What is the appropriate workup and management for a 2-year-old presenting with hematochezia (blood in stool)?

Workup and Management of Hematochezia in a 2-Year-Old Child

A thorough diagnostic workup is essential for a 2-year-old presenting with hematochezia, with initial focus on ruling out serious causes while considering common age-appropriate etiologies.

Initial Assessment

• Vital sign monitoring and IV access establishment for potential fluid resuscitation if signs of hemodynamic instability are present 1
• Digital rectal examination to characterize bleeding and assess for anorectal causes 1
• Assess for:
  • Volume and character of blood (bright red vs. darker blood)
  • Associated symptoms (abdominal pain, diarrhea, vomiting, fever)
  • Dietary history (recent introduction of cow's milk or other potential allergens)
  • Family history of inflammatory bowel disease or bleeding disorders

Laboratory Investigations

• Complete blood count to assess for anemia and inflammation
• Coagulation profile (PT/INR, PTT) to rule out bleeding disorders 1
• Consider type and screen if significant bleeding 1
• Stool studies:
  • Stool culture for bacterial pathogens (Salmonella, Shigella, Campylobacter, E. coli)
  • Fecal calprotectin and lactoferrin to assess for inflammation 2
  • Stool for ova and parasites if travel history or exposure

Diagnostic Procedures

First-line:

• Anoscopy or flexible sigmoidoscopy should be performed as first-line diagnostic tools to evaluate for anorectal causes of bleeding 1
• Colonoscopy is indicated if bleeding persists or is significant, as it provides higher diagnostic yield than sigmoidoscopy alone 3

Second-line (if indicated):

• Upper endoscopy if lower GI evaluation is negative or upper GI source is suspected 1
• Abdominal ultrasound to evaluate for intussusception or other structural abnormalities
• CT scan with contrast if there is concern for more serious pathology 1

Common Etiologies in 2-Year-Olds

1. Anal fissures - Most common cause of bright red blood per rectum in toddlers 2
2. Infectious colitis - Bacterial, viral, or parasitic infections
3. Food allergies/intolerances - Particularly cow's milk protein allergy 4, 5
4. Juvenile polyps - Can cause painless rectal bleeding
5. Intussusception - Typically presents with colicky abdominal pain and "currant jelly" stools
6. Meckel's diverticulum - Usually painless bleeding, often maroon or darker in color

Management Approach

For Mild Bleeding Without Systemic Symptoms:

• Consider trial of cow's milk elimination diet if milk protein allergy is suspected 4
• Monitor for resolution of symptoms
• Outpatient follow-up with pediatric gastroenterology

For Moderate to Severe Bleeding:

• Fluid resuscitation if needed
• Consider blood transfusion if hemoglobin drops significantly (target 7-9 g/dL) 1
• Urgent colonoscopy within 24 hours for active significant bleeding 1, 3
• Hospitalization for observation and further management if:
  • Hemodynamic instability
  • Significant anemia requiring transfusion
  • Persistent bleeding
  • Concerning associated symptoms (severe abdominal pain, high fever)

Important Considerations

• Unlike adults, rectal bleeding in young children is rarely due to hemorrhoids 2
• Inflammatory bowel disease, while less common in toddlers, should be considered if bleeding is persistent or recurrent 3
• In a 2-year-old with rectal bleeding, colonoscopy rather than just sigmoidoscopy is preferred as studies show up to 22% of polyps would be missed with sigmoidoscopy alone 3
• Cow's milk protein allergy is a common cause of rectal bleeding in infants and young toddlers, but formal elimination and challenge testing is necessary for diagnosis 4

When to Refer to Pediatric Gastroenterology

• Persistent or recurrent bleeding despite initial management
• Abnormal laboratory findings (anemia, elevated inflammatory markers)
• Concerning findings on initial imaging or endoscopy
• Family history of inflammatory bowel disease or polyposis syndromes

Pitfalls to Avoid

• Attributing bleeding solely to hemorrhoids without proper evaluation (rare in this age group) 2
• Assuming cow's milk allergy without proper elimination/challenge testing 4
• Performing only sigmoidoscopy instead of complete colonoscopy when indicated 3
• Failing to evaluate for coagulation disorders, especially with significant bleeding 6