1040 REVIEW ARTICLE: RECTAL BLEEDING Canad.Nov. 4,1961,M. A. vol.85J. The left ventricle, the arteries and the arterioles, served a most useful purpose. She has been the and hence the perfusion and the health of the means of synthesizing the departments of medi- myocardium, the cerebral and renal parenchyma, cine, surgery, anesthesia, biochemistry, pathology, all may have been compromised by the hyper- psychiatry and radiology over a common problem. tension due to a specific cause and these changes, In our turn, I hope we have helped her. including hypertension, may become irreversible. Some think that irreversible hypertension in these REFERENCES to secondary renal involvement. 1. BARBEAU, A. et at.: Union med. Canada, 87: 165, 1958. instances is due 2. KVALE, W. F. et at.: J.A.M.A., 164: 854, 1957. In our patient, renal function was grossly normal 3. VON EULER, U. S. AND STR6M, G.: Circulation, 15: 5. 1957. 4. GrrLow, S. E. et at.: Am. I. Med., 28: 921, 1960. but there were definite hypertensive retinal 5. Annotation: Laacet, 1: 967, 1960. 6. WALLACE, L. AND MCCRARY, J. D.: J.A.M.A., 157: 1404, changes, and left ventricular hypertrophy, and her 1955. 7. CARMAN, C. T. AND BRASHEAR, R. E.: New England J. blood pressure following operation did not return Med. 263: 419 1960. to normal although it was greatly diminished. It is 8. AXELROD, J.: Physiol. Rev., 39: 751, 1959. 9. DRUJAN, B. D. et at.: Canad. J. Biochem. i Physiol., 37: suggested that false negative Rogitine tests in some 1153, 1959. 10. VON EULER, U. S.: Noradrenaline, Charles C Thomas, cases of pheochromocytoma may be due to the Springfield, Ill., 1956. 11. CROUT, J. R. AND SJOERDSMA, A.: Cire.tlation, 22: 516, fact that irreversible hypertension is already 1960. 12. STRAUS, R. AND WURM, M.: Am. J. Olin. Path., 34: 403, established. Considering that hypertension of any 1960. one should attack 13. HOFFER, A. AND OSMOND, H.: J. Neuropsychiat., 21: 1961. cause may become irreversible, (In print) the remedial and specific causes without undue 14. MANGER, W. M., WATKIN, K. G. AND BOLLMAN, J. L.: Chemical quantitation of epinephine and norepinephrine delay. We do not know at the present time what in plasma, Charles C Thomas, Springfield, Ill., 1959. will 15. BELKIN, A., MACQUEEN, D. 0. AND DUFFIN, J. D.: Canad. course the hypertensive cardiovascular disease M.A.J., 64: 442, 1951. take in our patient. 16. Idem: Ibid., 71: 59, 1954. 17. FoRssELL, J. AND MALM, P.: Acta med. scandinav., 163: DR. NANSON. Thank you, gentlemen, for your 55, 1959. attention. Our time is up, but I think you will agree 18. FERTIG, H. H. et at.: Ann. mt. Med., 35: 1358, 1951. 19. KING, S. E. AND BALDWIN, D. S.: Am. ,J. Med., 20: 217, that this patient with pheochromocytoma has 1956 ".-.g . .8. .. RECTAL BLEEDING IN INFANCY of all patients under the age of 16 with rectal AND CHILDHOOD* bleeding or melena in two Edmonton hospitals only 63 charts were made available. None of the personal ROBERT A. MACBETH, M.D., F.R.C.S.[C],t cases were included in the records provided be- Edmonton, Alto. cause they were discharged as Meckel's diverti- culum, thrombocytopenic purpura and gastroin- FEW SYMPTOMS cause a mother to seek medical testinal angiomatosis. A complete review of local attention for her child with greater dispatch than experience was therefore virtually impossible. The does that of the appearance of fresh or altered excellent classification of Koop7 has consequently blood associated with the stool. This is indeed been selected as the background against which fortunate for, while the cause may be inconse- selected cases will be discussed in an attempt to quential, this symptom may herald the presence of clarify the differential diagnosis and treatment of serious disease requiring urgent therapy and even rectal bleeding in infancy and childhood. emergency surgery. The recent occurrence of three instances of severe SYMPTOMATOLOGY bleeding from the rectum in children in my practice has prompted me to examine the records of such There is rather universal agreement that a care- cases in this area and survey the rather meager fully elicited history is frequently the most valuable literature on the subject. It soon became apparent part of the evaluation of any case of rectal bleeding. that the standard coding of discharge diagnoses of The following points must be established, if at all hospitalized patients did not make it possible for possible. record librarians to provide charts of patients on a basis of their presenting complaint with any 1. How Much Blood Has Been Passed? consistency. In response to a request for the records This information may help with the diagnosis but is even more important in the assessment of *Presented at the Annual Meeting of the Saskatchewan the urgency of the situation. It must constantly be Division of the canadian Medical Association. October 18-21, 1960. and the Annual Meeting of the Alberta Division of the kept in mind that the loss of a quantity of blood Canadian Medical Association. September 25-28, 1961. tDepartment of Surgery, University of Alberta, Edmonton. which in the adult would be inconsequential may Canad. M. A. J. 1041 Nov. 4, 1961, vol. 85 REVIEW ARTICLE: RECTAL BLEEDING well constitute a massive hemorrhage in a small I. Syndromes Characterized by the Passage of infant. The loss of 40 c.c. of blood by a 6-lb. new- Bright Red Blood and Associated with Anal born, for example, is roughly equivalent, on a basis Pain of its effect on circulating blood volume, to a hemor- In this group one might include: (i) Fissure-in- rhage of 1000 c.c. in a 150-lb. adult. ano. (ii) Fistula-in-ano. (iii) Rectal prolapse. (iv) Hemorrhoids. (v) Rectal foreign body. 2. How Long Has the Patient Been Bleeding? Diagnosis here is seldom difficult and can usually This information, like that of the amount of be very simply -confirmed by examination of the blood passed, is usually more helpful in assessing perianal area and digital examination of the rectum. the gravity of the situation than in establishing the Of this group fissure-in-ano is by far the com- precise diagnosis. monest lesion. Out of 36 cases discharged from the Edmonton General Hospital over the last nine years with a diagnosis of rectal bleeding, 26 or 3. What Colour is the Blood? 72% were due to demonstrable anal fissures. In The colour of the blood passed depends on three office practice the preponderance is even greater. factors: (i) The proximity of the source of bleeding Fissures appear to occur in two forms: to the anal orifice. (ii) The rapidity with which it 1) Multiple minute superficial erosions which is conveyed from the source of bleeding to the are commonly seen in association with infantile anal orifice. (iii) Whether it has been in contact diarrheas, debilitating illnesses and where poor with acid secretions which give it a brownish perianal hygiene is apparent. Ten such cases colour as a result of the formation of acid hematin. were recorded but doubtless many more occurred It is not an uncommon error to fail to consider which went unmentioned in the discharge sum- these latter two considerations, for while it is (true mary and were therefore uncoded. The average that bright red bleeding usually indicates an ano- age of these patients was 9 months and the average rectal or at least a colonic lesion, large quantities duration of symptoms 4 weeks. In this type of of blood in the small intestine may be transmitted case the fissuring was usually ,of secondary im- along the bowel rapidly enough that it presents portance, the blood loss was minimal, and the at the anus as bright red in colour. erosions rapidly healed when the primary condition was corrected. Among the measures utilized to 4. Is the Blood Mixed With the Stool or Only minimize the perianal irritation, fastidious local on the Surface? hygienic measures, various analgesics and antibiotic Bleeding into the small bowel or colon above ointments and exposure to a heat lamp seemed to the sigmoid is usually intimately mixed with the be effective symptomatic measures. stool owing to the action of intestinal peristalsis 2) In addition to the group with multiple super- on the liquid or semi-solid feces. We have been ficial erosions were a group of 16 infants and surprised on reviewing charts to note how often children with the well marked symptomatology this information is missing, either because the and physical findings of a single anal fissure as because seen in the adult. In five of these the fissure had question was not asked or more commonly all the clinical features of a "chronic" anal fissure. the informant was unable to answer it. The age range in this group was 6 months to 10 years with an average of 4.4 years. The duration 5. What is the Relationship of the Passage of of symptoms varied from one month to nine years. Blood to the Passage of Stool? Four of the five patients with chronic fissures The significance of this can be best appreciated underwent surgical excision. The remaining 11 when specific disease entities are considered. cases had typical single acute ulcers that responded to conservative treatment. 6. Are There Any Associated Symptoms? Typical of the monotonously similar case histories The presence or absence of associated symptoms is that of a 7-year-old girl who was admitted to hospi- and their nature is probably the most helpful in- tal in 1955. Her mother stated that she had tended to formation in the establishment of a precise diag- be constipated since birth and had complained of pain nosis.