Primary diagnostic possibilities | Typical age group | Key clinical features | Initial diagnostic steps | ||||
Neonate | Infants and toddlers | Preschool period | School-aged | Adolescent | |||
Swallowed maternal blood | x | x | Breastfed; mother's nipples are cracked or bleeding | Apt test (hemoglobin alkaline denaturation test) | |||
Milk- or soy protein-induced colitis ("allergic" colitis) | 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 | |||
Necrotizing enterocolitis (especially if premature); malrotation with midgut volvulus; Hirschsprung disease | x | Acutely ill (vomiting, abdominal distension, diarrhea, and/or constipation) | Imaging, surgical consultation | ||||
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 | Typically in child with other vascular lesions (eg, HHT or infantile hemangiomatosis); may have epistaxis or iron deficiency | Endoscopy | |||
Gastrointestinal duplication cyst | 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 | ||
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) | ||
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) | Abdominal ultrasonography, water-soluble contrast enema, or air enema (for diagnosis and non-operative reduction) | |||
Meckel's 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, thromobocytopenia, elevated creatinine, onset 5 to 10 days after diarrheal illness | CBC, BUN, creatinine, peripheral blood smear, stool culture | ||
Henoch-Schönlein purpura (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 | Proctoscopy with biopsy; evaluation to rule out inflammatory bowel disease and infectious proctitis | ||
Juvenile polyps | x* | x* | Painless rectal bleeding, often intermittent | Examine anus closely to rule out fissure; digital rectal examination for polyp; colonoscopy | |||
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 |