Clinical Review

Management of bloody diarrhoea in children in primary care

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39542.440417.BE (Published 01 May 2008) Cite this as: BMJ 2008;336:1010
  1. M Stephen Murphy, senior lecturer in paediatrics and child health, consultant paediatric gastroenterologist12
  1. 1Division of Reproductive and Child Health, Medical School, University of Birmingham, Birmingham B15 2TT
  2. 2Birmingham Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH
  1. m.s.murphy{at}bham.ac.uk

    Bloody diarrhoea is an uncommon symptom in children, and it may indicate the presence of serious disease. This review focuses on children presenting in a primary care setting. The non-specialist should be aware of the likely causes, initial management, and indications for specialist referral. The emphasis is on children in the developed world, although traveller’s diarrhoea is also considered. The epidemiology and management of this condition are different in the developing world, where infectious causes predominate. In recent years the reported incidence of inflammatory bowel disease increased greatly in the developed world and important advances have been made in its management. This diagnosis should always be considered carefully.

    Sources and selection criteria

    I used the Medline database to search for evidence from the literature. Randomised controlled trials, meta-analyses, and Cochrane reviews were used when relevant and available. Other sources of evidence included large case series and cohort studies. I obtained information on the incidence of specific pathogens from the UK Health Protection Agency’s Centre for Infections

    What are the most likely causes of bloody diarrhoea in children?

    The likely diagnoses vary depending on age (box). At every age intestinal bacterial infections are an important cause. Inflammatory bowel disease may occur at any age but is more likely in older children (>1 year). In young infants non-specific (perhaps allergic) colitis is most likely. Other conditions are rarer but should be considered as they can be serious and even life threatening.

    Causes of bloody diarrhoea (real or apparent) in infants and children

    Infants aged <1 year
    Common causes
    • Intestinal infection

    • Infant colitis

      • Non-specific colitis

      • Breast milk colitis

      • Cow’s milk colitis

    Less common or rare causes
    • Intestinal ischaemia

      • Intussusception

      • Malrotation and volvulus

    • Necrotising enterocolitis

    • Hirschsprung’s disease

    • Inflammatory bowel disease

      • Crohn’s colitis

      • Ulcerative colitis

    • Systemic vasculitis

    • Factitious illness

    Infants aged >1 year
    Common causes
    • Intestinal infection

    • Inflammatory bowel disease

      • Crohn’s colitis

      • Ulcerative colitis

    • Juvenile polyp

    Less common or rare causes
    • Intestinal ischaemia

      • Intussusception

      • Malrotation and volvulus

    • Mucosal prolapse syndrome

    • Henoch-Schönlein purpura or other forms of systemic vasculitis

    • Factitious illness

    How common is infection compared with inflammatory bowel disease?

    This is an important question because if it is assumed that bloody diarrhoea …

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