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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 2  |  Page : 247-251

Colonoscopic findings in children with lower gastrointestinal bleeding


1 Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Kafer Elsheikh Medical Center, Kafer Elsheikh, Egypt

Date of Web Publication18-Oct-2016

Correspondence Address:
Heba A. Abd Elghany Abo El-Khair
Kafer Elsheikh Medical Center, Kafer Elsheikh, 33511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.192425

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  Abstract 

Objective: 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. Background: 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. Results: 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. Conclusion: 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 2019 Nov 21];29:247-51. Available from: http://www.mmj.eg.net/text.asp?2016/29/2/247/192425


  Introduction Top
Lower gastrointestinal bleeding (LGIB) means bleeding from sites distal to the ligament of Treitz and presents as rectal bleeding [1]. LGIB can be presented in four forms:
  1. 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.
  2. 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.
  3. Occult bleeding with symptoms of fatigue and pallor. It is usually detected by laboratory tests revealing iron deficiency anemia or positive fecal blood test.
  4. Symptom of severe blood loss, such as malaise, tachycardia, or even shock [2].
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 [3]. Chronic cases of minor LGIB produce significant anemia; thus, localization of the source of bleeding is important in the management of these children [4]. 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 [5]. 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 [6]. The safety and effectiveness of colonoscopy in the investigation of lower GI tract pathology in children has been established for more than two decades [7]. Colonoscopy has several advantages and is generally regarded as the preferred initial test in the majority of cases. The advantages are as follows:
  1. Ability to identify bleeding source regardless of the rate or presence of bleeding,
  2. Multiple therapeutic possibilities,
  3. Efficiency given diagnostic and therapeutic potential,
  4. Irrespective of initial testing, colonoscopy is required for definitive diagnosis, and
  5. Safety.
Disadvantages are as follows:
  1. Requirement for colon preparation,
  2. Need for sedation, experienced staff, and endoscopy facilities,
  3. hemorrhage, and
  4. Invasive nature [8].

  Patients and Methods Top
Consent The procedure of colonoscopy was explained to the parents and consent was taken. Study design 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. Inclusion criteria 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. Statistical analysis 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:
  1. Description of quantitative variables as mean, SD, and range.
  2. Description of qualitative variables as number and percentage.
  3. χ2-Test was used to compare qualitative variables between groups.
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.
  Results Top
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]).
Table 1: Associated complains of the studied patients

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In all, 26 (34.66%) patients showed normal examination and 31 (41.33%) patients showed pallor ([Table 2]).
Table 2: The general clinical examination of the studied groups

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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]).
Table 3: Frequency of colonoscopic finding in patients

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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]).
Table 4: Frequency of pathologic finding in patients

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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]).
Table 5: The causes of rectal bleeding according to the age

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Figure : Frequency of colonoscopic finding in patients

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Figure : Frequency of pathologic finding in patient

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Figure : Causes of rectal bleeding according to the age

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  Discussion Top
Rectal bleeding is an alarming symptom and requires additional investigation [9]. It is a common reason for referral to pediatric gastroenterologists and surgeons [0]. 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 [9]. 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 [1]. We found polyp in 44% of patient; this is quite different from another study, which was 10% [0]. Our rate was however very less than the relative frequency of 75% reported by others [2]; 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 [3]. The peak age in patients with polyps in this study was between 3 and 6 years; in addition, in Mandhan's [2] 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 [4]. These polyps are usually hamartomatous and account for 90% of all polyps found in children [5]. 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 [6]. 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 [7]. Rectal bleeding is the main presenting symptom in most patients with ulcerative colitis [8]. GI infections are considered as one of the most common causes of LGIB and dysentery in any age group [9]. 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 [0]. 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 [2]. 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 [1].
  Conclusion Top
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.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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