PM Pediatrics

Dr. Christina Johns
Senior Medical Advisor, PM Pediatrics

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Number 2 and You

We’ve known each other for over a year already so we can talk about…stuff…right?

I didn’t want to bring up the “ick” factor right out of the gate, but enough parents have brought their kids in for the concern of “blood in the stool” that I just can’t NOT talk about it any longer.  So- sorry if this gives you the full-on stomach turn but let me tell ya, people are talking about their kids’ #2.  And I mean A LOT.  Especially if there appears to be ANYTHING that might resemble blood in it. That would gross out AND scare anybody. So in the interest of taking away one of these elements, let’s talk about what might cause this situation so we can all be less nervous about it when appropriate.  As with all the medical stuff, it seems, some of the potential causes are serious, but many are not.  Here we go.  I’ll resist the urge (get it? LOL) to make bathroom jokes despite the fact that TOILET HUMOR continues to be popular with my kids for reasons unclear to me at this time.

Far and away the MOST COMMON CAUSE of blood in the stool is a FALSE ALARM.

What I mean by that is that while it appears that there is a bright red toilet bowl or diaper full of blood, in fact the red color is caused by SOMETHING ELSE in the gastrointestinal (GI) tract.  Food coloring like in frosting, red dye #2 (the dye # irony is not lost on me), certain actual foods such as red Jell-o, beets, cranberries, red or grape Kool-Aid, or tomato skins or juice can all give the stool a varying hue of red. 

Some medicines can also have this effect, like the antibiotic Cefdinir. In this clinical picture, kids look quite well and are happy as clams; not sick at all.  They have normal vital signs and aren’t pale or bleeding elsewhere.  They are eating normally and are only upset because they believe that they are being slowed down by an irritating doctor visit.  Usually the history alone can clue in the clinician as to a non-bloody cause of red appearing poop, but after a physical exam there’s a fairly easy test that can determine for sure if the red substance is actually blood.  I know what you’re thinking—do people really bring in dirty diapers to be examined? And, do people really bring in a stool sample on their own, without it being an ordered test from a physician?  Yes and yes. Been there, done that.

Now let’s move on to actual blood in the stool. Or around the stool.

Because yes, TMI….but it does make a difference. Blood around the stool and not mixed in it suggests that the blood isn’t coming from way inside the GI tract. In adults, this is most commonly caused by hemorrhoids, which are engorged veins right around the anus, and in children the most common cause is constipation, which can cause a little tear in the anal opening that is called a “fissure.” This split in the skin can cause some bright red blood streaks around the outside of the stool or across the diaper. It may or may not be uncomfortable for the child, but the good news is that it heals well all on its own with just some stool softener or petroleum jelly or lubricant right at the anus, plus increased water drinking, so that the stool exits the body more easily and with decreased straining. Typically, children with a fissure look well,  have normal vital signs, eat normally and all that, except that they may appear to strain when having a bowel movement.  Sometimes that’s our best clue, and then we can often see the fissure when we have a look “down there.”

How Common Is It?

Infectious diarrhea is common, but thankfully bloody infectious diarrhea is not. Bloody infectious diarrhea is LESS suggestive of a simple viral cause and MORE suggestive of a bacterial cause, like Shigella or E. Coli or Salmonella. The clinical picture here is a mixed bag: early on in the course of the illness a child can look fine except that they are having diarrhea that has blood and often mucus mixed in it. In many instances these children don’t even complain of a stomachache, but if there’s been bloody diarrhea for several days, a child can become dehydrated and in many cases will need a stool sample sent to the lab for culture and identification. Treating these infections most often means rehydration and doesn’t always mean antibiotics: sometimes the infection just has to run its course. But clearly this is a more serious clinical scenario that warrants a clinical evaluation and close follow up.

 

When It’s An Emergency

There are more urgent and serious causes of bloody stools. Some are surgical emergencies like intussusception (25¢ word) when part of the intestine telescopes into an adjacent segment, cutting off the blood supply, thereby causing inflammation and internal bleeding. I’ve never been wild about this description but the classic descriptor is “red currant jelly” appearing stools—darker and gelatinous. Most children with this disorder actually look quite toxic and many are in a lot of pain, curled up in the fetal position. This situation requires immediate therapy with either a radiologic study called a contrast enema, where contrast (a safe dye-like substance that shows up on radiologic studies)  is inserted into the rectum like an enema in the hopes of straightening out the telescoping segments of intestine, or if that doesn’t work, then the child needs surgery to have the telescoping segments fixed manually in the operating room. Vigorous IV fluids and close observation are very important during recovery to ensure that a re-telescoping doesn’t occur.

A visual representation of currant jelly

Another cause that is typically classified as “painless rectal bleeding” is when there’s a small outpouching in the intestine that we call a Meckel’s diverticulum (25¢). This can cause a fair amount of bleeding and requires radiologic testing to be correctly diagnosed. The concern with any amount of continuous bleeding is that the body can’t keep up with the losses production-wise, and we need our blood to carry oxygen to our tissues, so stopping the bleeding as soon as possible is critical.

The intent of this brief body function review is to demonstrate the wide range of causes that run through my mind when I hear the words “blood in the stool.” I’m happy to report that the vast majority of cases are not really cases at all, but because of the fact that there’s potential for emergent sickness I really encourage everyone who believes that their child is having bloody stools to get checked out right away. I don’t mind giving the false alarm speech, and I’d rather catch an emergency sooner rather than later.

Are you still thinking about all the various foods that cause poop to have a red color? Always blame the Kool-Aid.Image result for kool aid oh yeah

#nowyouknow  

 

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