Patient education: Bloody stools in children (Beyond the Basics)
- Nishaben Patel, MD
Nishaben Patel, MD
- Assistant Professor Pediatric Gastroenterology & Nutrition
- University of Rochester Medical Center
- Marsha Kay, MD
Marsha Kay, MD
- Chair, Department of Pediatric Gastroenterology and Nutrition
- Cleveland Clinic
Seeing blood on your child's stool can be frightening. However, this is a common condition in children and is usually not serious. There are many possible causes of bloody stools, also known as "rectal bleeding." The most likely cause depends on the frequency and amount of blood, and on your child's age and underlying condition. A healthcare provider can help to determine the source of the bleeding and the most appropriate treatment.
This article will review some of the common causes of bloody stools and tests that may be used to evaluate your child. Bloody stools in adults is discussed separately. (See "Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)".)
WHEN TO SEEK HELP
Most children with minor rectal bleeding do not have a serious condition. However, it is not possible to know the cause of rectal bleeding without an examination. Thus, if you notice that your child has rectal bleeding, you should talk to your child's healthcare provider to determine if an examination is needed. (See 'Rectal bleeding tests' below.)
TYPES OF RECTAL BLEEDING
Bloody stools usually indicate bleeding in the upper digestive tract (stomach and small intestine) and/or the lower digestive tract (the colon, rectum, and anus) (figure 1).
●Bleeding from the upper digestive tract usually causes black, tarry stools. In many cases, the child also vomits red or black material that looks like coffee grounds.
●Bleeding from the lower digestive tract usually causes the stool to be coated or mixed with bright red blood, or occasionally to appear maroon colored.
●Certain foods and medications can also cause the stool to appear bloody. A list of these foods and medications is provided in table 1 (table 1).
However, it is not always possible to know the source or type of rectal bleeding based upon the appearance of the stool alone. Bloody stools can even come from other places, including bleeding from the nose and throat. An evaluation and physical examination is necessary in most cases. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic approach".)
RECTAL BLEEDING CAUSES
Anal fissure — An anal fissure is a cut or tear in the lining of the anus (the opening through which stool passes out of the body) that can develop when an infant or child passes a large or hard stool. Anal fissures can occur in all age groups, from newborns to school-aged children and even adults (see "Patient education: Anal fissure (Beyond the Basics)"). The symptoms of an anal fissure include pain, straining, or grunting during a bowel movement, and bright red blood on the outside of the stool or with wiping.
Many infants and children with anal fissures also have a history of constipation or fairly hard stools. Treatment of constipation is discussed separately. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)
Milk or soy protein intolerance — Milk or soy protein intolerance (also known as milk- or soy protein-induced colitis, or protein-induced proctitis or proctocolitis) is a condition that can develop in infants. It is caused by a sensitivity to the protein in cow's milk or soy, and usually develops after starting formula. It can also occur in breastfed infants, as a result of cow's milk or soy products consumed by the mother. The protein intolerance frequently resolves by one year of age.
Symptoms of milk or soy protein intolerance may include vomiting and diarrhea, in addition to blood-tinged or bloody stools. If milk or soy protein intolerance seems to be the most likely cause after an evaluation by the medical provider, a diet that does not contain milk or soy protein is often prescribed. This is described in a separate article. (See "Food protein-induced proctocolitis of infancy", section on 'Management' and "Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)", section on 'Milk-free diet'.)
Less common causes
●Inflammatory bowel disease, also known as Crohn disease or ulcerative colitis, is a chronic inflammatory condition in which the lining of the digestive tract becomes inflamed. The inflammation leads to symptoms, such as bloody stools, diarrhea, lack of appetite, and weight loss. Crohn disease and ulcerative colitis are discussed in more detail in a separate article. (See "Clinical manifestations of Crohn disease in children and adolescents" and "Management of mild to moderate ulcerative colitis in children and adolescents".)
●Infectious diarrhea is diarrhea caused by a virus, bacterium, or parasite that can cause bloody stools in preschool and school-aged children, as well as in adolescents. Infectious diarrhea can develop as a result of eating or drinking contaminated foods/drinks/water, or less commonly, after taking a course of antibiotics. (See "Patient education: Food poisoning (foodborne illness) (Beyond the Basics)" and "Patient education: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)".)
Symptoms of infectious diarrhea usually include bloody diarrhea, fever, and abdominal pain. Treatment of diarrhea in children is discussed separately. (See "Patient education: Acute diarrhea in children (Beyond the Basics)".)
●Juvenile polyps are growths of tissue projecting from the inner lining of the colon that can develop in children, typically between the ages of two and ten years. Symptoms usually include painless rectal bleeding. Single juvenile polyps are not usually cancerous or precancerous but should be evaluated by a healthcare provider and usually require removal.
Rarely, multiple or large polyps are present in the colon in children or adolescents and cause rectal bleeding. Some of the conditions associated with this presentation in children and teenagers are: juvenile polyposis coli (JPC), adenomatous polyposis coli (APC), or Hereditary nonpolyposis colon cancer (HNPCC) syndrome (formerly known as Lynch syndrome). These conditions are often inherited and patients often have family members who are affected (see "Patient education: Familial adenomatous polyposis (The Basics)" and "Peutz-Jeghers syndrome: Epidemiology, clinical manifestations, and diagnosis"). In addition, tumors may present with rectal bleeding, but tumors are a very rare cause of rectal bleeding in children and adolescents. The tumors may be primary, meaning they originate in the gastrointestinal tract, or may be metastatic, which means they may originate elsewhere in the body.
●Meckel's diverticulum is a congenital (present at birth) outpouching in the lower part of the small intestine and is leftover from the umbilical cord. It may contain cells normally found in the stomach that can secrete acid and cause ulcers and bleeding in the small bowel near the diverticulum, which results in bleeding from the rectum. Occasionally, bleeding from a Meckel's diverticulum can be dangerous, so if suspected, an evaluation should be done promptly. (See "Patient education: Meckel's diverticulum (The Basics)".)
●A number of other more serious conditions can cause rectal bleeding because of obstruction (blockage) of the bowels. These include intussusception (a form of bowel obstruction in which a part of the intestine "telescopes" into an adjacent part of the intestine) or Hirschsprung's disease (a form of colon obstruction that develops before birth and caused by the absence of nerve cells in the large bowel). Most of these conditions cause the infant or child to become ill suddenly. If your child suddenly develops bloody stools and becomes lethargic, has abdominal pain, fever, or other unusual symptoms, call your child's healthcare provider immediately. (See "Intussusception in children" and "Congenital aganglionic megacolon (Hirschsprung disease)".)
●Other conditions that can cause rectal bleeding include a blood clotting disorder or abnormalities of the blood vessels inside the bowel, which can cause excessive bleeding. These causes may be accompanied by changes in the skin (easy bruising, certain rashes, or other findings) or other symptoms that can help the doctor or nurse choose tests to diagnose the problem.
RECTAL BLEEDING TESTS
Sometimes a clinician can determine the cause of the bleeding by inspecting the outside of the anus. This may include a brief examination of the inside of the anus using a finger (rectal examination). The clinician can also test a sample of stool to be sure whether or not it contains blood. The stool can be tested for infection by a bacteria, virus, or parasite, by sending a specimen to the lab for testing.
This examination may be all that is necessary. If the cause of the bleeding is not clear based upon the examination, further testing may be recommended. This might include blood tests and in some cases a colonoscopy. Colonoscopy is an examination of the lower part of the gastrointestinal tract (also known as the colon or large bowel), which is performed by insertion of a thin, flexible tube with a camera attached that allows your doctor to examine the inner lining of the colon or large bowel. Imaging tests (x-ray, ultrasound, or nuclear medicine studies in the case of a suspected Meckel's diverticulum) might also be helpful in some cases. The clinician chooses between these tests depending on the child's history and symptoms.
RECTAL BLEEDING TREATMENT
As discussed above, there are a number of potential causes of bloody stools. Your child's healthcare provider will determine if the underlying condition requires treatment. Even if your child's bleeding seems minor or resolves on its own, your child should be evaluated by a healthcare provider.
WHERE TO GET MORE INFORMATION
Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: GI bleed (The Basics)
Patient education: Angiodysplasia of the GI tract (The Basics)
Patient education: Meckel's diverticulum (The Basics)
Patient education: Ulcerative colitis in children (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)
Patient education: Anal fissure (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)
Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)
Patient education: Food poisoning (foodborne illness) (Beyond the Basics)
Patient education: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)
Patient education: Acute diarrhea in children (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Lower gastrointestinal bleeding in children: Causes and diagnostic approach
Clinical features and diagnosis of necrotizing enterocolitis in newborns
Clinical presentation and diagnosis of inflammatory bowel disease in children
Food protein-induced proctocolitis of infancy
Management of necrotizing enterocolitis in newborns
Clinical manifestations of Crohn disease in children and adolescents
Management of mild to moderate ulcerative colitis in children and adolescents
Intussusception in children
Congenital aganglionic megacolon (Hirschsprung disease)
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute of Diabetes and Digestive and Kidney Diseases
- Balkan E, Kiriştioğlu I, Gürpinar A, et al. Sigmoidoscopy in minor lower gastrointestinal bleeding. Arch Dis Child 1998; 78:267.
- Teach SJ, Fleisher GR. Rectal bleeding in the pediatric emergency department. Ann Emerg Med 1994; 23:1252.
- Lee BG, Shin SH, Lee YA, et al. Juvenile polyp and colonoscopic polypectomy in childhood. Pediatr Gastroenterol Hepatol Nutr 2012; 15:250.
- Boyle JT. Gastrointestinal bleeding in infants and children. Pediatr Rev 2008; 29:39.
- Neidich GA, Cole SR. Gastrointestinal bleeding. Pediatr Rev 2014; 35:243.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.