Prepare for the PANCE® with this challenging clinical scenario involving a 5-year-old girl with pain during defecation, bloody TP, and blood streaks on her stool. What’s the most likely diagnosis? Let’s find out!
A 5-year-old girl is brought to the clinic due to bright red blood noted on toilet paper over the past week. A caregiver reports blood streaks on the surface of formed stool. The child describes pain during defecation but otherwise appears healthy and active. There has been no vomiting, fever, or abdominal pain. There is no family history of bleeding disorders. Immunizations are up to date. Temperature is 36.9°C (98.4°F), blood pressure is 92/60 mmHg, heart rate is 94 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 99% on room air. Abdominal examination reveals no tenderness, distension, or palpable masses. A chaperoned visual inspection of the anal region reveals a superficial tear in the anal mucosa and minimal bright red blood. Which of the following is most likely to be present in further history?
A. Recent travel outside the country
B. Constipation
C. Chronic diarrhea
D. Family history of ulcerative colitis
E. Abdominal pain and bloating after eating gluten-containing foods
Scroll down to find the answer!
The correct answer to today’s PANCE® Question is…
B. Constipation
Correct: See Main Explanation.
Incorrect Answer Explanations
A. Recent travel outside the country
Incorrect: Travel history becomes relevant when considering infections, such as parasitic causes of gastrointestinal bleeding (e.g. Entamoeba histolytica), which typically present with diarrhea, abdominal pain, and systemic symptoms. This patient’s history and physical examination findings are more consistent with an anal fissure.
C. Chronic diarrhea
Incorrect: Chronic diarrhea may irritate the perianal region but usually presents with loose or watery stools rather than formed stools with blood streaks. Pain during defecation is also less typical in chronic diarrhea. This patient’s history and physical examination findings are more consistent with an anal fissure.
D. Family history of ulcerative colitis
Incorrect: Although ulcerative colitis can cause rectal bleeding, it more often presents with bloody diarrhea, abdominal pain, and systemic symptoms. The presence of a localized anal mucosal tear makes this diagnosis less likely.
E. Abdominal pain and bloating after eating gluten-containing foods
Incorrect: Celiac disease may present with abdominal pain and bloating in response to gluten. However, celiac disease would likely present with additional symptoms such as skin rashes (e.g. dermatitis herpetiformis) and symptoms of malabsorption like poor growth and weight gain and pale, foul-smelling stools. This patient’s history and physical examination findings are more consistent with an anal fissure.
Main Explanation
This well-appearing 5-year-old child’s presentation of bright red blood streaks on stool, pain during defecation, and a superficial tear in the anal mucosa on examination is strongly suggestive of an anal fissure. Constipation can lead to the passage of hard stools, which may cause trauma to the anal mucosa and result in superficial tears.
When evaluating a child with hematochezia, first, confirm the red discoloration represents true blood. Ask about recent ingestion of beets, berries, tomatoes, candy, or crayons. Clarify stool appearance. Bright red streaks on formed stool suggest an anal fissure. Blood mixed with mucus is more consistent with intussusception. Painless, large-volume bleeding raises concern for Meckel diverticulum or juvenile polyps. Ask about fever, abdominal pain, diarrhea, constipation, fatigue, or syncope, which may indicate infectious enterocolitis, inflammatory bowel disease, or anemia. Review diet changes, toilet-training stressors, travel, medications, and any family history of inflammatory bowel disease, polyps, or bleeding disorders.
On exam, assess general appearance and vital signs. Evaluate for abdominal tenderness, distension, or masses. Inspect the perineum for fissures, ulcers, hemorrhoids, rectal prolapse, or visible polyps. Visual inspection may confirm a fissure, and a digital rectal exam may detect active bleeding. Document stool color and perform occult blood testing at the bedside to support the diagnosis and guide further evaluation.
Major Takeaway
Constipation is a common trigger for anal fissures in children, which can present with bright red blood streaks on the stool accompanied by pain during defecation.
Want to learn more about this topic?
Watch this Osmosis video: Anal fissure
References
- Baker RD, Baker SS. Gastrointestinal Bleeds. Pediatr Rev. 2021;42(10):546-557. doi:10.1542/pir.2020-000554
- Chandel K, Jain R, Bhatia A, Saxena AK, Sodhi KS. Bleeding per rectum in pediatric population: A pictorial review. World J Clin Pediatr. 2022;11(3):270-288. Published 2022 May 9. doi:10.5409/wjcp.v11.i3.270
- Fox VL. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29(1):37-v. doi:10.1016/s0889-8553(05)70107-2
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