BMJ 2008;336:1010-1015 (3 May), doi:10.1136/bmj.39542.440417.BE
Clinical Review
Management of bloody diarrhoea in children in primary care
M Stephen Murphy, senior lecturer in paediatrics and child health, consultant paediatric gastroenterologist1,2
1 Division of Reproductive and Child Health, Medical School, University of Birmingham, Birmingham B15 2TT, 2 Birmingham Children’s Hospital NHS Foundation Trust, Birmingham B4 6NH
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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?
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