{"id":9243,"date":"2026-02-18T00:05:22","date_gmt":"2026-02-18T08:05:22","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=9243"},"modified":"2026-01-09T16:59:12","modified_gmt":"2026-01-10T00:59:12","slug":"pance-question-of-the-day-bloody-stool","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool","title":{"rendered":"PANCE\u00ae Question of the Day: Bloody stool"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this challenging clinical scenario involving a 5-year-old girl with pain during defecation, bloody TP, and blood streaks on her stool. What&#8217;s the most likely diagnosis? Let&#8217;s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>5-year-old girl<\/strong> is brought to the <strong>clinic<\/strong> due to <strong>bright red blood<\/strong> noted on <strong>toilet paper<\/strong> over the past week. A <strong>caregiver<\/strong> reports <strong>blood streaks on the surface of formed stool<\/strong>. The child describes <strong>pain during defecation<\/strong> but otherwise appears <strong>healthy and active<\/strong>. There has been <strong>no vomiting<\/strong>, <strong>fever<\/strong>, or <strong>abdominal pain<\/strong>. There is <strong>no family history of bleeding disorders<\/strong>. <strong>Immunizations are up to date<\/strong>. <strong>Temperature is 36.9\u00b0C (98.4\u00b0F)<\/strong>, <strong>blood pressure is 92\/60 mmHg<\/strong>, <strong>heart rate is 94 beats per minute<\/strong>, <strong>respiratory rate is 18 breaths per minute<\/strong>, and <strong>oxygen saturation is 99% on room air<\/strong>. <strong>Abdominal examination<\/strong> reveals <strong>no tenderness<\/strong>, <strong>distension<\/strong>, or <strong>palpable masses<\/strong>. A <strong>chaperoned visual inspection of the anal region<\/strong> reveals a <strong>superficial tear in the anal mucosa<\/strong> and <strong>minimal bright red blood<\/strong>. <strong>Which of the following is most likely to be present in further history?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Recent travel outside the country<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Constipation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Chronic diarrhea<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Family history of ulcerative colitis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Abdominal pain and bloating after eating gluten-containing foods<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Everybody loves Osmosis.org\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kizbJZ9cdLg?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Constipation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Recent travel outside the country<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> <strong>Travel history<\/strong> becomes relevant when considering <strong>infections<\/strong>, such as <strong>parasitic causes of gastrointestinal bleeding<\/strong> (e.g. <strong>Entamoeba histolytica<\/strong>), which typically present with <strong>diarrhea<\/strong>, <strong>abdominal pain<\/strong>, and <strong>systemic symptoms<\/strong>. This patient\u2019s <strong>history and physical examination findings<\/strong> are more consistent with an <strong>anal fissure<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Chronic diarrhea<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> <strong>Chronic diarrhea<\/strong> may irritate the <strong>perianal region<\/strong> but usually presents with <strong>loose or watery stools<\/strong> rather than <strong>formed stools with blood streaks<\/strong>. <strong>Pain during defecation<\/strong> is also less typical in chronic diarrhea. This patient\u2019s <strong>history and physical examination findings<\/strong> are more consistent with an <strong>anal fissure<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Family history of ulcerative colitis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Although <strong>ulcerative colitis<\/strong> can cause <strong>rectal bleeding<\/strong>, it more often presents with <strong>bloody diarrhea<\/strong>, <strong>abdominal pain<\/strong>, and <strong>systemic symptoms<\/strong>. The presence of a <strong>localized anal mucosal tear<\/strong> makes this diagnosis less likely.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Abdominal pain and bloating after eating gluten-containing foods<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> <strong>Celiac disease<\/strong> may present with <strong>abdominal pain<\/strong> and <strong>bloating<\/strong> in response to <strong>gluten<\/strong>. However, celiac disease would likely present with additional symptoms such as <strong>skin rashes<\/strong> (e.g. <strong>dermatitis herpetiformis<\/strong>) and symptoms of <strong>malabsorption<\/strong> like <strong>poor growth and weight gain<\/strong> and <strong>pale, foul-smelling stools<\/strong>. This patient\u2019s <strong>history and physical examination findings<\/strong> are more consistent with an <strong>anal fissure<\/strong>.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>This well-appearing 5-year-old child\u2019s presentation<\/strong> of <strong>bright red blood streaks on stool<\/strong>, <strong>pain during defecation<\/strong>, and a <strong>superficial tear in the anal mucosa<\/strong> on examination is strongly suggestive of an <strong>anal fissure<\/strong>. <strong>Constipation<\/strong> can lead to the passage of <strong>hard stools<\/strong>, which may cause <strong>trauma to the anal mucosa<\/strong> and result in <strong>superficial tears<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">When evaluating a child with <strong>hematochezia<\/strong>, first, <strong>confirm the red discoloration represents true blood<\/strong>. Ask about recent ingestion of <strong>beets<\/strong>, <strong>berries<\/strong>, <strong>tomatoes<\/strong>, <strong>candy<\/strong>, or <strong>crayons<\/strong>. <strong>Clarify stool appearance<\/strong>. <strong>Bright red streaks on formed stool<\/strong> suggest an <strong>anal fissure<\/strong>. <strong>Blood mixed with mucus<\/strong> is more consistent with <strong>intussusception<\/strong>. <strong>Painless, large-volume bleeding<\/strong> raises concern for <strong>Meckel diverticulum<\/strong> or <strong>juvenile polyps<\/strong>. Ask about <strong>fever<\/strong>, <strong>abdominal pain<\/strong>, <strong>diarrhea<\/strong>, <strong>constipation<\/strong>, <strong>fatigue<\/strong>, or <strong>syncope<\/strong>, which may indicate <strong>infectious enterocolitis<\/strong>, <strong>inflammatory bowel disease<\/strong>, or <strong>anemia<\/strong>. Review <strong>diet changes<\/strong>, <strong>toilet-training stressors<\/strong>, <strong>travel<\/strong>, <strong>medications<\/strong>, and any <strong>family history of inflammatory bowel disease<\/strong>, <strong>polyps<\/strong>, or <strong>bleeding disorders<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">On exam, assess <strong>general appearance<\/strong> and <strong>vital signs<\/strong>. Evaluate for <strong>abdominal tenderness<\/strong>, <strong>distension<\/strong>, or <strong>masses<\/strong>. Inspect the <strong>perineum<\/strong> for <strong>fissures<\/strong>, <strong>ulcers<\/strong>, <strong>hemorrhoids<\/strong>, <strong>rectal prolapse<\/strong>, or <strong>visible polyps<\/strong>. <strong>Visual inspection<\/strong> may confirm a <strong>fissure<\/strong>, and a <strong>digital rectal exam<\/strong> may detect <strong>active bleeding<\/strong>. Document <strong>stool color<\/strong> and perform <strong>occult blood testing at the bedside<\/strong> to support the diagnosis and guide <strong>further evaluation<\/strong>.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Constipation<\/strong> is a <strong>common trigger for anal fissures in children<\/strong>, which can present with <strong>bright red blood streaks on the stool<\/strong> accompanied by <strong>pain during defecation<\/strong>.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch this Osmosis video: <\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Anal_fissure\"><strong>Anal fissure<\/strong><\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Baker RD, Baker SS. <strong>Gastrointestinal Bleeds.<\/strong> Pediatr Rev. 2021;42(10):546-557. doi:10.1542\/pir.2020-000554<\/li>\n\n\n\n<li>Chandel K, Jain R, Bhatia A, Saxena AK, Sodhi KS. <strong>Bleeding per rectum in pediatric population: A pictorial review.<\/strong> World J Clin Pediatr. 2022;11(3):270-288. Published 2022 May 9. doi:10.5409\/wjcp.v11.i3.270<\/li>\n\n\n\n<li>Fox VL. <strong>Gastrointestinal bleeding in infancy and childhood.<\/strong> Gastroenterol Clin North Am. 2000;29(1):37-v. doi:10.1016\/s0889-8553(05)70107-2<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?w=700\" alt=\"\" class=\"wp-image-4433\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>PANCE\u00ae-style practice questions<\/strong>? Try <strong>Osmosis by Elsevier<\/strong> today! Access your\u00a0<a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>\u00a0and discover why millions of current and future <strong>clinicians and caregivers<\/strong> love <strong>learning by Osmosis<\/strong>.<\/em><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A child presents with bright red blood stool and pain during bowel movements. Understanding key history elements helps guide diagnosis and care.<\/p>\n","protected":false},"author":204,"featured_media":9246,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[20,38,1371,37,1366],"tags":[2674,2670,1584,2569,1025,2671,653,1029,2668,797,2673,267,2667,2669,2672],"class_list":["post-9243","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-anal-mucosa","tag-bright-red-blood","tag-child-health","tag-constipation","tag-differential-diagnosis","tag-gi-symptoms","tag-hematochezia","tag-nursing-care","tag-painful-defecation","tag-pediatric-assessment","tag-pediatric-gi-disorders","tag-pediatric-nursing","tag-pediatric-rectal-bleeding","tag-stool-blood-streaks","tag-stool-evaluation"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PANCE\u00ae Question of the Day: Bloody stool - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"PANCE\u00ae Question of the Day: Bloody stool - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A child presents with bright red blood stool and pain during bowel movements. Understanding key history elements helps guide diagnosis and care.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2026-02-18T08:05:22+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-01-10T00:59:12+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/02\/PANCE-Question-of-the-Day-Bloody-Stool.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Rowan Bell, MD &amp; Marina Horiates Kerekes, MD\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-bloody-stool\"},\"author\":{\"name\":\"Rowan Bell, MD &amp; 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