Differential diagnosis of the pediatric patient with small to moderate rectal bleeding (hemodynamically stable)

Primary diagnostic possibilities	Typical age group					Key clinical features	Initial diagnostic steps
Primary diagnostic possibilities	Neonate	Infants and toddlers	Preschool period	School-aged	Adolescent	Key clinical features	Initial diagnostic steps
Swallowed maternal blood	X	X				Breastfed; mother's nipples are cracked or bleeding	Apt test (hemoglobin alkaline denaturation test)
Milk- or soy protein-induced colitis ("allergic" colitis)	X	X^*				Well-appearing; stools with low-moderate blood; with or without diarrhea	Assess diet and perform trial of eliminating milk and soy from the diet
Necrotizing enterocolitis (especially if premature); malrotation with midgut volvulus; Hirschsprung disease	X					Acutely ill (vomiting, abdominal distension, diarrhea, and/or constipation)	Imaging, surgical consultation
Coagulopathy (eg, vitamin K-deficient bleeding, hemophilia, von Willebrand disease, maternal immune thrombocytopenia)	X	X				Other bleeding symptoms (cephalohematoma, mucocutaneous bleeding, petechiae)	Coagulation workup
Hirschsprung-associated enterocolitis	X	X				Ill, with abdominal distension, fever, vomiting, diarrhea, in patient with known or suspected Hirschsprung disease	Abdominal plain film^¶
Vascular malformation or hemangioma	X	X				Typically in child with other vascular lesions (eg, HHT or infantile hemangiomatosis); may have epistaxis or iron deficiency	Endoscopy
Gastrointestinal duplication cyst	X	X	X			Variety of presentations, including gastrointestinal bleeding, infection or intussusception; more common in infants, but may present later	Imaging; most are in the small bowel
Infantile and very early-onset inflammatory bowel disease (VEO-IBD)	X	X	X			Diarrhea (with or without blood), poor weight gain and growth, severe perianal disease, recurrent infections, atypical endoscopy or histology findings, skin lesions, and associated autoimmune diseases	Immunodeficiency evaluation; consider whole-exome sequencing (in addition to tests listed under "inflammatory bowel disease" below)
Infectious colitis	X	X^*	X^*	X^*	X	Loose, bloody stools; abdominal pain; fever	Culture of stool for enteric pathogens; C. difficile testing (toxin or PCR); fecal leukocytes
Anal fissure	X^*	X^*	X^*	X^*	X^*	Well-appearing; stools with low-moderate blood; often associated with constipation	Examine anus closely
Intussusception		X	X			Sudden-onset abdominal pain and lethargy, with or without grossly bloody stools ("currant jelly" appearance)	Abdominal ultrasonography, water-soluble contrast enema, or air enema (for diagnosis and non-operative reduction)
Meckel's diverticulum		X	X	X	X	Painless rectal bleeding, especially if recurrent and an anal fissure is excluded; bleeding may be profuse	Meckel scan
Hemolytic-uremic syndrome			X	X	X	Hemolytic anemia, thromobocytopenia, elevated creatinine, onset 5 to 10 days after diarrheal illness	CBC, BUN, creatinine, peripheral blood smear, stool culture
Henoch-Schönlein purpura (IgA vasculitis)			X	X	X	Cutaneous purpura (palpable), abdominal pain, arthralgias	Clinical diagnosis if typical features are present; skin or kidney biopsy if atypical presentation; abdominal ultrasonography if intussusception is suspected^Δ
Solitary rectal ulcer syndrome			X	X	X	Rectal blood and mucus, tenesmus, sense of incomplete evacuation	Proctoscopy with biopsy; evaluation to rule out inflammatory bowel disease and infectious proctitis
Juvenile polyps			X^*	X^*		Painless rectal bleeding, often intermittent	Examine anus closely to rule out fissure; digital rectal examination for polyp; colonoscopy
Inflammatory bowel disease				X^*	X^*	Diarrhea (with or without blood) and abdominal pain, often with growth failure or delayed puberty; may have weight loss or fever	CBC, ESR, or CRP, albumin; imaging; colonoscopy and upper endoscopy Additional tests – PT/PTT, AST, ALT, amylase, lipase; fecal calprotectin, stool culture and C. difficile testing; O&P

ALT: alanine transaminase; AST: aspartate transaminase; BUN: blood urea nitrogen; C. difficile: Clostridioides difficile; CBC: complete blood count; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; HHT: hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome); IgA: immunoglobulin A; O&P: ova and parasites; PCR: polymerase chain reaction; PT/PTT: prothrombin time/partial thromboplastin time.

* Relatively common cause in the given age group.

¶ On abdominal radiography, signs suggestive of Hirschsprung-associated enterocolitis include absence of air in the distal rectosigmoid colon, with an abrupt cutoff at the level of the pelvic brim ("cutoff" sign).

Δ Henoch-Schöenlein purpura may be complicated by intussusception, with the involved bowel serving as a lead point for the intussusception.

Graphic 95764 Version 10.0

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Differential diagnosis of the pediatric patient with small to moderate rectal bleeding (hemodynamically stable)