The Bottom Line from Neonates to Older Adults Michelle D Sakala MD Michael Oliphant MD Evelyn Y Anthony MD From the Department of Radiology Wake Forest Baptist Medical Center Medical Center Blvd WinstonSalem NC 27157 ID: 911241
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Slide1
Bright Red Rectal Bleeding: The Bottom Line from Neonates to Older Adults
Michelle D.
Sakala
, MD
Michael Oliphant, MD
Evelyn Y. Anthony, MD
From the Department of Radiology, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157
Address correspondence to M.D.S. (e-mail: michelle.sakala@gmail.com)
Presented as an education exhibit at the 2015 RSNA Annual Meeting
Slide2Introduction
The causes of rectal bleeding are myriad across the life span. This presentation highlights the imaging diagnosis of the most common causes of bright red rectal bleeding, with these causes stratified according to age. Imaging plays an important role in identifying the cause and site of disease, and a critical factor in imaging evaluation and interpretation is the understanding of how the differential diagnosis for rectal bleeding changes with patient age.
Causes covered include necrotizing enterocolitis, malrotation with midgut volvulus, Hirschsprung disease and milk protein allergy with enterocolitis, intussusception, complicated Meckel diverticulum, polyps, inflammatory bowel disease (ulcerative colitis and Crohn disease), diverticulosis, intestinal vascular disease with ischemia, and intestinal neoplasms. Examples will emphasize radiologic patterns, modality-specific techniques, and multimodality approaches when necessary.
Bright red rectal bleeding is never normal and may be a harbinger of diseases with high morbidity and mortality. The mortality rate in the setting of
malrotation
is reported in some series to be as high as 14%
(1)
. Approximately 10% of patients with intussusception requiring surgical reduction also require partial bowel resection
(2)
. The overall complication rate of patients undergoing surgery for inflammatory bowel disease has been reported as 27%
(3)
, and colorectal cancer is the second leading cause of cancer death in the United States
(4)
.
Slide3Offer an appropriate differential diagnosis for rectal bleeding according to patient age, concentrating on the most common causes diagnosed by using imaging.Recognize worrisome bowel gas patterns on abdominal radiographs and become familiar with the next step in imaging evaluation by using a case-based approach.
Identify key characteristics on cross-sectional imaging studies for diagnosing the cause of rectal bleeding and communicating important information for immediate medical or surgical management.
Learning Objectives
Based on Key Concepts
Slide4Neonates
Most common causes of rectal bleeding in this age group:
Neonates
(0–30 days)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Slide5Supine kidney, ureters, bladder (KUB) radiograph
Gastric distention out of proportion of distal bowel gas
Double bubble
sign: gas in stomach and proximal duodenum
Differential diagnosis classically includes duodenal atresia or web. Be suspicious of obstruction.
Neonate:
Malrotation with
Midgut
Volvulus
Abnormal or arrested rotation during development predisposing to
midgut
volvulus
About 40% of cases of malrotation are diagnosed in the 1st week of life, 50% in the 1st month, 75% in the 1st year, and 25% after the 1st year
(5)
.
Slide6Neonate: Malrotation with Midgut Volvulus
Upper gastrointestinal (GI) series (
anteroposterior
[AP])
Duodenal course
: Duodenal-
jejunal
junction does not reach the
left pedicle
or
the level of the
duodenal bulb
, indicating malrotation.As the duodenum descends, it creates a corkscrew pattern of midgut volvulus secondary to
malrotation
.
Minimal passage of contrast material into the jejunum
Upper GI series
(lateral)
Lack of retroperitoneal course of the duodenum is another sign of malrotation. The
second
through
fourth
portions of the duodenum are too anterior in this patient because of
nonfusion of the dorsal mesentery.
Slide7Gray-scale and color Doppler ultrasonographic (US) images
Swirling mesentery and vessels were visualized with US in this patient after an equivocal upper GI series.
Neonate:
Malrotation with
Midgut
Volvulus
Malrotation predisposes to midgut volvulus.
For this reason,
malrotation
in the setting of bright red rectal bleeding is an urgent finding as it may indicate ischemia caused by midgut volvulus.
Slide8Supine KUB radiograph
Pneumatosis in the right lower quadrant (most common location) is seen as
mottled bowel
and
air in the bowel wall
.
Branching lucencies
in the liver indicate
portal venous gas
.
Incidental air-filled bowel in a
left inguinal hernia
.
Neonate:
Necrotizing
Enterocolitis
Idiopathic ischemia is seen in low-birth-weight and/or premature infants (90% of cases).
Timing of presentation depends on estimated gestational age (EGA) or degree of fetal maturity. Averages are 20.2 days if born at less than 30 weeks EGA, 13.8 days if 31–33 weeks EGA, and 5.4 days if more than 34 weeks EGA
(6)
.
Slide9Most common causes of rectal bleeding in this age group:
Neonates(0–30 days)
Infants
(1 month–1 year)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Infants
Slide10Supine KUB radiograph Left lateral decubitus abdominal radiograph
Infant:
Intussusception
Soft-tissue mass
in the right hemiabdomen persists on both images.
Cecum
does not completely fill with air on the decubitus view.
Note no evidence of free air or
pneumatosis
, which, if present, would contraindicate fluoroscopic reduction.
History classically includes currant jelly stools with intermittent crampy abdominal pain. Vomiting completes triad of symptoms.
Most cases of intussusception in infants occur between 5 and 8 months, with 67% by 1 year
(7)
.
In infants, the most common cause is idiopathic. Others causes involve lead points, such as Meckel diverticulum or duplication cyst.
Right
Slide11Infant: Intussusception
US image
Target sign (also known as crescent in a doughnut sign) is characteristic. Another sign not shown is the kidney sign.
Lamellated
appearance results from
hypoechoic
bowel walls alternating with
hyperechoic
mucosa:
inner bowel (intussusceptum)
and
outer bowel (
intussuscipiens
)
.
Air-contrast enema study (AP)
Persistent
soft-tissue mass
of the
ileocolic
intussusception
The intussusception was reduced with disappearance of the soft-tissue mass.
Slide12Contrast enema study (lateral)
This patient is 7 months old in the postoperative period.
Mucosal irregularity
of the rectum suggests
ulceration,
and
thumbprinting
of the more distal
anastamosed
colon indicates
mucosal edema
.
Caution must be exercised as perforation can occur with active inflammation during enema.
Most common cause of morbidity and mortality in patients with
Hirschsprung
disease
Can occur preoperatively,
perioperatively
, and postoperatively up to several years after surgery and can be recurrent
(8)
Infant:
Enterocolitis in
Hirschsprung Disease
Slide13Prevalence of rectal bleeding from cow’s milk protein allergy is 0.16% (9), but this may be underestimated. Bleeding resolves after removing milk from diet.
Although milk protein allergy itself is not a radiologic diagnosis, associated colitis can be seen.
Infant:
Enterocolitis in Milk Protein Allergy
Supine KUB radiograph
Irregular mucosa
in the descending colon with luminal narrowing secondary to mucosal edema
Slide14Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Toddlers
Most common causes of bright red rectal bleeding in this age group:
Slide15Toddler: Meckel Diverticulum
Painless bright red rectal bleedingCan be a lead point in intussusception or can be inflamed (diverticulitis)
Rule of 2’s: Affects 2% of the population, complications occur by age 2 years, are 2 inches long, are located 2 feet proximal to the ileocecal valve, and two of three have ectopic mucosa (two types, gastric and pancreatic).
Axial contrast material–enhanced computed tomographic (CT) images
(Selected images arranged cranial to caudal)
Meckel diverticulum
originating from the distal ileum with a blind-ending tubular structure in the right pelvis
Slide16Nuclear medicine scintigram with 99m
Tc pertechnetate
Focal uptake
in the left pelvis matched the timing and intensity of gastric uptake and persisted over time, consistent with
Meckel diverticulum
.
Toddler:
Meckel Diverticulum
The bleeding occurs secondary to presence of ectopic gastric mucosa, which releases acid, or ectopic pancreatic tissue, which releases enzymes. The mucosa becomes eroded and bleeds.
Only those with ectopic gastric mucosa are avid with technetium 99m (
99m
Tc)
pertechnetate
.
Slide17School-aged Children
Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
School-aged
Children
(5–12 years)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Intussusception
Meckel diverticulum
Polyps
Most common causes of bright red rectal bleeding in this age group:
Slide18School-aged Children: Intussusception
Although most intussusceptions occur by age 1 year, intussusception can be seen into childhood.
The most common cause is lymphoid hyperplasia in school-aged children.
A pathologic lead point must still be considered. The most common lead points are Meckel diverticulum, duplication cyst, polyp, and lymphoma (in decreasing order)
(7)
.
Left lateral decubitus abdominal radiograph
Soft-tissue mass
in the right lower quadrant and incomplete gaseous distention of the
cecum
Gray-scale US image
The classic target sign helps make the diagnosis.
This patient was surgically treated.
Pathologic findings showed lymphoid hyperplasia.
Right
Slide19School-aged Children: Polyp(s)
Solitary juvenile polyp is the most common in children. Juvenile refers to the histologic type and not the age of the patient
(10)
.
Usually benign if solitary. However, multiple polyps, such as in familial adenomatous polyposis syndromes, have increased cancer risk in teenagers and adults. Recall that adenomatous polyps are precancerous.
Supine abdominal radiograph
Rounded
soft-tissue mass
projects over bowel lumen in the left upper quadrant.
Gray-scale US image
Intussusception was initially suspected and thus US was performed.
A
mixed solid and cystic
mass
is seen. The mass was hypervascular (not shown). The classic target sign is not present to suggest intussusception.
Slide20Air-contrast enema study (AP)
Although intussusception was considered less likely, intussusception remained in the differential diagnosis, and air-contrast enema examination was performed.The rounded
soft-tissue mass
persisted with air refluxing proximal to the mass.
Axial contrast-enhanced
CT image
Intraluminal
enhancing soft-tissue mass
in the left
hemiabdomen
was identified in the splenic flexure.
At colonoscopy, the finding was a pedunculated polyp. Pathologic findings revealed a juvenile polyp.
School-aged Children:
Polyp(s)
Slide21Teenagers
(13–19 years)Inflammatory bowel disease
Polyps
Teenagers
Most common causes of bright red rectal bleeding in this age group:
Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
School-aged
Children
(5–12 years)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Intussusception
Meckel diverticulum
Polyps
Slide22Teenager: Inflammatory Bowel Disease—
Ulcerative Colitis
Ulcerative colitis causes diarrhea with blood and mucus.
Ulcerative colitis is limited to the rectum and colon, but backwash ileitis can occur.
Involvement is always contiguous without skip lesions, in contrast to the presence of skip lesions in the majority of cases of Crohn disease.
Axial contrast-enhanced CT image
Bowel wall thickening
Mucosal
hyperenhancement
Adjacent
inflammatory stranding
and
free fluid
Note these are acute findings involving the rectosigmoid colon.
Involvement was
pancolonic
(not shown).
*
Slide23Teenager: Inflammatory Bowel Disease—Crohn Disease
Coronal contrast-enhanced CT image
Bowel
wall thickening
Mucosal
hyperenhancement
Inflammatory stranding
about the bowel wall
Mesenteric hyperemia (comb sign)
Crohn disease can have greater bowel wall thickening than ulcerative colitis because of
transmural
inflammation versus inflammation of the mucosa and submucosa in ulcerative colitis.
Skip lesions occur from mouth to anus.
*
Slide24Teenager: Inflammatory Bowel Disease—Crohn Disease
T1-weighted contrast-enhanced magnetic resonance images (repetition time, 4.36 msec; echo time, 2.06
msec
)
(Selected images arranged cranial to caudal)
Discontinuous skip lesions
involving the transverse, descending, and sigmoid colon with
intervening normal colon
at the splenic flexure
Mucosal
hyperenhancement
and bowel wall thickening reflect active inflammation.
Slide25Teenagers (13–19 years)
Young Adults(19–45 years)
Inflammatory bowel disease
Polyps
Inflammatory
bowel disease
Polyps
Young Adults
Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
School-aged
Children
(5–12 years)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Intussusception
Meckel diverticulum
Polyps
Most common causes of bright red rectal bleeding in this age group:
Slide26Young Adult: Inflammatory Bowel Disease—Ulcerative Colitis
This patient with pancolonic chronic ulcerative colitis had refractory bleeding necessitating total colectomy.
Axial contrast-enhanced CT image
Bowel
wall thickening
Mild
mucosal
hyperenhancement
Mild
inflammatory stranding
Mesenteric hyperemia
*
*
Slide27*
Young Adult:
Inflammatory Bowel Disease—
Ulcerative Colitis
*
Coronal contrast-enhanced CT image
Mild
wall thickening
Mild
mucosal
hyperenhancement
Mild
inflammatory stranding
about the bowel wall
Mesenteric hyperemia (comb sign)
This patient with
pancolonic
chronic ulcerative colitis had refractory bleeding necessitating total colectomy.
Slide28*
Young Adult:
Inflammatory Bowel Disease—
Ulcerative Colitis
Sagittal contrast-enhanced CT image
Bowel
wall thickening
Mild
mucosal
hyperenhancement
Mild
inflammatory stranding
This patient with
pancolonic
chronic ulcerative colitis had refractory bleeding necessitating total colectomy.
Slide29Teenagers
(13–19 years)
Young Adults
(19–45
years)
Older Adults
(45 years+)
Inflammatory bowel disease
Polyps
Inflammatory
bowel disease
Polyps
Tumor
Polyps
Diverticulosis
Ischemic
colitis
Older Adults
Most common causes of bright red rectal bleeding in this age group:
Neonates
Infants
Toddlers
School-Aged Children
Malrotation with Midgut
Volvulus
Necrotizing Enterocolitis
Necrotizing
Enterocolitis
Intussusception
Intussusception
Meckel’s Diverticulum
Intussusception
Meckel’s Diverticulum
Polyps
Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
School-aged
Children
(5–12 years)
Malrotation with
midgut
volvulus
Necrotizing
enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Intussusception
Meckel diverticulum
Polyps
Slide30Older Adult: Polyps
Virtual CT
colonoscopic
images
Pedunculated
polyp
of the sigmoid colon
Pathologic findings showed tubular adenoma.
Case courtesy of James
Perumpillichira
, MD, Wake Forest Baptist Medical Center, Winston-Salem, NC
Polyps can manifest as either bright red blood per rectum or as positive guaiac test results. Optical colonoscopy is the preferred method of evaluation in the acute or urgent setting and is commonly used for colon cancer screening. Imaging methods such as CT colonoscopy and double-contrast barium enema (DCBE) examination are performed only for colon cancer screening in those with low-to-average risk of colon cancer.
Slide31DCBE and
colonoscopic
studies
Polyp
with a thin stalk and tufted head
Pathologic findings showed
pedunculated adenoma.
Older Adult:
Polyps
Patients with low-to-average colon cancer risk and positive fecal occult blood test results may undergo:
Colonoscopy
Virtual CT colonoscopy (American College of Radiology [ACR] Appropriateness Criteria of 9, usually appropriate)
DCBE examination (ACR Appropriateness Criteria of 6, may be appropriate)
(11)
.
Case courtesy of David
Ott
, MD, Wake Forest Baptist Medical Center, Winston-Salem, NC
Slide32DCBE and colonoscopy studies Polyp with cauliflower appearance and broad base
Pathologic findings showed tubulovillous adenoma.
Older Adult:
Polyps
Patients with low-to-average colon cancer risk and positive fecal occult blood test results may undergo:
Colonoscopy
Virtual CT colonoscopy (ACR Appropriateness Criteria of 9, usually appropriate)
DCBE examination (ACR Appropriateness Criteria of 6, may be appropriate)
(11)
.
Case courtesy of David
Ott
, MD, Wake Forest Baptist Medical Center, Winston-Salem, NC
Slide33Older Adult: Tumor
Axial contrast-enhanced CT images
Heterogeneously enhancing
mass
Rounded metastatic lymph
nodes
Adjacent inflammatory
stranding
CT can be performed as initial workup for any type of rectal bleeding or for staging when a mass is found at colonoscopy.
Slide34Maximum intensity projection from CT angiography Active bleeding
into the hepatic flexure from an identifiable source vesselNearby diverticulae
(
noninflamed
)
Patient went on to undergo angiography and embolization.
Older Adult:
Diverticulosis
The most common site of diverticulosis is the sigmoid colon, but the most common site of bleeding from diverticulosis is the right colon.
Mucosa and submucosa show
outpouching
at the location of the vasa recta, the weakest part of the wall.
Slide35Coronal contrast-enhanced CT image Mural edema
with thickened bowel wall of the hypoenhancing left colon. In early ischemia, however, the wall can be
hyperenhancing
.
Nonenhancing
mesenteric vessels
Surrounding inflammatory stranding and/or fluid
Note that positive oral contrast material can obscure visualization of active contrast material extravasation and is not preferred when evaluating GI bleeding.
Older Adult:
Ischemic Colitis
During
hypoperfusion
, the left colon and/or either watershed zone can be affected.
Watershed zones: splenic flexure and rectosigmoid colon junction
*
Slide36Summary
Teenagers (13–19 years)
Young Adults
(19–45
years)
Older Adults
(45 years+)
Inflammatory bowel disease
Polyps
Inflammatory
bowel disease
Polyps
Tumor
Polyps
Diverticulosis
Ischemic colitis
Most common causes of bright red rectal bleeding change with patient age:
Neonates
(0–30 days)
Infants
(1 month–1 year)
Toddlers
(1–5 years)
School-aged
Children
(5–12 years)
Malrotation with
midgut volvulusNecrotizing enterocolitis
Enterocolitis
Intussusception
Intussusception
Meckel diverticulum
Intussusception
Meckel diverticulum
Polyps
Slide37The causes of bright red rectal bleeding change with patient age. Neonates and infants are more likely to have a congenital cause.Toddlers and school-aged children are more likely to have an infectious and/or inflammatory process in addition to congenital abnormalities.Teenagers and young adults are found to have inflammatory and/or autoimmune conditions.
Older adults most commonly have neoplasms, among other degenerative causes.
Summary
Conclusion
Accurate interpretation of imaging studies requires a knowledge of differential diagnoses based on age.
Detecting any of these diseases early can substantially improve outcomes.
The index of suspicion for urgent intervention improves when the radiologist has robust familiarity with the possibilities and complications of rectal bleeding across the patient age spectrum.
Slide38Fox VL. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29:37–66.
Gore RM, Levine MS. Textbook of gastrointestinal radiology. 4th ed. Vol
1. Philadelphia: W.B. Saunders, 2015.
O'Hara SM. Acute gastrointestinal bleeding.
Radiol
Clin
North Am 1997;35:879-95.
Recommended Reading
Slide39Messineo A, MacMillan JH, Palder
SB, Filler RM. Clinical factors affecting mortality in children with malrotation of the intestine. J Pediatr Surg. 27 (1992):1343-1345. Link to abstract.
Fallon SC, Lopez ME, Zhang W, et al. Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction. J
Pediatr
Surg. 48 (2013):1032-1036.
Link to abstract.
Ba’ath ME,
Mahmalat
MW,
Kapur
P, et al. Surgical management of inflammatory bowel disease. Arch Dis Child. 92 (2007):312-316.
Link to article.
American Cancer Society: Cancer facts and figures 2016. American Cancer Society. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. Accessed February 1, 2016.
Link to PDF.
Bensard
DD, Acker SN,
Kulungowski
AM. Intestinal
malrotation
. Medscape. WebMD.
http://emedicine.medscape.com/article/930313-overview#a6. Updated October 8, 2015. Accessed October 27, 2015. Link to
Web
site.
Springer SC, Anibale DJ. Necrotizing
enterocolitis. Medscape.
WebMD. http://emedicine.medscape.com/article/977956-overview#a6. Updated November 14, 2014. Accessed October 27, 2015. Link to
Web
site.
Applegate KE. Intussusception in children: evidence-based diagnosis and treatment. Pediatr Radiol 39.Suppl 2 (2009): S140-3. Link to abstract.Frykman PK, Short SS. Hirschsprung-associated enterocolitis: prevention and therapy. Seminars in Pediatric Surgery 21.4 (2012): 328-335. Link to article.Elizur A, Cohen M, Goldberg MR, Rajuan
N, Cohen A, Leshno M, Katz Y. Cow's milk associated rectal bleeding: a population based prospective study.
Pediatr Allergy Immunol
23.8 (2012): 766-70. Link to abstract.
Durno
CA. Colonic polyps in children and adolescents. Can J
Gastroenterol
21.4 (2007): 233-239.
Link to abstract.
Expert Panel on Gastrointestinal Imaging: Judy Yee, David H. Kim, Max P. Rosen,
Tasneem
Lalani
, Laura R.
Carucci
, Brooks D. Cash, Barry W.
Feig
, Kathryn J. Fowler, Douglas S. Katz, Martin P. Smith,
Vahid
Yaghmai
. Colorectal cancer screening. ACR Appropriateness Criteria
.
American College of Radiology. https://acsearch.acr.org/docs/69469/Narrative/. Published 1998. Last review date 2013. Accessed October 27, 2015.
Link to document.
References