What is the management for a child who passed a fleshy mass per rectum without a protruding mass?

Management of a Child Who Passed a Fleshy Mass Per Rectum

This child most likely passed a juvenile polyp, and the immediate priority is to confirm hemodynamic stability, perform a digital rectal examination and anoscopy/proctosigmoidoscopy to identify any remaining polyps or bleeding source, and arrange for complete colonoscopy to exclude multiple polyps or polyposis syndromes. 1, 2

Immediate Assessment

Clinical Evaluation

• Check vital signs and assess for anemia from blood loss, as rectal polyps are the most common cause (2%) of gastrointestinal bleeding in children under 10 years 1, 3
• Perform digital rectal examination to assess for any remaining masses, bleeding, or mucosal abnormalities 4
• Obtain complete blood count to evaluate for anemia and assess hemodynamic status 4, 2

Initial Diagnostic Steps

• Proctosigmoidoscopy should be performed first as it reveals the majority of etiologies in pediatric lower GI bleeding and can identify any remaining polyps 2
• Complete colonoscopy is essential to evaluate the entire colon for additional polyps, as multiple juvenile polyps significantly increase cancer risk in adolescents and adults 1

Pathology Assessment of the Passed Mass

• Send the passed tissue for histopathologic examination to confirm it is a juvenile polyp versus other pathology 1, 5
• Histologic confirmation distinguishes isolated juvenile polyps from adenomatous polyps or other concerning lesions 1, 5

Risk Stratification Based on Findings

If Single Juvenile Polyp (Most Likely)

• Isolated juvenile polyps are benign and the most frequent type identified in children 1
• Complete colonoscopy remains mandatory to confirm no additional polyps are present 1
• No further surveillance is typically required if truly isolated 1

If Multiple Polyps Identified

• Multiple juvenile polyps indicate juvenile polyposis syndrome, which carries significant risk of intestinal cancer in adolescents and adults 1
• Genetic evaluation and family screening should be initiated for polyposis syndromes including juvenile polyposis syndrome, familial adenomatous polyposis (FAP), attenuated FAP, and MYH-associated polyposis 1
• Regular surveillance colonoscopy will be required based on the specific syndrome identified 1

Management of Complications

If Active Bleeding Present

• Establish rapid IV access and administer normal saline 20 ml/kg for volume replacement if hemodynamically significant bleeding 2
• Administer Vitamin K 5-10 mg IV and consider acid suppression with H2 antagonists or proton pump inhibitors 2
• Perform nasogastric lavage to rule out upper GI source if diagnosis unclear 2

If Polyp Remains Prolapsed

• Attempt gentle manual reduction under mild sedation if the polyp is still protruding but not ischemic 6, 4
• Immediate surgical excision is indicated if the prolapsed polyp shows signs of ischemia, gangrene, or causes hemodynamic instability 6, 4, 3

Common Pitfalls to Avoid

• Do not assume a single passed polyp means no additional polyps exist - complete colonoscopy is mandatory to exclude polyposis syndromes that dramatically increase cancer risk 1
• Do not confuse prolapsed polyps with rectal prolapse - palpation of a stalk on physical exam should raise suspicion of a polyp rather than true rectal prolapse 5
• Do not delay endoscopic evaluation - proctosigmoidoscopy should be performed promptly as it identifies the majority of causes in pediatric lower GI bleeding 2
• Do not overlook family history - polyposis syndromes have important inheritance patterns requiring family screening and genetic counseling 1