Version October 2024
| Primary diagnostic possibilities | Typical age group | Key clinical features | Initial diagnostic steps | ||||
| Neonates | Infants and toddlers | Preschool period | School-aged | Adolescents | |||
| Swallowed maternal blood | X | X | Breastfed; mother's nipples are cracked or bleeding | Apt test (hemoglobin alkaline denaturation test) | |||
| Necrotizing enterocolitis (especially if premature) | X | Acutely ill (vomiting, abdominal distension, diarrhea, and/or constipation) | Imaging, surgical consultation | ||||
| Food protein-induced proctocolitis (typically due to milk and/or soy proteins) | X | X* | Well-appearing; stools with low-moderate blood; with or without diarrhea | Assess diet and perform trial of eliminating milk and soy from the diet | |||
| Malrotation with volvulus | X | X | |||||
| Coagulopathy (eg, vitamin K-deficient bleeding, hemophilia, von Willebrand disease, maternal immune thrombocytopenia) | X | X | Other bleeding symptoms (cephalohematoma, mucocutaneous bleeding, petechiae) | Coagulation work-up | |||
| Hirschsprung-associated enterocolitis | X | X | Ill, with abdominal distension, fever, vomiting, diarrhea, in patient with known or suspected Hirschsprung disease | Abdominal plain film¶ | |||
| Vascular malformation or hemangioma | X | X | X | X | X | Typically in child with other vascular lesions (eg, HHT or infantile hemangiomatosis); may have epistaxis or iron deficiency | Upper endoscopy and colonoscopy; wireless capsule endoscopy |
| Gastrointestinal duplication cyst | X | X | X | X | Variety of presentations, including gastrointestinal bleeding, infection or intussusception; more common in infants, but may present later | Imaging; most are in the small bowel | |
| Infectious colitis | X | X* | X* | X* | X | Loose, bloody stools; abdominal pain; fever | Culture of stool for enteric pathogens; C. difficile testing (toxin or PCR); fecal leukocytes |
| Anal fissure | X* | X* | X* | X* | X* | Well-appearing; stools with low-moderate blood; often associated with constipation | Examine anus closely |
| Intussusception | X | X | Sudden-onset abdominal pain and lethargy, with or without grossly bloody stools ("currant jelly" appearance); may occur at any age in a patient with a lead point | Abdominal ultrasonography, water-soluble contrast enema, or air enema (for diagnosis and non-operative reduction) | |||
| Meckel diverticulum | X | X | X | X | Painless rectal bleeding, especially if recurrent and an anal fissure is excluded; bleeding may be profuse | Meckel scan | |
| Hemolytic-uremic syndrome | X | X | X | Hemolytic anemia, thrombocytopenia, elevated creatinine, onset 5 to 10 days after diarrheal illness | CBC, BUN, creatinine, peripheral blood smear, stool culture | ||
| IgA vasculitis | X | X | X | Cutaneous purpura (palpable), abdominal pain, arthralgias | Clinical diagnosis if typical features are present; skin or renal biopsy if atypical presentation; abdominal ultrasonography if intussusception is suspectedΔ | ||
| Solitary rectal ulcer syndrome | X | X | X | Rectal blood and mucus, tenesmus, sense of incomplete evacuation | Colonoscopy with biopsy; evaluation to rule out inflammatory bowel disease and infectious proctitis | ||
| Juvenile polyps | X* | X* | X | Painless rectal bleeding, often intermittent | Examine anus closely to rule out fissure; digital rectal examination for polyp; colonoscopy | ||
| Infantile and very early-onset inflammatory bowel disease (VEO-IBD) | X | X | X | Diarrhea (with or without blood), poor weight gain and growth, severe perianal disease, recurrent infections, atypical endoscopy or histology findings, skin lesions, and associated autoimmune diseases | Immunodeficiency evaluation; consider whole-exome sequencing (in addition to tests listed under "inflammatory bowel disease" below) | ||
| Inflammatory bowel disease | X* | X* | Diarrhea (with or without blood) and abdominal pain, often with growth failure or delayed puberty; may have weight loss or fever | CBC, ESR, or CRP, albumin; imaging; colonoscopy and upper endoscopy Additional tests – PT/PTT, AST, ALT, amylase, lipase; fecal calprotectin, stool culture and C. difficile testing; O&P | |||
ALT: alanine transaminase; AST: aspartate transaminase; BUN: blood urea nitrogen; C. difficile: Clostridioides difficile; CBC: complete blood count; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; HHT: hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome); IgA: immunoglobulin A; O&P: ova and parasites; PCR: polymerase chain reaction; PT/PTT: prothrombin time/partial thromboplastin time; VEO-IBD: very early-onset inflammatory bowel disease.
* Relatively common cause in the given age group.
¶ On abdominal radiography, signs suggestive of Hirschsprung-associated enterocolitis include absence of air in the distal rectosigmoid colon, with an abrupt cutoff at the level of the pelvic brim ("cutoff" sign).
Δ IgA vasculitis (previously known as Henoch-Schöenlein purpura) may be complicated by intussusception, with the involved bowel serving as a lead point for the intussusception.Do you want to add Medilib to your home screen?
