Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This is a frightening symptom with which the parents rush to the doctor. They have noticed that their child passes blood from the anus and an associated mass comes out when the child goes to pass stool. The blood scares them and the mass confuses them, and very often they feel that these are piles. Piles rarely if ever, occur in a child hence that possibility should not be entertained. There are 3 possible conditions that could present with bleeding and mass coming out of the rectum – a rectal polyp, rectal prolapse and lastly but least commonly is an intussusception.
The differentiation of these conditions is necessary as the treatment is completely different for each of these conditions. Here the observations by the parents are extremely important to help reach the diagnosis along with a proper examination. The age and other symptoms of the child are important and must be asked for.
A child of 2-4 years with painless bleeding per rectum and a rounded mass coming out after passage of stool, no associated constipation, and blood being bright red fresh and not mixed with stool or mucus is most likely to be a rectal polyp.
A child with a recent history of diarrhea, gastroenteritis; or even a child with chronic constipation with straining to pass stool, painful defecation and a mass coming out of the rectum long with blood that is mixed with mucus. The mass coming out may be all around and with typical folds seen and goes back on its own – is likely to be a partial mucosal rectal prolapse. These children may also complain of abdominal pain off and on.
An infant 6 – 9 month old who is having episodes of acute colicky severe pain with drawing p of legs, screaming followed by periods of sudden quietness, with passage of blood & mucus mixed together is likely to be an intussusception. This is telescoping of intestine over each other resulting in intestinal obstruction, congestion of the blood supply and oozing of the blood into the lumen of the large intestine. This is a semi emergency and requires admission and therapy.
A thorough examination must be done to come to the correct diagnosis. Besides examining the abdomen and the history, a per rectal examination is a must to be done with a gloved finger. This can often differentiate between the 3 conditions.
If the finger goes in easily and is moved around in circular fashion, the mass may be felt at one point of the circumference of the inner wall of the rectum and the rest of the wall is normal – this goes in favour of a rectal polyp. The mass will have a base, an elongated stalk and a mass at the tip which may be brought out easily of the rectal opening.
If the finger goes in easily, and no mass can be felt all round the inner wall, but there are the presence of loose transverse mucosal folds inside, this may well be the loose mucosal that prolapses out and looks like a mass. Straining while passing stool and loose mucosal cuse the congestion and the blood in the lumen that comes out.
If the finger goes in easily, and the mass is felt in the rectum and the examining finger can go all around the mass on all sides then this could be intussusception.
The therapy will naturally depend on the cause of the mass.
Polyp: the only therapy possible is surgical. The child is taken under general anesthesia, and through the rectum speculum is inserted and the polyp is visualized. Gentle traction on the polyp will help to deliver it out of the anal opening and the base and the stalk are identified. A clamp is then applied to the base and the polyp and the stalk is excised. There is usually a blood vessel supplying the polyp and this is then tied off with a suture. The child can go home the same day and need not stay in the hospital. The polyp that has been removed, must be sent to the laboratory for a histological examination to know what type it is, chances of recurrence, more than one being present higher up etc.
Base of Polyp
Prolapse: In this condition, the cause is important in deciding the treatment. Chronic constipation if present needs to be corrected by proper diet, a laxative and proper stool training. If it has occurred after a bout of recurrent diarrhea then controlling the loose stools and then giving a good nutritious diet to improve the weight and the para rectal fat support of the rectum is very important. Active therapy of the prolapse is again non surgical as far as possible – this is done by asking the parents to give strapping by bringing the 2 buttocks together to close the anal opening and giving external support with sticking plaster all day except when the child passes stool. This is continued for a few weeks. Along with this the child is referred to a good physiotherapist who is asked to teach the child sphincter exercises to increase the tone of the anal sphincter and prevent prolapse. Also Faradic stimulation a type of electrical stimulation of the sphincters is done to increase the tone and power which can be given for 6 weeks. In almost 90% children this is all adequate to stop the prolapse and nothing more is required. In those where the prolapse persists or is of a long standing duration when the child is brought to us, or there is a failure of the above mentioned methods to treat the prolapse, then surgery is undertaken which may be a simple suture to narrow the sphincter and prevent the prolapse, or more extensive surgery where the rectum is attached to the sacrum and sutured to avoid the recurrence. This is done either with open surgery or through the laparoscope.
Intussusception: Since this is a telescoping of the intestine over the immediate adjacent one, intervention is must and that too urgently. Today, with good image intensifiers, it is possible to reduce the telescoping and send the child home within 1 day. This is possible by using either the Barium solution with an enema can to allow the barium to flow under hydrostatic pressure into the bowel. This pressure reduces the intussusception gradually till the entire intestine is restored to normal. I have done many of these with great success, at times with a good sonologist, this same procedure can be carried out with Ultrasound monitoring and using Saline. The advantage is that this does not expose the child to radiation of x ray machine. If this is not possible – then the option is only open surgery to look for the segment of intestine affected and then manually reduce the intussusception and then send the child home after a few days.
Last Updated: 27th January 2009