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Home , Colic, Hematochezia, Proctitis, Proctocolitis, Rectal bleeding

Problems in Family Practice

Rectal

James Graham, MD Springfield, Illinois The diagnosis and management of problems varies with the urgency of the situation, the age of the patient, and the applicability of available diagnostic methods. Every instance of rectal bleeding is a problem that demands investi­ gation by endoscopic, radiographic, and laboratory means. A physician can be misled by the patient’s understatement or underobservance of bleeding. A good history obtained as quickly as possible in urgent circumstances and in great detail under more relaxed circumstances is of immeasurable diag­ nostic value. The manner of investigating a rectal bleeding Urgency problem will depend upon: Massive gastrointestinal hemorrhage, either 1. The urgency of the situation, ranging from red, maroon, or tarry, with a drop in levels of exsanguinating hemorrhage with physiologic crisis blood pressure, hemoglobin, and hematocrit, the and shock, to a patient’s simple observation of a presence of pallor, and a rise in pulse rate de­ small amount of blood on the toilet tissue. mands emergency action. Replacement by blood 2. The general history and symptoms. transfusions is begun immediately. Diagnostic 3. The character and quantity of the blood ob­ testing is initiated simultaneously. The diagnostic served, whether red, dark, clotted, or tarry, and effort is directed first toward distinguishing be­ the nature of the bleeding, whether on the tissue, tween upper and lower in the water, or mixed with the stool. hemorrhage. of blood is conclusive for 4. The age of the patient. upper gastrointestinal tract bleeding. In the ab­ 5. The applicability of available diagnostic sence of vomiting, a nasogastric tube must be methods. passed. Blood through the tube will establish that This paper presents a logical and practical clini­ bleeding is proximal to the ligament of Treitz. cal approach to the patient with rectal bleeding Rarely, blood in the may not escape with particular reference to the urgency of the through a nasogastric tube. situation, history, age of the patient, and applica­ Digital rectal and proctoscopic examinations bility of available diagnostic methods. will confirm the color of the blood. These exam­ inations will rarely establish, however, the origin of massive hemorrhage simply because bleeding of this amount ordinarily is from a site higher than the examiner can feel or see. The history may suggest peptic ulcer or diver­ ticular disease. A history of previous bleeding episodes of similar pattern may be elicited, such as From the Springfield Clinic and Southern Illinois University School of Medicine, Springfield, Illinois. Requests for re­ presence of cramping or absence of pain, presence prints should be addressed to Dr. James Graham, or absence of , or Springfield Clinic, 1025 South Seventh Street, Springfield, IL 62703. , or . X-ray studies will depend upon 0094-3509/78/0703-0169$02.00 ® 1978 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 1: 169-176, 1978 169 RECTAL BLEEDING the state of the abdomen, whether painful or dis­ Table 1. Sequence of Investigation, Upper Gl tended. If pain and distention are present, scout Bleeding x-ray films may show gas patterns diagnostic of obstruction. This is important because a normal 1. Gastroscopy film precludes obstruction. Free air, indicating 2. Angiography perforation, is a rarity except with trauma. Mas­ 3. Barium x-ray (later) sive escape of blood from the occurs gen­ erally when the stomach and intestine are un­ Table 2. Sequence of Investigation, Lower Gl obstructed, except for intussusception. With this Bleeding condition there may be both voluminous bleeding and obstruction. The cause of massive rectal 1. Digital hemorrhage from the unobstructed gut is most 2. likely to be peptic ulcer, varix, , colonic 3. Angiography diverticular disease, , or a Meckel diver­ 4. Barium x-ray (later) ticulum. There are numerous less frequent causes. 5. The character of the blood may offer a clue to the site of bleeding. Although blood may vary be­ inations have priority. These investigations are fol­ tween tarry and red from any place in the stomach lowed by angiography, not colonoscopy or barium or intestine, blood from the left colon more often is x-ray as one might be led to think. Angiog­ red, right colonic blood generally is maroon, and raphy yields 75 percent positive results of working upper gastrointestinal blood is mostly tarry. It is diagnostic value so long as the patient is bleeding transit time that makes the difference. A 60-minute actively at the time of the examination.1 The diag­ rush of blood from the stomach or duodenum may nostic yield (about five percent) of barium x-ray slide through the hyperperistaltic intestine, reach studies for massive hemorrhage from lesions distal the rectum with its hemoglobin unchanged, and to the ligament of Treitz is so poor as to be negli­ then bolt out through the anus still red rather than gible.1 Colonoscopy is of no value in these circum­ tarry. stances because stool and blood cannot be cleared from the colon through the seven and nine French Sequence of Investigations, Urgent suction channels of colonoscopes. As in upper Upper gastrointestinal bleeding bleeding, the vascular catheter, which in this case If first efforts have placed the site of bleeding in is left in the inferior mesenteric artery, may be used to arrest colonic bleeding by perfusion of the upper tract, the next diagnostic measures should be endoscopic or angiographic. Esoph- vasoactive agents in solution. Table 2 summarizes agogastroscopy will determine the level of the sequence of investigations for lower gastroin­ bleeding and the nature of the lesion. It will indi­ testinal bleeding. cate the advisability of ice water cooling, medica­ tions, electrocoagulation of a vessel, or removal of Other tests a polyp, if such is discovered as the cause of the Intestinal tube tests and fluorescein string tests hemorrhage. Angiography can be diagnostic of the are not only of questionable value but are too time location of bleeding but not of the nature of the consuming and too uncomfortable for a patient pathologic process. In addition to being diagnos­ who is bleeding profusely.2 tic, angiography allows infusion of vasoactive substances. Table 1 summarizes the sequence of Surgery, Urgent investigations for upper gastrointestinal bleeding. A decision for surgical treatment may have to be made before a diagnosis is forthcoming, if Lower gastrointestinal bleeding bleeding does not stop within a reasonable period In urgent situations in adults, scout x-ray films of blood replacement. The method of making this are taken first if the patient has or determination, however, should be a variable one. if the abdomen is distended. In the absence of It may be based upon either a predetermined these symptoms, digital and proctoscopic exam­ number of blood replacement units with failure to

170 THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 1, 19?8 RECTAL BLEEDING maintain satisfactory blood pressure and solved from a patient’s history alone and that a hematocrit levels, or upon a time period during rectal examination is necessary. Yet, despite such which there is continuous but ineffective replace­ recognition, a physician can be led into slighting, ment of blood, either slow or pressurized. Age, or even omitting, a rectal examination because of general physical condition, and medications make the patient’s understatement or underobservance differences here. A young and pliable artery is of bleeding: “It was bright red blood, of course” ; more likely to contract and thereby control hemor­ “It was just a couple of times” ; “It was only on rhage than an old and sclerotic vessel. Likewise, a the toilet paper.” young and resilient vessel will be more responsive It is worth keeping in mind that even in the face to vasoactive infusions. of such understatements, if a patient comes in be­ While rigid rules for volume replacement and cause of bleeding, it was blood that brought him or time can encourage haste and lead to dangerous her to the physician for examination. Further­ decisions, procrastination is similarly dangerous. more, if a history of bleeding is elicited from the The important concerns are maintenance of blood physician’s direct question about rectal bleeding, pressure and hematocrit levels while a diagnosis the likelihood of understatement is still greater. evolves or until all reasonable diagnostic measures have been pursued. The final decision may be for either medical or surgical management. General History Exploratory laparotomy in the absence of a Several symptoms and signs may provide help­ diagnosis can be very unsatisfactory and harmful. ful clues in searching for the cause and location of The surgeon may not find the bleeding vessel even rectal bleeding. Among significant symptoms are: though it is tempting to think this would be easier (1) pain, (2) change in bowel pattern, and (3) color to find during active bleeding. Bleeding may stop of stool and mixture with blood and mucus. during the administration of anesthesia so that the Pain, if it accompanies rectal bleeding, may surgeon can open a viscus at the most proximal offer a strong lead to the lesion. Intestinal muscu­ point of intraluminal blood and clear out the clots lar layers are sensitive to tension from such but not find the bleeder. This may be the experi­ as occurs in intussusception, and to stretching ence in 25 percent of cases.2 from obstructed gas or stool. Colonic pain, often Slowing and cessation of bleeding are deter­ relieved by passage of flatus, is usually experi­ mined by diminishing rectal output of blood to­ enced in the hypogastrium either to the right or left gether with maintenance of blood pressure and depending upon the location of the lesion. Discom­ hematocrit levels as blood replacement is reduced fort that stems from the rectosigmoid area may be and discontinued. located just above the symphysis; pain that arises in the rectum is referred to the sacral area or the perineum. The location of abdominal pain then Nonurgent Situations may offer a lead to the site of bleeding. Rectal bleeding in most instances is a nonurgent Tenesmus, or voluntary inhibition of a strong matter encountered among ambulatory patients in urge to defecate with tightening of the gluteal and an office or outpatient setting. perineal muscles, occurs frequently with ulcera­ The causes of rectal bleeding are both minor tive and with ulcerative rectal neoplasms. and grave, numerous and varied. The minor and The character of the bleeding lesion thus may be grave are disconcertingly capable of simulating suggested by tenesmus. each other very closely. The physician, therefore, pain caused by cryptitis and hemor­ must continue investigation of the problem until rhoids is dull with a pressure element. Pain is the site and nature of the bleeding have been de­ constant and throbbing with a thrombosed hemor­ termined or until all pertinent diagnostic measures rhoid and it diminishes once bleeding sets in. Fis­ have been considered. Every instance of rectal sure pain is severe, like a knife, and is at its worse bleeding demands careful search by endoscopic, during the 15 or 20 minutes following a bowel radiographic, and laboratory means. movement. All of this is generally recognized. It is also rec­ Peptic ulcer pain has its own characteristics, ognized that a rectal bleeding problem cannot be post-prandial and referred to the sternal area.

171 the JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 1, 1978 RECTAL BLEEDING

Change in bowel pattern Table 3. Order of Frequency of Gl Bleedina in There are some characteristics of constipation Children and diarrhea that may point to the site of bleeding. Constipation of recent date when associated with 1. Anal conditions (fissures) bleeding, but without pain or vomiting, suggests a 2. Rectal and colonic polyps site in the distal colon, often an annular, constrict­ 3. Peptic ulcer ing carcinoma. Polypoid neoplasms, on the other 4. Meckel diverticulum hand, being intraluminal rather than intramural, 5. Intussusception are more likely to produce diarrhea in association 6. Systemic diseases 7. Other conditions with bleeding. If a polyp is large and on a stalk, it may be forced along the lumen to produce an in­ tussusception, with cramps accompanying the colon, or from the in the case of bleeding bleeding. from a Meckel diverticulum with aberrant gastric Severe constipation such as in or mucosa, or even from the stomach and duodenum, debilitating disease allows impaction of hard stools may pass quickly through the distal colon and, still that produce stercoral ulcers with bleeding. This is red, on out through the anus. a distal colon phenomenon. Hard and large stools Generally, a tarry stool is produced from blood accompanied by pain at the anal area during and that originated in the stomach or duodenum with after bowel movement are indicative of anal le­ hemoglobin changing in composition and color sions such as fissures. Itching about the anus with during transit through the and ileum over blood on the underclothing or on the toilet tissue a period of several hours. Very dark red stools, suggests perianal . almost tarry, may, however, arise in the right A normal colon may be deluged with a large colon or even in the left colon in the presence of volume of blood entering it suddenly as in massive severe constipation when blood can be held back upper gastrointestinal hemorrhage. Here, the vol­ in the bowel for excessively long periods of time. ume of each stool passed per rectum will be large, Blood on a formed stool rather than in the stool “ large stool diarrhea,” an indication that bleeding signifies a lesion distal to the sigmoid where a stool is from the stomach or , sometimes takes its form. Mucus originates in goblet cells and from the cecum. more so in the distal colon and rectum, where gob­ Quite the opposite situation pertains with in­ let cells are more numerous. For this reason, a flammatory disease, as in ulcerative . Here, mixture of mucus with blood indicates that the le­ the threshold for stimulation by intraluminal con­ sion is more likely to be found in the rectum, the tent is lowered and the accumulation of even small sigmoid, or the descending colon. amounts of stool is not tolerated. Small quantities of stool are passed frequently, “small stool Age diarrhea.” The patient so afflicted may experience frequent urge to stool with passage of only a small Children amount of feces together with some blood, and Although children are subject to almost all of with or without mucus. Here is a clue pointing to the conditions that cause rectal bleeding in adults, the distal colon or the rectum as the site of bleed­ from to rectal cancer, the order ing. of incidence differs with children: anal conditions, polyps, peptic ulcer, Meckel diverticulum, intus­ susception, and systemic diseases (Table 3). As with adults, a rectal bleeding problem in a Color of stool and mixture with blood or child must be pursued until a diagnosis is reached mucus or until all applicable diagnostic measures have Bright red blood has its origin in the distal colon been explored. Grave conditions closely simulate or rectum unless hemorrhage is massive and the minor ones. Massive hemorrhage in particular stools are large, loose, and frequent. When large demands an aggressive approach to diagnosis and stools come frequently, a rapid transit time can be treatment because the relatively small blood vol­ assumed. In this circumstance blood from the right ume of children allows a child to bleed out quickly.

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Anal fissures portant. The condition may disappear spontane­ Most anal fissures bleed. They are observed in ously.4 association with diarrhea or with severe constipa­ Since any polyp may begin early in life, it is of tion and hard stools. The blood is quite red and importance to identify its type. Then therapy can bowel movements are painful and are held back. be properly conservative or radical. Fragmentary Examination is difficult because of extreme ten­ of polyps can be misleading; removal of derness. Examination under anesthesia may be an entire polyp for examination by the pathologist necessary. The anesthetic may be of additional is safer.5 help in that it allows dilation of the anal sphincters and excision of the fissure, if this appears indi­ cated. Peptic ulcer In Spencer’s series of 476 instances of rectal bleeding in hospitalized infants and children, 54 of them bled from an ulcer of the stomach or Polyps duodenum.6 Half were infants less than one year The polyps encountered most frequently in of age. The mortality in this group was 65 percent childhood are of the juvenile type. The highest in­ because of the high proportion of stress ulcers that cidence is at about age four. Juvenile polyps are were associated with other critical illnesses. inflammatory in nature and have a tendency to disappear later in life. Bleeding, rarely profuse, occurs in episodes, due perhaps to intermittent and irregular trauma from stools. The usual Meckel diverticulum juvenile polyp is single, round, smooth, and on a stalk. Such polyps arise generally in the distal Bleeding in this condition may be small in colon and rectum. Some prolapse through the amount and intermittent, or massive and critical. anus. Most of them can be removed by sigmoido­ Blood mixed with stool varies from brick red to scopy or colonoscopy. tarry. Aberrant gastric mucosa in the diverticulum Other types of polyps, such as adenomatous is the most frequent cause of profuse and painless polyps and polypoid carcinomas, are unusual in lower gastrointestinal hemorrhage in an appar­ children. Polyp formation, as a manifestation of ently healthy infant.6 Bleeding can be the same in familial polyposis or of Gardner syndrome, makes older children. its appearance for the most part after puberty. However, after age two the margin of safety These latter two conditions, which are viewed as from hemorrhage grows wider with each added precursors of cancer or which eventually may re­ year of growth.7 quire proctocolectomy with permanent ileostomy, The most important diagnostic test is abdominal are unusual in childhood. Peutz-Jeghers polyposis scanning with sodium pertechnetate Tc 99 m, on the other hand is quite likely to begin during which is selectively taken up by gastric mucosa in childhood. This condition does not have malignant the diverticulum. Barium studies by x-ray either potential. A non-neoplastic form of bleeding poly­ by swallow or enema are unlikely to demonstrate a posis seen in both children and adults is lymph­ Meckel diverticulum.8 oid polyposis. The lesions, usually sessile, may be scattered or they may carpet the mucosa. They represent enlarged lymphoid follicles or aggre­ Intussusception gates of lymphocytes.3 They can be mistaken for Rectal bleeding is an early symptom of intus­ adenomatous polyps during either endoscopic or susception because of venous stasis in the submu­ radiologic examinations. Lymphoid polyposis is cosa with extravasation of blood through the mu­ probably inflammatory in nature. Even though the cosa. The mesenteric vessels are pulled in be­ polyps bleed, the condition need not be treated tween the tightly telescoped layers of the bowel. surgically. The distinction of lymphoid polyposis Blood flows in slowly under arterial pressure but from bleeding, familial polyposis is, therefore, im­ cannot escape through the blocked veins.

THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 1, 1978 173 RECTAL BLEEDING

anorectum must be checked by endoscopic exam­ Table 4. Order of Frequency of Gl Bleeding in Adults ination at six-month intervals. Each time, a benign condition must be confirmed as the cause of bleed­ 1. ing and a malignant lesion ruled out. 2. Fissure Patients dangerously assume they are “still 3. Polyps bleeding from the hemorrhoids.” Physicians, un­ 4. Proctitis fortunately, fall into the same trap. 5. Peptic ulcer 6. 7. Ulcerative 8. Gastritis 9. Diverticular disease Polyps 10. Systemic diseases Rectal and colonic polyps bleed episodically, usually in amounts large enough to color the water in the toilet bowl but rarely in sufficient volume to alter the hemoglobin and hematocrit levels. These Sudden colic in a well-nourished infant followed neoplasms can and should be removed through a quickly by a normal stool and then a currant jelly- sigmoidoscope or colonoscope, if only to eliminate like stool of mucus and blood constitutes the classi­ a source of bleeding that might later cause confu­ cal picture of intussusception. In older children and sion in differential diagnosis. adults the intussuscipiens may be led by a pedicled Bleeding is a chief sign of cancer. If the gas­ polyp or a malignant neoplasm. Because of the trointestinal tract can be kept clear of benign obviously obstructed character of the symptoms bleeding lesions, bleeding then is more likely to of intussusception, a barium enema is used rather arouse suspicion of cancer. While the majority of than angiography. Reduction of intussusception is colorectal carcinomas arise de novo from normal frequently accomplished by fluoroscopic control mucosa or from villous adenomas, prevailing opin­ of the barium enema. ion allows the possibility of metamorphosis of simple colorectal adenomas to invasive adenocar­ cinomas.5 Adults With adults the most frequent causes of rectal bleeding in the lower tract are anorectal vascular and inflammatory conditions, colorectal neo­ Colorectal cancers plasms, either polyps or cancers, ulcerative proc­ Bleeding from cancer of the rectum and tocolitis, diverticular disease, and systemic dis­ rectosigmoid is frequently visible and red. Blood is eases (Table 4). In the upper tract, ulcer, gastritis, the common presenting sign of low lying cancers. and varices are most frequently responsible for Right colon cancers bleed, but blood is more often massive hemorrhage. Bleeding with these condi­ occult; the patient visits the physician because of tions may also be minimal and chronic. The bleed­ weakness and , and the chemical stool test ing associated with gastric carcinoma and polyps then shows blood. generally is occult.

Ulcerative proctocolitis Anorectal conditions Bloody stools with mucus are characteristic of Bleeding from hemorrhoids and fissures is ulcerative proctitis and . The rarely serious in itself. The danger lies in assuming stools may be loose and frequent, or they may be that all rectal bleeding subsequent to the time of formed and even constipated. Bleeding is rarely diagnosis of the benign condition is still due to the the sole symptom of this disease. Other signs usu­ same benign condition. When these patients con­ ally accompany the bloody stools: cramps, tenes­ tinue to bleed, regularly or intermittently, the mus, fever, arthralgia, dermatitis.

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Diverticular disease strated abnormality represents the site of bleeding. Minimal and occult bleeding are not often Nonurgent situations are a different matter; encountered in diverticular disease. Ordinarily barium studies in that case provide the most sig­ when bleeding occurs it is massive. Angiography nificant resource, a high degree of accuracy, and a is the prime tool for diagnosis. With a barium x-ray relatively noninvasive technique that is expedient, examination the radiologist can confirm the pres­ adapted to ambulatory conditions, and economi­ ence of diverticula, but he/she cannot demonstrate cal. that the source of bleeding is or is not in the colon. Angiography This technique is of value chiefly in emergency Systemic co n d itio n s situations. Successful, selective angiography of Systemic conditions of wide variety may be re­ the superior mesenteric and inferior mesenteric sponsible for rectal bleeding. There is nothing vessels for hemorrhage requires active bleeding at characteristic about the blood, which may be the time of the study. Additionally, to be suc­ bright or dark, moderate, massive, or occult. cessful, vascular radiography must come as a first Either or may be the first test. A barium enema will preclude satisfactory symptom or systemic disease, but more often visualization and interpretation for several days. If rectal bleeding will follow in the wake of other a bleeding point is identified on the diagnostic an­ . Petechiae, ecchymoses, giogram, perfusion of a vasoactive substance , enlarged lymph nodes, enlarged liver such as vasopressin or epinephrine can be started and spleen, melanin spots on the skin or mucous immediately. Increasing concentrations of perfu­ membranes, any of these signs may appear as sate can be added as the effects are checked at leads to a diagnosis of blood dyscrasia, lymphoma, intervals of 20 to 30 minutes. Catheters can be left or coagulopathy. Platelet count, partial thrombo­ in place for continuous perfusion over a 24-hour plastin time, or prothrombin time may be abnor­ period, depending upon the clinical status of the mal. The history of medications may yield impor­ patient as measured by blood pressure and tant diagnostic clues. hematocrit levels and stool output.' Bleeding may arise at a single site or in multiple Angiography is of great help with nonurgent areas, either as extravasations or as frank bleeding bleeding problems that require vascular definition. from ulcerated mucosa. A mucous membrane ul­ Gastrointestinal arteriovenous abnormalities, ceration can be the first sign of a leukemic process. some of which are responsible for previously un­ Although the mouth is the commonest site of such explained rectal bleeding, are readily demon­ lesions in agranulocytosis, aplastic anemia, and the strated by angiography.10 other neutropenias, the anorectal region may simi­ larly show breakdown of the mucosa or anoderm.9 Occult blood There is a lack of relationship between the amount of blood that is bled into the stomach or intestine and the gross appearance of blood in the Applicability of Diagnostic Methods stools. As much as 100 ml of blood may be present Gastrointestinal x-rays in a specimen without being visible to the naked Barium x-ray studies are of limited value for eye." To determine the amount of blood required localizing the site of gastrointestinal bleeding for tarry stools, experimental analyses have been under the urgent conditions of massive hemor­ made on healthy subjects who swallowed meas­ rhage. The barium x-ray demonstration of ured quantities of citrated and fresh blood.1213 In esophageal varices, peptic ulcer, or diverticula can some persons 100 ml of ingested blood appeared in be of value in these situations, but it does not pro­ the stools as gross blood, either red or maroon and vide a conclusion upon which the physician can without tarry aspect. In one subject 1400 ml pro­ act to control bleeding. The physician cannot be duced tarry stools for five days. The minimal certain from the barium study that the demon- amount of blood for tarry stools appears to be

THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 1, 1978 175 RECTAL BLEEDING about 100 ml. The coloring effect on stools de­ No diagnosis pends upon the number of stools, the volume of Not infrequently, a clear-cut demonstration of separate evacuations, and the time intervals be­ the cause of rectal bleeding is not forthcoming de­ tween stools. spite the application of all suitable diagnostic Tests for occult blood may be positive for ten measures and cessation of bleeding. If there is re­ days after bleeding. Persistence of tarry stools or currence of massive bleeding from the lower tract occult blood does not necessarily indicate con­ a concerted effort should be made to repeat an­ tinuation of bleeding. giography as quickly as possible. If hemorrhage is Tests for occult blood in the stools may be done obviously from the stomach or duodenum, either on a problem oriented basis as indicated by endoscopy would be preferable as a first step. a patient’s history or on a routine screening basis. With nonurgent bleeding the physician is in a Simple, random clinical tests for occult blood have position to assure the patient that a serious illness not been trustworthy. For reasons unexplained, has not turned up. If bleeding continues, selected normal persons may lose as much as 3 ml of blood in examinations and tests can be repeated at reason­ the stools daily.14 A single specimen taken from able intervals. the gloved examining finger is of little value when negative. Tests should be repeated several times under controlled conditions. A patient should be on a meat free diet for four days prior to testing. Specimens may be collected at home as small smears placed on glass slides, such as Hemocult.* An electrophoretic filter paper impregnated with guaiac is developed with a solution of hydrogen peroxide and denatured alcohol.

References 1. Mock J: Colonic diverticular disease: Angiography for diagnosis of bleeding. Dis Colon Rectum 18:565,1975 2. Abu-dalu J, Urea I, Gart I: Selective angiography as a diagnostic aid in acute massive gastrointestinal bleeding. Arch Surg 106:17, 1973 Endoscopy 3. Beck AR, Turell R: Pediatric proctology. Surg Clin North Am 52:1055, 1972 Esophagogastroscopy is employed successfully 4. Luow JH: Polypoid lesions of the large bowel in children with particular reference to benign lymphoid under emergency and elective conditions. The polyposis. J Pediatr Surg 3:195, 1968 stomach can be cleared effectively by lavage in 5. Graham J: Colorectal adenomas and adenocar­ cinomas. Ill Med J 101:189, 1973 cases of massive bleeding to provide satisfactory 6. Spencer R: Gastrointestinal hemorrhage in infancy visualization. Endoscopy is a first measure in and childhood. Surgery 55:718, 1964 7. Brown WE: Gastrointestinal hemorrhage in chil­ upper tract bleeding. and photography ac­ dren. Abdominal Surg 17:214, 1975 complished with upper tract endoscopy establish 8. Meguid MM, Wilkinson RH, Canty T, et al: Futility of barium sulfate in diagnosis of bleeding Meckel diver­ an exact diagnosis of gastric lesions. The fi­ ticulum. Arch Surg 108:361, 1974 berscopes are used therapeutically to arrest gastric 9. Cuttner J, Wassermann LR, Horowitch S: Diseases of the anus and rectum associated with hematologic disor­ bleeding, making use of both fulgurating tips and ders. In Turell R (ed): Diseases of the Colon and Rectum. snares. Colonoscopy exposes all areas of the colon Philadelphia, WB Saunders, 1969, p 1238 10. Flagood MF, Gathright JB: Hemangiomas of the to the eye for photography, for biopsy, or for re­ skin and gastrointestinal tract: Report of case. Dis Colon moval of polypoid tumors by snare and elec­ Rectum 18:141, 1975 11. Izak G, Stein Y, Karshai A: Quantitative determina­ trocoagulation. Direct observation of the colonic tion of gastrointestinal bleeding using Cr5'-labeled red mucosa is of inestimable value in assessing the blood cells. Am J Dig Dis 5:24, 1960 12. Schiff L, Stevens RJ, Shapiro N, et al: Observation extent and degree of ulcerative colitis. Colonos­ of the oral administration of citrated blood in man. Am J copy is only elective. Med Sci 203:409, 1942 . 13. Daniel WA, Egan S: The quantity of blood required to produce a tarry stool. JAMA 113:2232, 1939 14. Stephens FO, Lawrenson KB: The pathologic significance of occult blood in feces. Dis Colon Rectum *Hemocult: Smith Kline Diagnostics 13:425, 1970

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