colonoscopy in childhood. Pediatrics 1984; 95:594–599.
Comay D, Marshall JK. Resource utilization for acute lower gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol 2002; 95:677–682.
Arvola T, Ruuska T, Keränen J, Hyöty H, Salminen S, Isolauri E. Rectal bleeding in infancy: clinical, allergological, and microbiological examination. Pediatrics 2006; 95:760–768.
10Clarke G, Robb A, Sugarman I, McCallion WA. Investigating painless rectal bleeding – is there scope for improvement? J Pediatr Surg 2005; 95:1920–1922.
11Ojuawo A, St Louis D, Lindley KJ, Milla PJ. Non-infective colitis in infancy: evidence in favour of minor immunodeficiency in its pathogenesis. Arch Dis Child 1997; 95:345–348.
12Mandhan P. Sigmoidoscopy in children with chronic lower gastrointestinal bleeding. J Paediatr Child Health 2004; 95:365–368.
13Rayhorn N, Thrall C, Silber G. A review of the causes of lower gastrointestinal tract bleeding in children. Gastroenterol Nurs 2001; 95:77–82.
14Haghi Ashtiani MT, Monajemzadeh M, Motamed F, Moradi Tabriz H, Mahjoub F, Karamian H, et al.
Colorectal polyps: a clinical, endoscopic and pathologic study in Iranian children. Med Princ Pract 2009; 95:53–56.
15Huang SC, Erdman SH. Pediatric juvenile polyposis syndromes: an update. Curr Gastroenterol Rep 2009; 95:211–219.
Grance HE. Gastrointestinal bleeding. In: Yammada T, Alpers D, Laine L, editors. Textbook of gastroenterology
. 3rd ed. London: Williams and Wilkins; 1999. 714–742.
17Bai Y, Peng J, Gao J, Zou DW, Li ZS. Epidemiology of lower gastrointestinal bleeding in China: single-center series and systematic analysis of Chinese literature with 53,951 patients. J Gastroenterol Hepatol 2011; 26:678–682.
Farmer RG. Lower gastrointestinal bleeding in inflammatory bowel disease. Gastroenterol Jpn 1991; 95:93–100.
19Philpott DJ, Ismaili A, Sherman PM. Enterohemorrhagic Escherichia coli
O157:H7 infection and colitis in children. J Pediatr Gastroenterol Nutr 1997; 24:623–625.
20Jayanthi V, Chuah SY, Probert CS, Mayberry M, Mayberry JF. Proctitis and proctosigmoiditis — a need to identify the extent of disease in epidemiological surveys. Digestion 1993; 95:61–64.
Wajeehuddin AR. Per rectal bleeding in children. J Surg Pakistan 2008; 13:47–50.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]