Rectal Bleeding in Children

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Henoch-Schönlein Purpura
  • Solitary Rectal Ulcer Syndrome
  • Volvulus
  • Necrotising Enterocolitis (in Neonates)
  • Vascular Lesion/Bleeding Tendency

Ready Reckoner

Key distinguishing features of the most common diagnoses

Swallowed Maternal BloodAnal FissureGastroenteritisCMPIRectal Polyp
ConstipatedNoYesNoPossibleNo
Anal PainNoYesNoNoNo
DiarrhoeaNoNoYesPossibleNo
Repeated EpisodesNoPossibleNoYesYes
VomitingNoNoPossiblePossibleNo

Possible Investigations

  • In most cases, primary care investigations will be unnecessary – the diagnosis will either be obvious and harmless (e.g. anal fissure) or will require admission or referral and investigation in secondary care. So the following are the only investigations likely to be performed in primary care:
  • Stool: M, C and S for gastroenteritis
  • Faecal calprotectin: If IBD suspected.
  • FBC, CRP, ESR: If IBD suspected.

Top Tips

  • Remember that red stools do not necessarily imply blood – discolouration can be caused by food, drink and medication.
  • Rectal bleeding caused by an anal fissure should be obvious through the history – it should not be necessary to traumatise the child further via a digital examination.
  • As in adults, the nature of the bleeding will help locate its origin, with bright blood usually from distal, and altered blood from more proximal, sites.
  • If gastroenteritis is suspected, then Campylobacter or Shigella are likely

Red Flags

  • Always be alert to the rare possibility that rectal bleeding might be the result of nonaccidental injury.
  • The classic redcurrant jelly stool is a fairly late feature of intussusception. Consider this especially in young children (usually under two) with episodes of severe distress/abdominal pain associated with pallor
  • Many symptoms are attributed to possible CMPI. It certainly can cause rectal bleeding, but remember other possible causes if a trial of cow’s milk protein-free feeds does not resolve the problem, and ensure investigation.

Published: 1st August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.