July 9, 2021
On this episode of Talking Pediatrics Crack the Case, guest host Dr. Bryan Fate is joined by Dr. Kayla Olson, pediatric resident, to discuss one of our favorite subjects in pediatrics…..poop. Bloody stool carries a wide differential spanning infection, inflammatory bowel disease and anatomic variants; and what appears to be blood isn’t always so. Through this case, we discuss the importance of a thorough stooling history to guide decision making and when to be worried about dangerous causes of bleeding. We also highlight the familiar clinic experience of pivoting from a listed chief complaint to something quite different once in the room with family.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge and perhaps change how you care for the most amazing people on earth, kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. On today’s episode of Crack the Case with Dr. Bryan Fate, Dr. Fate entertains one of our favorite subjects in pediatrics, poop. I for one never knew how much I would be discussing kid’s stool habits until I became a pediatrician. And the reality is that sometimes all we have to do is offer reassurance, but sometimes there’s something more serious going on. Join Dr. Fate and his guest Dr. Kayla Olson as they discuss a case of bloody stool and see if you too can crack the case.
Dr. Bryan Fate: Welcome to Crack the Case with Dr. Fate. I am Dr. Bryan Fate. On today’s show we are going to dissect a real case seen in our clinic about bloody diarrhea. And with me today is one of our fabulous residents, now an R3, Dr. Kayla Olson. And Kayla briefly for our listeners can you tell me a little bit about what got you into pediatrics and what’s next after residency?
Dr. Kayla Olson: I originally got involved with peds I think just because I’ve always liked kids. Throughout college and med school, I always volunteered at daycares. I taught swim lessons. I just think kids are a lot of fun. So it combined both my love for kids and medicine. Next year, I will be the chief resident for the program, which I’m really excited about. And then following that, I will be applying to my infectious disease fellowship.
Dr. Fate: Dr. Olson, we’re going to go into the case now.
Dr. Olson: So Dr. Fate, I have a case for you coming from our general pediatrics clinic. So I saw a nine-year-old girl who came into clinic for abdominal pain and bloody stools. She first noticed the blood in her stool a few weeks ago. She notices about 5 to 10 drops of blood [00:02:30] every time she goes to the bathroom. Sometimes the blood is on the toilet paper. Sometimes the blood is mixed in the toilet. But since it was not a large amount of blood, Mom was not concerned enough to bring her in until today. She also states she has pretty significant abdominal pain following her bowel movements.
Dr. Fate: Based on what you’ve told me so far Kayla, this is a more chronic as opposed to acute change if it’s been going over weeks, as opposed to a few days. If it’s over a few days, I think about acute infection such as infectious bacterial enteritis. But chronicity changes your differential. I’ll also say that the character of the poop is important as is what the blood looks like. If it’s that bright red blood, usually that’s a lower bleed as opposed to melanoma, which is that tar black looking poop. So I want her to describe the poop because you can certainly have constipation and anal fissures. Always important to rule out the really common stuff with abdominal pain and bright red blood. So seeing her Bristol caliber, seeing how often she poops. If it’s diarrhea, if it’s formed and then ruling out anal fissure too.
Dr. Olson: I asked her more about how much she goes to the bathroom. She says she, “Does not go every day, but the stool is very soft”. And when I showed her the Bristol Stool Chart, she was more on the hard end, but not the really hard pebbles that we think about in classic constipation. She did say that, “They’re very large in nature”. And even Mom commented on how much she poops and how big the bowel movements are. So Mom was concerned about the lack of fiber in her diet at first. So she started giving her very fiber rich foods. So lots of fruits, green vegetables, nuts, bananas, berries, trying to get her stool a little bit more regular and see if that could help with all of these issues. She didn’t notice a change in her bowel habits, but the blood continued and started to get a larger amount in nature and more blood in the stool.
Another thing that I asked her about was how hard it is for her to go to the bathroom. Like I said before, her stools seem soft in nature, but she did say that she, “Has to push pretty hard to get things out”. And she does not have a lot of pain during defecation but she does have some pretty severe abdominal pain afterwards. When I asked a little bit more about her bowel habits throughout childhood, Mom said that “She’s never really had these issues before”. She doesn’t have a long timeline of constipation or diarrhea, and she’s never had any dietary intolerances that Mom knows about. So she eats all different types of foods, including gluten and dairy and she’s never noticed a change in symptoms or bowel patterns with those foods.
Dr. Fate: So it sounds like you characterize the stool well. It’s not what I think of as classic diarrhea, which is honestly hard to define. But the WHO defines it as at least three stools a day, loose, watery. So it doesn’t sound like that. It sounds like blood in the stool is [00:05:30] the primary concern here without the diarrheal piece. I would want to know if there’s mucus in the stool, which can indicate underlying inflammation as in things like inflammatory bowel disease. If she’s had fevers because again, that opens up a whole line of doors for different infections in addition to less common things like pseudomembranous colitis. If you’ve been on recent antibiotics, I would want to know that. And then also interesting travel, animals. She’s a big petting zoo fan, all ID doctors love that because that opens a door for different protozoans and less common infections, which I know is your forte.
Dr. Olson: Her social history is overall pretty benign. She does not have any rare animals, no recent contacts with strange animals, petting zoos, aquariums, anything like that. Overall, she’s been pretty healthy besides this abdominal pain and blood in the stool. So she’s not had any fever. She’s not had any weight loss or recent illnesses, no weird rashes. So this was an interesting case for me because I went in with the same thought process as you, bloody diarrhea is on the differential for the clinic intake chief complaint. And then you got to pivot in the room. And so then we talked a little bit with her family too about family history of any of those inflammatory bowel diseases that you asked about. Mom said that she’s heard of all those diseases, but she doesn’t have any in her family. So I asked about Crohn’s disease and celiac, inflammatory bowel disease, ulcerative colitis. All of those things are benign. There was no family history of any of those things.
Dr. Fate: So to summarize so far, it’s a nine year old who’s had what sounds like bright red blood in her poops. Large caliber stools though, what does not sound like true diarrhea without systemic symptoms or really any other associated symptoms aside [00:07:30] from abdominal pain after defecation. Otherwise, healthy and growing well.
Dr. Olson: Yeah.
Dr. Fate: Should we move on to the exam and the vitals Dr. Olson?
Dr. Olson: So her vitals, she did not have a fever. Her temperature was 98. Her heart rate was also normal for age at 80. Her blood pressure was 105/62. And her respiratory rate was 18.
Dr. Fate: And describe your exam to me if you can.
Dr. Olson: Generally speaking, she was pretty well appearing. She’s sprightly nine-year-old girl. Looks well nourished. She’s pretty pale, but everybody in the family was pretty pale. But her energy level was good. Her HEENT exam was benign. She didn’t have any oral ulcers. Her ears and tympanic membranes were normal. Didn’t have any injection in her eyes. And then her sclera were also not completely white, which I thought was something important to look at. Her heart and lungs sounded beautiful. She didn’t have any murmurs. Like I said, her heart rate was normal. So no tachycardia. Her lungs were clear. There was nothing of note in the lung exam. Her abdominal exam, she was soft everywhere. She didn’t have any pain. She didn’t have any rebound, no guarding. Really benign abdominal exam. So I didn’t have anything to report there. No hepatosplenomegaly.
Her skin, she did have a red, maybe just a dermatitis looking rash on her hands and around her mouth. That was interesting I thought. And then musculoskeletal, no concern. She was moving all four of her extremities. Her gait was normal. Her spine was normal. Everything else was benign. I did talk to family about doing a genital and anal exam, just given the history of the complaint. So her genital exam was completely normal. Her Tanner stage was a three. And then on her anal exam, she actually had a small skin tag/fissure at the 12 o’clock position. That was not actively bleeding, but it did look pretty sore. And I think it’s important to always do an anal and genital exam when you have this type of chief complaint, even in pediatrics because it’s just so important.
Dr. Fate: I didn’t hear that another important part of the history, especially if there’s diarrhea is urine output and fluid intake. But I think that’s a very important piece is what her fluid status is. So what is her capillary refill? Is it nice and buoyant, less than two seconds? Does she have moist mucus membranes? She’s not tachycardic, which we know. It sounds like she is still keeping hydrated because that’s the number one management piece of the area is making sure that we keep patients euvolemic. Her abdominal exam does not sound like I would be concerned about anything in the acute admin realm, like appendicitis. We talked about less common things like toxic megacolon and yet at the abdominal exam for things more autoimmune, etiologies like inflammatory bowel disease can be pretty fluctuating. So sometimes you can’t really capture it in the moment so that can be more challenging.
But the pallor is concerning to me for potentially blood loss to the point of becoming anemic, because we know she’s losing blood in likely the lower GI tract. And I would also think about, even though it doesn’t sound like true diarrhea, we never want to miss HUS. So hemolytic uremic syndrome, which is a complication from Shiga toxin producing e-coli, which has many different acronyms. All which are confusing, but that’s the one that is most commonly associated with that. And pallor would concern me because you can become anemic your platelets drop, so you can have petechiae. And then the uremia piece is kidney failure. So your urine output drops off, you become edematous. So that piece is a little bit more concerning for me too and I wouldn’t want to miss that. So we do have a source of bleeding, but let’s move in to what your decision-making was after this Dr. Olson.
Dr. Olson: We also thought about making sure she didn’t appear super anemic. So she was pale, but like I said, the family in general was pale. There were some siblings there. She had really nice color under her eyes, which was reassuring to me. And then her vital signs looked so normal that I wasn’t too concerned about an acute anemia leading to volume status problems or oxygen delivery problems. And overall, she was so well appearing that we decided not to do any labs at the time. We’d talked to Mom a lot about all of the concerning signs to keep an eye out for. Some of what you just mentioned. So if her urine output started to drop off, if she started to have more bowel movements per day and they started becoming more watery, that would also be concerning and a reason to come back.
She started to develop the pinpoint red rash. So the Petechiae you mentioned, she did not have any on exam. But we did tell Mom if she developed any of those red flag symptoms to come back and we would consider doing some of those labs, like a CBC to make sure she wasn’t too anemic. If she continued to have the bloody diarrhea or the bloody stools that she mentioned, we would talk about doing a stool PCR. And then we also talked about if she had gotten to the point where she was dehydrated, that we would have to bring her back in for IV fluids. And because they mentioned that it was bloody diarrhea, but on her history, she just was not pooping as often as they made it originally seem. She looked so well that we decided just to give them good counseling about how to make stools a little bit softer and a little less big.
And so, like I said in the beginning, Mom was concerned about the large stools with a little bit of blood in them. And so we talked to Mom a little bit about how giving a child too much fiber can make stools really, really big and really hard to pass. And that can put you at risk for things such as hemorrhoids and anal fissures. And it’s great to prevent constipation, but if you do too much, it can be a catch 22. So we talked to Mom about scaling back some of those fiber foods and adding in a little MiraLAX, which sounds counterintuitive for somebody who presents with diarrhea. But just given that she wasn’t truly having diarrhea, she was really struggling to get these stools out. So we thought that was a good first step. So that’s where we started. Mom was very comfortable with that plan, with all [00:14:00] the return precautions and scary things to look for.
And so our decision was to just monitor her for a while, see if the MiraLAX would help and then come back if any of those things develop. And I think just important things to point out in the exam that I mentioned that were negative that I specifically did on purpose, where kids who do have Crohn’s disease can present more benign in the beginning, not having that inflammatory diarrhea or inflammatory abdominal pain all the time, the waxing and waning. And so I really looked in her mouth for any type of oral ulcers. She did not have any of those. She did have that anal fissure skin tag, but if you see any like fistulas or more concerning things in her anus, that would be another reason to maybe do a little bit more exploring. I mentioned the things about the pallor. Those are just the scary things that I want to make sure I rule out on my physical exam for somebody that I’m not going to keep watching.
Dr. Fate: In that moment of time, she’s well-appearing. There’s not some of the scary symptoms like fluid depletion, weight loss, true diarrhea that would have us do an extensive lab work now. But with the right counsel, family will come back if it’s persistent and new things arise. After this history and exam, why did you decide not to get lab work?
Dr. Olson: A, she was super well-appearing during our entire visit. We talked a little bit about the pallor, but her vital signs did not really show any signs of acute blood loss leading to profound anemia. Her belly exam was benign. Her diarrhea did not seem to be as extensive as originally mentioned in the chief complaint. And so she seemed well hydrated. It did not seem like she was losing a large amount of blood. And some of those red flags symptoms that we talked about earlier on such as the petechiae or the edema or lack of urine output were really not present in this exact moment. And so we figured with Mom’s comfortability with our follow-up plan and her being so well appearing, we could watch and wait and see what happened. And if any of those red flags symptoms showed up, then she could come back to the office.
Dr. Fate: That highlights a excellent primary care topic of just having only a snapshot in time of a patient and a very sliver of one at that, because usually you have 20 minutes or 30 minutes as opposed to in the hospital where you can watch overnight, you can see how things change. And I think counseling is so important about when to come back, knowing your family as well in terms of who’s going to come back. Sometimes you want to capture as much as you can on that one visit because you’re not sure when you’ll see them again. But I think that is definitely an art of trying to give very good guidance about what worries you. And it sounds like you guys did a great job of that.
And I agree based on your history and what you’ve told me that it sounds like the fissure is the most attributable place for the bleeding. It doesn’t sound like there’s been true diarrhea based on the lack of loose stools and frequent stools. And that is something that always worries me more, if it’s acute and there’s fevers because again, we really want to think about getting a stool PCR and making sure that there’s not that dangerous kind of e-coli which can cause kidney failure and homolysis and all of that stuff. Can you give us a summary of what happened after?
Dr. Olson: We encouraged her to try MiraLAX in small doses, just to see if they could make that stool a little bit softer to help her pass easier and prevent hemorrhoids and fissures that she was experiencing. Mom did really well with that plan. They have been doing great. Her fissures, as far as I know, have not returned. And her bowel movements have been a little bit easier to pass. So in the case of bloody diarrhea, it actually ended up being large stools causing anal fissures was quite the twist.
Dr. Fate: The chief complaint can be misleading.
Dr. Olson: Yes, that’s true.
Dr. Fate: Good job discerning that and I’m glad she’s doing better. If you had a couple take home points that you want for our viewers today, what would they be?
Dr. Olson: I think it’s really Important to rule out the scary stuff. And so if she were having bloody diarrhea and we were concerned about HUS. That’s something you do not want to miss because it could lead to kidney failure and lifelong morbidity. So that’s one thing. Also discerning what you said about an acute infectious episode. So if someone has fever and acute bloody stools, or has those exposures like a waterpark or a picnic where everybody got sick. Making sure that your histories are really good to discern whether something is acute or chronic. And then one thing that I like to mention just because it came up, she is nine years old. And so she’s starting to enter puberty and always just making sure that the blood is actually coming where they think it’s coming from. Because I thought that was a great point because some people don’t think about nine-year-old girls starting their periods, but it’s something we talked about with the family, just to make sure we didn’t completely miss that.
Dr. Fate: Thank you, Dr. Olson for an excellent summary of our thought process through lower GI bleeds, as well as bloody diarrhea. With your help, we’ve cracked another case. As always, here’s a musical summation of some of our points today.
Dr. Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. For more information and additional episodes visit childrensmn.org/talkingpediatrics.