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Patient education: Blood in bowel movements (rectal bleeding) in babies and children (Beyond the Basics)

Patient education: Blood in bowel movements (rectal bleeding) in babies and children (Beyond the Basics)
Authors:
Nishaben Patel, MD
Marsha Kay, MD
Section Editor:
Melvin B Heyman, MD, MPH
Deputy Editor:
Alison G Hoppin, MD
Literature review current through: Nov 2022. | This topic last updated: Aug 26, 2022.

INTRODUCTION — Seeing blood in your child's bowel movements (sometimes known as "rectal bleeding" or "bloody stools") can be frightening. However, this is a common observation in children and, in most cases, is not a sign of a serious problem. A health care provider can help to determine the most likely cause of the bleeding based on information such as the frequency and amount of blood, your child's age, and whether they have other symptoms or underlying medical conditions.

This article will discuss some of the common causes of blood in bowel movements and tests that may be used to evaluate your child. Blood in bowel movements in adults is discussed separately. (See "Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)".)

WHEN TO SEEK HELP — In most cases, a small amount of blood in a child's bowel movement is not a sign of a serious condition. However, it's important to talk with your child's health care provider if you notice any amount of bleeding. Depending on your child's age and symptoms, they may recommend an examination and/or tests to figure out the cause of the bleeding and determine whether treatment is needed. (See 'Evaluation' below.)

If your child suddenly becomes very ill or has other concerning symptoms, call their health care provider for advice right away.

WHERE IS THE BLOOD COMING FROM? — Blood in a child's bowel movement usually originates somewhere in the digestive tract (figure 1).

Lower digestive tract – In most cases, visible blood in bowel movements comes from the lower digestive tract. The lower digestive tract is made up of the large intestine (colon), rectum, and anus. Bleeding from the anus (the opening through which bowel movements leave the body) is common in children of all ages. Bleeding from the lower digestive tract usually causes the bowel movements to be coated or mixed with bright red blood (or sometimes maroon colored).

Upper digestive tract – Less commonly, the blood comes from the upper digestive tract. The upper digestive tract is made up of the esophagus, stomach, and small intestine. Bleeding from these areas usually causes black, sticky (tar-like) bowel movements. This is because blood is degraded in the gastrointestinal tract by normal intestinal bacteria, which turns the blood black in color. If the child had blood in their stomach, they might also vomit red or black material that can look like coffee grounds. A small amount of bleeding in the upper digestive tract may not be noticeable. Usually, it takes a moderate to large amount of blood from the upper digestive tract to cause visible changes in bowel movements.

Other sources – Blood in bowel movements might also come from the child's nose and throat (for example, if they have a nosebleed and swallow some of the blood).

Red- or black-colored bowel movements are not always caused by blood. Foods and medicines that can look like blood in the bowel movement are listed in the table (table 1). A health care provider can do a simple test on the bowel movement to find out if it contains blood.

CAUSES — Many different things can cause blood in bowel movements. Some are common conditions, while others are less common.

Common causes

Anal fissure – Anal fissures are a common cause of blood in bowel movements in all age groups. An anal fissure is a cut or tear in the lining of the anus. In most cases, anal fissures cause only a small amount of bleeding. The blood usually coats the bowel movement and/or can be seen on the diaper or toilet paper, and it might come and go. (See "Patient education: Anal fissure (Beyond the Basics)".)

Anal fissures are often caused by constipation. When a child is constipated, their bowel movements are usually large and/or hard and might cause a small tear in the lining of the anus. The child might strain or have pain when moving their bowels, or they might try to avoid going because of the discomfort. A health care provider can sometimes find an anal fissure by looking closely while spreading the skin around the anus. Constipation in children is discussed separately. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)

Milk or soy protein intolerance – Milk or soy protein intolerance is a common cause of blood in a baby's bowel movements. The condition is also known as "allergic" colitis, milk or soy protein-induced colitis, or food protein-induced allergic proctocolitis.

This condition is usually caused by a sensitivity to cow's milk protein or soy protein. It most often develops after a baby starts to drink formula. It can also occur in breastfed babies because the cow's milk and soy proteins that the mother consumes go into the breast milk. Most babies with this condition are healthy, and the only symptom is blood in bowel movements. However, some babies also have diarrhea, vomiting, irritability, poor weight gain, and/or eczema (a type of skin rash).

Babies with blood in bowel movements, or any of the other above symptoms, should be evaluated by a health care provider. If the provider concludes that milk or soy protein intolerance is likely, the next step is to eliminate milk or soy from the diet. This diet is discussed separately. (See "Patient education: Acid reflux (gastroesophageal reflux) in infants (Beyond the Basics)".)

In most cases, the symptoms will go away when milk (and/or soy) is removed from the diet. Sometimes, the blood reappears from time to time, usually because the baby (or their mother, if breastfeeding) consumed a small amount of milk after having avoided it for some time. The problem usually resolves by one year of age, after which the child is usually able to tolerate milk or soy again, and there are no long-term consequences.

Less common causes

Hemorrhoids – Hemorrhoids are swollen veins in the rectum and anus. They can cause itching, bleeding, and pain. Hemorrhoids are a common cause of blood in bowel movements in adults and, sometimes, adolescents but are uncommon in younger children. (See "Patient education: Hemorrhoids (Beyond the Basics)".)

Infectious diarrhea – Infectious diarrhea is caused by a virus, bacterium, or parasite. The infection can come from another person with infectious diarrhea, from eating or drinking contaminated foods/drinks/water, or, less commonly, after taking a course of antibiotics. (See "Patient education: Foodborne illness (food poisoning) (Beyond the Basics)" and "Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)".)

Symptoms of infectious diarrhea usually include diarrhea, fever, belly pain, and, sometimes, vomiting (especially with a virus). Visible blood in bowel movements only happens with certain types of infections, some of which can be serious. Infectious diarrhea rarely causes blood in the bowel movement without other symptoms. More information about diarrhea in children is available separately. (See "Patient education: Acute diarrhea in children (Beyond the Basics)".)

Inflammatory bowel disease (IBD) – IBD is a condition in which the lining of the digestive tract becomes inflamed. There are two main types of IBD: ulcerative colitis and Crohn disease. The inflammation might cause bloody bowel movements, diarrhea, lack of appetite, abdominal pain, and weight loss. Crohn disease and ulcerative colitis are discussed in more detail separately. (See "Patient education: Crohn disease (Beyond the Basics)" and "Patient education: Ulcerative colitis (Beyond the Basics)".)

Intestinal obstruction – Intestinal obstruction (blockage) is a more serious condition that can cause blood in bowel movements. However, in addition to the blood in the stool, most of these conditions cause the baby or child to become ill suddenly. If your child suddenly develops blood in their bowel movements and also becomes lethargic, or has abdominal pain, fever, vomiting, a distended (swollen) abdomen, or other unusual symptoms, call their health care provider immediately. Causes of intestinal obstruction in children are:

Intussusception – This is a condition in which a part of the intestine slides ("telescopes") into an adjacent part of the intestine. It usually happens suddenly in infants or toddlers and requires urgent treatment.

Malrotation – This is a condition that a child is born with that can cause a sudden obstruction (due to twisting of the intestine). The obstruction often occurs in babies and young children but can happen at any age including adulthood. If an obstruction happens, it requires immediate attention.

Hirschsprung disease – This is a serious condition that a child is born with that usually causes symptoms of severe constipation or colon obstruction in a newborn. Sometimes, it causes inflammation (called "enterocolitis") with bloody diarrhea. It is usually diagnosed in infancy or, sometimes, later in childhood. In these cases, the main symptom is constipation starting at a very young age.

Meckel diverticulum – Meckel diverticulum is a small pouch on the wall of the lower small intestine. Children with this condition are born with it. Most people who have a Meckel diverticulum never have symptoms and will likely never find out they have it, but some have blood in bowel movements. The bleeding can happen at any age, but approximately one-half of the cases are in young children. Occasionally, a Meckel diverticulum can cause a very large amount of bleeding, which can be dangerous and requires immediate medical and surgical attention.

Colon polyps – Polyps are growths that form on the inner lining of the large intestine (colon). Most polyps in children are a noncancerous (benign) type called "juvenile polyps." They are usually diagnosed in children between 2 and 10 years old. The child usually has no symptoms other than blood in bowel movements. Juvenile polyps can be easily diagnosed and removed during a colonoscopy.

Rarely, children can have multiple or large juvenile polyps or a different type of polyp that might be cancerous or precancerous. When this happens, it is usually because the child has an underlying condition such as Peutz-Jeghers syndrome or familial adenomatous polyposis. These conditions are often inherited, and patients may have family members who are affected. (See "Patient education: Colon polyps (Beyond the Basics)" and "Patient education: Familial adenomatous polyposis (The Basics)".)

Other conditions – Other conditions that might cause blood in bowel movements include blood clotting disorders and abnormalities of the blood vessels inside the intestine. Clues to these conditions might include easy bruising, certain rashes, or other findings. If a health care provider suspects one of these conditions, they may order additional tests to diagnose the problem.

EVALUATION — The evaluation of a child with blood in bowel movements includes a careful medical history, physical examination and sometimes tests.

Physical examination — Sometimes, a health care provider can find the cause of the bleeding with an examination. The examination includes looking carefully at the outside of the anus. It might also involve a brief examination of the inside of the anus using a finger (rectal examination).

This examination may be all that is necessary. If the cause of the bleeding is not clear based upon the examination, further testing might be done. (See 'Tests' below.)

Tests — Depending on the situation, many different tests can be used to look for the cause of blood in bowel movements. Your child's health care provider will recommend tests based on the child's age, medical history, and symptoms.

Tests might include:

Stool tests – The provider might test a sample of the bowel movement (stool) to be sure whether or not it contains blood or signs of inflammation. If they think that the bleeding might be caused by an infection, they might send a sample of the bowel movement to a laboratory to test for bacterial, viral, or parasitic infection.

Blood tests – Blood tests can help determine how severe the blood loss has been. For example, blood tests can check for anemia (a condition that can happen when a person loses a lot of blood). Blood tests can also be used to investigate underlying diseases that could be causing the bleeding such as clotting abnormalities or severe inflammation.

Colonoscopy – This test looks at the lining of the entire colon (figure 1). During this test, a doctor puts a thin tube (called an endoscope) into the anus, then passes it into the rectum and colon (figure 2). The tube has a camera on it. It also has tools that can be passed through the endoscope so the doctor can take samples of tissue to look at under a microscope (biopsy). If a polyp is found, this can also be removed during the colonoscopy. (See "Patient education: Colonoscopy (Beyond the Basics)".)

Upper endoscopy – This test looks at the lining of the esophagus, stomach, and upper part of the small intestine, called the "duodenum." During this test, a doctor puts a thin tube with a camera on the end into a person's mouth and passes it through the esophagus, then into the stomach and duodenum (figure 3). Samples of tissue can also be obtained during this test. (See "Patient education: Upper endoscopy (Beyond the Basics)".)

Additional tests – If more information is needed to find the source of bleeding, additional tests may be recommended, such as:

Imaging tests – These might include an upper gastrointestinal series with small bowel follow-through (UGI/SBFT), magnetic resonance enterography, computed tomography (CT), ultrasound, or nuclear medicine study (Meckel scan or tagged red blood cell scan).

Other tests – These might include wireless video capsule endoscopy or angiography.

TREATMENT — Treatment depends on the cause(s) of the bleeding. Your child's health care provider will determine if the underlying condition requires treatment. Even if your child's bleeding seems minor or resolves on its own, you should ask their health care provider if they should be evaluated, so any underlying condition can be identified and treated appropriately. (See 'When to seek help' above.)

WHERE TO GET MORE INFORMATION — Your child's health care 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 website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care 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: Bloody stools (The Basics)
Patient education: GI bleed (The Basics)
Patient education: Anal fissure (The Basics)
Patient education: Intussusception (The Basics)
Patient education: Meckel's diverticulum (The Basics)
Patient education: Ulcerative colitis in children (The Basics)
Patient education: Crohn disease in children (The Basics)
Patient education: Hemorrhoids (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: Anal fissure (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)
Patient education: Blood in the stool (rectal bleeding) in adults (Beyond the Basics)
Patient education: Foodborne illness (food poisoning) (Beyond the Basics)
Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)
Patient education: Acute diarrhea in children (Beyond the Basics)
Patient education: Ulcerative colitis (Beyond the Basics)
Patient education: Crohn disease (Beyond the Basics)
Patient education: Hemorrhoids (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
Approach to upper gastrointestinal bleeding in children
Food protein-induced allergic proctocolitis of infancy
Clinical presentation and diagnosis of inflammatory bowel disease in children
Clinical manifestations and complications of inflammatory bowel disease in children and adolescents
Intussusception in children
Meckel's diverticulum

The following organizations also provide reliable health information.

National Library of Medicine

(www.medlineplus.gov/ency/article/003130.htm)

GI Kids (from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition)

(www.gikids.org/content/41/en/bleeding/lower)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges George D Ferry, MD, who contributed to earlier versions of this topic review.

This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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