Barry Shandling, M.B., Ch.B., F.R.C.S.(Eng.), F.R.C.S.(C).
The Hospital for Sick Children, Toronto, Ontario, and Department of Surgery, University of Toronto, Canada
(Submitted April 16; revision accepted for publication December 7, 1964.)
ADDRESS: 555 University Avenue, Toronto 2, Ontario.
PEDIATRICS, May 1965
LAPAROTOMY
FOR
RECTAL
BLEEDING
T
lIE PROBLEM of the infant or child with rectal bleeding is familiar to allclini-cians. The term “rectal bleeding” has through common usage come to mean the
passage of l)lOOd from the rectum-whether
it he bright red or dark, unrelated to, on the surface of, or mixed with the stool. Anal or gastrointestinal bleeding would he a more accurate term, but for the purposes
of this paper rectal bleeding will be used in its widest connotation. This study was tin-(lertaken to attempt to evaluate the place
of surgery in the investigation and
treat-lileITIt of this perplexing condition.
The literature is surprisingly barren of any series of this kind. Several authors of
textbooks On pediatric surgery1 do not even mention the possibility of a fruitless abdominal exploration. Others appear to hazard a guess. However, Nixon and
O’Donnell5 state that probably one-third of patients with rectal bleeding never have the cause diagnosed. White and Dennison4
give 20% as a likely figure. Cross,5 in a small review of 65 patients presenting with rectal
bleeding as a diagnostic problem, could find no cause for the bleeding in 18, i.e., 27%. Of the 18 patients who were operated upon, only 4 had negative laparotomies.
Nevertheless, he states that in an
astound-ing proportion of cases the cause for the rectal bleeding is never found, even after extensive investigation and laparotomy.
Macheth in a recent paper refers to the
difficulties in gathering a series of cases
with available methods of coding. Fortri-natelv, at The Hospital for Sick Children,
Toronto, case notes arc coded in such a way
that the histories of patients with rectal bleeding are readily available. Accordingly, it was decided to review all those patients
who underwent laparotomy as part of the
investigation of the symptom of rectal bleeding. Patients from whom a history of
hematemesis was obtained or in whom the cause of the bleeding was apparent were not included. For example, a patient with hepatosplenomegaly and esophageal varices presenting with melena would have been excluded. Colonic polpi, peptic ulcers, and ulcerative colitis were likewise not
con-sidered. Also excluded were patients in whom laparotomy was indicated for
rea-sons others than the passage of blood and
was therefore not strictly diagnostic, as in
intussusception.
Over a period of ten years, beginning in
1952, 801 patients were admitted to this hos-pital with a history of rectal bleeding. Of these 801 patients there were 61 infants and children who underwent laparotomy in an effort to elucidate the source of the bleeding. This paper is concerned only with these 61 patients. It should be noted that
all investigations were negative, including barium studies, procto-sigmoidoscopy, and
coagulation studies.
RESULTS
In this series the youngest patient was 3 months of age and there were 21 infants of 1 year of age or less (Fig. 1).
Of the 61 patients operated upon, 50% had negative findings (Fig. 2).
There were 30 patients who undervent
laparotomy and in whom a lesion was
dis-covered (Fig. 3).
Apart from 24 patients with Meckel’s diverticula, 6 children had relatively un-usual findings. A patient with polypi was thought to have a polyp in the sigmoid
op-20
18
16
i 14
S 12
, 10 18
88
ly. 1.2 23 3.4 4.5 6-6 6.7 7.8 89 910 10.11 11.12 1213 13.14
Y..,.,f.q.
788 RECTAL BLEEDING
FIG. 2. Laparotomy findings. Fic. 3. Positive findings.
61
1LLLLIJILI
FIG. 1. Age distribution.
eration, however, the sigmoid colon was normal, but four polypi were found in the cecum and ascending colon. Thus the
diag-nosis was totally unexpected.
In one patient who gave a history of rectal bleeding over a period of three years,
jejuno-jejunal intussusception was a
sur-prise finding. One can only speculate whether this would have accounted for the
presence of blood in the stools over such
a length of time. Another patient had been
investigated over a period of three years for abdominal pain and anemia. Her hemoglobin on the second admission was 6.6 gm/100 ml and there was occult blood
in her stools. At laparotomy a colloid car-cinoma was found 18 in. from the duodeno-jejunal flexure. There was one patient with
a duplication of the ileum, one with he-mangiomata of the terminal ileum, and one
with an area of inflammation in the
de-scending colon.
Because Meckels’ diverticulum figures so prominently in the etiology of rectal
bleed-ing, a closer look at this group of patients is indicated. There were 24 patients who had resections of Meckel’s diverticula. Of these, 20 showed ectopic mucosa and the
remaining 4 had normal ileal tissue present. One of these 4 has had a recurrence of bleeding postoperatively. It is difficult to
understand how a “normal” Meckel’s di-verticulum can result in gastrointestinal bleeding, but these have been included
tinder the heading of positive findings. The surgeon is frequently only too pleased to find any departure from normality in this
type of operation.
It is possible that the figures are even
more biased toward the negative side. If we regard the jejuno-jejunal
intussuscep-tion as an incidental finding, together with the four “normal” Meckel’s diverticula, we
are left with 36 negative and 25 positive
laparotomies-60% and 40% respectively.
Of the 24 patients with Meckel’s
divertic-ula, there were 7 who gave a history of a bleeding episode limited to the preceding
72 hours. The average age of these pa-tients was 15 months. Seventeen patients had histories of considerably longer dura-tion and in many cases of several months.
The average age here was 38 months. Hemoglobin levels were generally lower
in those patients with Meckel’s diverticula as compared to those in whom nothing ab-normal was found (Fig. 4). Of these 31
pa-POSITIVE 30 NEGATIVE 31
M.ck.1s diverticu1un 24
Carcinoma of lejunum 1
H.ntangiomata of ileum 1
Unsusp.ct.d intussusception 1
Colonic polypi 1
Il.al duplication 1
Hb G% 10.11 9-10 8.9 7.8 6.7 5.6 4.5 4.
Meckeis Dverticuium Negative Findings
I
--
-I
-
I
-
I
-
I
#{149}15patients ‘8 patients
I I I I I I
2 4 6 8
I I I 1 I
2 4 6 8
Vie. 4. Ectopic mucosa in Meckel’s diverticulum. tients with negative findings, there were
only 6 patients with a hemoglobin of 10 gin
or less. Two patients were recorded as being in shock as the time of admission to
hospital.
FOLLOW-U P
Sixteen of the 31 children with negative
laparotomies have been contacted no less
than eighteen months and up to ten years from the date of laparotomy.
Eleven have had no further bleeding
since the operation.
Of the remaining 5, there were 4 children who had had one recurrence of bleeding. One of these had streaking on the surface
of the stool; another had associated
diar-rhea at the time.
The sixteenth patient had a recurrence with demonstration of a rectal polyp which
was removed and lie has not had any fur-ther bleeding.
COMMENT
In the majority of small patients with
rectal bleeding, a diagnosis will be made. Furthermore, it seems that even when a diagnosis is not made, the symptom is a benign one, perhaps recurring, but tending
to disappear with the passage of time.
Nevertheless, it is necessary to remember that the loss of 60 ml of blood in a 6-kg baby
is equivalent to a hemorrhage of 600-700
ml in an adult. Koop7 states that dangers of
exsanguination in the younger age group
are so great that the indications for
laparot-omy are more liberal than in larger chil-dren.
This series was carefully analyzed in an
attempt to define indications for operation or as a guide to the anticipated findings. Could the character of the bleeding provide an indication of the pathology subsequently found? In this series this was not the case.
Demonstrable ectopic mucosa.... 20 (83%)
Normal ileal mucosa 4
Number of patients
.P1. 3 pt,,ts h0 ‘.,,, ‘PIfls 2
sh,:l, od / ,, dmtted n b1od
Fic. 5. Preoperative lwmoglobin estimations of 10%
or less.
In both positive and negative findings groups, stools varied from bright red to
black, often in the same patient. In some pa-tients clots were passed with and without
feces. Not all the histories provided minute details as to the relationship of the bleeding
to the stool but in 80% of cases where this was done the bleeding was unrelated to the
stool.
Although the single severe episode of
tal bleeding from a Meckel’s diverticulum tended to occur in young infants, no sig-nificant conclusions could be drawn from the patient’s age (Fig. 5). More patients under the age of 12 months were fruitlessly explored than at any other age. On the other hand, more patients under the age of 12 months harbored Meckel’s diverticula
than at any other age.
The duration of symptoms was of no di-agnostic value, and most patients had
his-tories extending over several weeks or
months. Perhaps the estimation of the hemoglobin level, considered with the
clini-cal picture, may be the least misleading of all preoperative considerations.
The pediatrician and the pediatric stir-geon are often faced with the problem of unexplained rectal bleeding. The fact that
1-2
2-3
3.4
4.5
MECKELS PRESENT NEGATIVE FINDINGS
5.6
I
>. S
U
U
6-7
7-8
8-9
9-10
10-11
11-12
12-13
13.14
I
790 RECTAL BLEEDING
;
Vie. 6. Age distribution in the two groups.
tipon exploration should not unduly
in-fluence one toward conservatism. Obvi-ously, the ideal is to reduce unnecessary
operations if possible. Judging by this
series, however, it is not possible to
postu-late any absolute guiding principles when
approaching the problem. It is almost
self-evident that the young infant with massive
bleeding and a serious degree of anemia will be considered for operation with great alacrity, and it should be remembered that
the objects of the operation are not only
therapeutic, but also diagnostic. A valuable
service is performed by the surgeon who can assure the pediatrician and parents that there is no Meckel’s diverticulum,
duplica-tion, tumor, or other remediable condition which could otherwise result in the death
of the patient.
Based on experience at The Hospital for
Sick Children, Toronto, negative operative
findings may be expected in at least 50% of
the patients. It is probable that 60% is a
more accurate figure.
It would seem, then, that the decision to
operate is one requiring mature surgical
judgment. It was interesting to note that the more senior the surgeon, the more
stringent were his criteria for laparotornv and the higher his incidence of positive findings. In the absence of any definite
mdi-cations for operation, what is needed in the
treatment of unexplained rectal bleeding in infants and children is an enthusiastic
pedi-atrician and a reluctant surgeon.
REFERENCES
1. Swenson, 0. : Pediatric Surgery. New York:
Ap-pleton-Centurv-Crofts, 1962, p. 379.
2. Benson, C. D., and Mustard, W. T. : Pediatric
Surgery. Chicago: Year Bock Publishers, 1962.
p. 839.
3. Nixon, H. H., and O’Donnell, B. : The
Essen-tials of Paediatric Surgery. London:
Ihine-man, 1961.
4. White, M., and Dennison, \V. NI. : Surgery in
Infancy and Childhood. Edinburgh :
Living-stone, 1958, p. 189.
5. Gross, R. E. : The Surgery of Infancy and
Childhood : Its Principles and ‘l’echniqucs.
Philadelphia: \V. B. Sauilers, 1953, p 370.
6. Macbeth, R. A.: Rectal bleeding in infancy and
childhood. Canad. Med. Ass. J., 85:1040,
1961.
7. Koop, E. C.: Rectal bleeding in infants and
