A young girl, age 20 months, was brought to the clinic after passing maroon-colored stool twice during the past week. The mother reported no change in the girl’s diet or behavior. Typically the patient had one or two bowel movements per day; the stool was usually well-formed and semisoft. The mother reported no fever, vomiting, irritability, skin rashes, or lethargy.
The child was born at 39.5 weeks’ gestation. Apgar scores following an uneventful spontaneous vaginal delivery were 9 at one minute and 10 at five minutes. The baby was breastfed for four months, after which she was fed formula, followed by progressive introduction of cereals, vegetables, and fruits starting at age 5 months. Development had been normal. At presentation, the girl was in the 75th percentile for height and weight.
The child was interactive during the interview and cooperative with the exam. Skin was without lesions or pallor. Conjunctivae were clear. Heartbeat was regular; no murmurs were heard. Lungs were clear. Abdominal exam revealed normoactive bowel sounds; no guarding or rigidity was observed. Liver and spleen were not palpable; there were no palpable masses. The anal area was without redness, lesions, or excoriations.
The first step in managing patients with apparent blood in the stool is to assure that they are hemodynamically stable. Dehydration or hypotension should alert the clinician that aggressive treatment is needed. The girl in this case appeared stable.
The next step is to confirm the presence of blood through fecal occult blood testing. Bloody-appearing stools can have a number of causes, including iron preparations; bismuth; dyes; and certain fruits and vegetables, namely beets. None of these possibilities was revealed on questioning our patient’s mother. Hemoccult testing was positive.
Blood that has been present in the GI tract for a prolonged time manifests as melena, or black, tarry, odorous stool. Melena suggests bleeding proximal to the ileocecal valve above the ligament of Trietz. Hematochezia can manifest as bright red blood per rectum or maroon-colored stool and typically indicates bleeding from the lower GI tract. There are exceptions, however, especially if the patient has slower or more rapid than usual GI motility. Our patient had hematochezia.
2. Finding the underlying cause
The causes of hematochezia in a child include anorectal fistula, infectious colitis, inflammatory bowel disease, intussusception, and Meckel diverticulum.
Viral gastroenteritis characteristically causes nonbloody diarrhea and vomiting with fever; infection with shigella or salmonella may cause dysentery. Intussusception presents with irritability and pain evidenced by kicking and/or drawing up of the knees, followed by passage of lumpy, mucus-laden stool (described as resembling currant jelly); vomiting is common and may turn bilious. The features of inflammatory bowel disease include abdominal pain, dietary associations, and systemic complaints. In the absence of pain and an external opening, anorectal fistula was ruled out.
Meckel diverticulum is the most common congenital defect of the small intestine. It represents an incomplete obliteration of the vitelline duct, resulting in ectopic gastric tissue in the intestinal tract. The rule of twos applies: Meckel diverticulum is estimated to be present in 2% of the population (most patients are asymptomatic), about 2% of the affected population presents with clinical findings (typically before age 2 years), and the condition is two times more common in males than females.
Complications are infrequent and include inflammation, obstruction (intussusceptions or volvulus), or ectopic tissue. Males are more often affected by complications than females.
The most common presentation of symptomatic Meckel diverticulum in childhood is painless hematochezia. Stools can be dark maroon (most common), bright red, or tarry. Bright red bleeding suggests hemorrhage. Pain is infrequent unless obstruction or severe inflammation develops. Occasionally, infarction occurs, causing pain, fever, and acute peritoneal signs.
Diagnosis is suggested by the history and physical exam. Lab studies are normal unless bleeding has been severe enough to cause anemia. Technetium-99m pertechnetate scintiscan is the imaging study of choice (sensitivity 80%-90%, specificity 95%) to confirm Meckel diverticulum. Scintiscan will show a “hot spot” at the site of the ectopic tissue. Barium studies or arteriography may be helpful if the scintiscan is equivocal. Plain films and barium studies are not generally helpful unless a volvulus or intussusception has occurred. Arteriography may be needed if bleeding is intermittent and scan is equivocal.
3. Treatment and outcome
Medical treatment involves stabilization and replacement of fluids in acute bleeds. Surgical correction is the definitive treatment. Administration of broad-spectrum antibiotics both prior to surgery and perioperatively is recommended in the presence of obstruction, inflammation, or sepsis.
An asymptomatic Meckel diverticulum is often found incidentally during a workup for other conditions. Surgical correction in such cases is controversial but usually recommended in younger patients to prevent development of complications.
In our patient, scintiscan confirmed the presence of the diverticulum. She underwent surgical correction five days later. The postoperative course was uneventful, and she was discharged home on a full regular diet three days after surgery.
Ms. Babcock O’Connell is associate professor in the physician assistant program at the New Jersey Medical School and Rutgers University, Piscataway, N.J., and a contributing editor to The Clinical Advisor.