Rectal Bleeding In Infants Research Articles

Lactobacillus rhamnosus Helps to Reduce the Duration of Bleeding in Breastfed Infants with Allergic Proctocolitis.

Background: Cow's milk protein allergy (CMPA) is the most common food allergy in infants. The current standard of care (SOC) involves eliminating the allergen from both the infant's and mother's diet for 2-4 weeks. The purpose of this study is to assess the effectiveness of Lactobacillus rhamnosus (Ramnoflor) in reducing the duration of bleeding in these infants. Methods: This randomized clinical trial was conducted at Bahrami Children's Hospital on breastfed infants who were diagnosed with CMPA and had a positive occult blood (OB) test. Patients were randomly assigned to either the control or case groups. All patients received SOC therapy, with the case group receiving Ramnoflor and the control group receiving a placebo. Data were recorded on the checklist, and the children were followed and visited three times during the study, with an OB assessment at each visit. Results: The study enrolled 48 infants. Among the infants in the case group, the OB test was positive in four cases (8.3%) on the fifth day. However, there were no positive cases on the 14th and 30th days. The prevalence of this test was significantly lower in patients who received probiotics compared to the control group on the fifth day (p < 0.001). There were no positive OB tests on the 14th and 30th days in any of the groups, and no significant difference was observed between the groups. Conclusion: The addition of L. rhamnosus to SOC therapy led to a decrease in the duration of rectal bleeding in infants with CMPA compared to the control group.

The infant with rectal bleeding

Although rectal bleeding in infants is often minor, either as the result of swallowed maternal blood or anal fissure there is the potential for the patient to be significantly unwell and require urgent management. This article discusses common and rarer but not to be missed causes of rectal bleeding in infants and their immediate management. The aim is to provide a guide for the general paediatrician.

Rectal Bleeding and Cow’s Milk Protein-induced Allergic Proctocolitis: A Prospective Study

To assess time to resolution of food protein–induced allergic proctocolitis (FPIAP).In this study, researchers evaluated 76 infants aged <4 months with rectal bleeding (RB) referred to the pediatric gastrointestinal department at Trousseau Hospital in Paris, France, between May 2014 and December 2017. Only infants whose RB responded to a cow’s milk elimination diet were included in the study.This was a prospective cohort of infants with concern for cow’s milk protein (CMP) allergy who had resolution of RB with CMP elimination. Exclusion criteria included RB because of another etiology and exclusively breastfed infants. A total of 2 to 8 weeks after resolution of RB, CMP oral food challenge (OFC) was completed. If FPIAP was confirmed, OFC was repeated every 2 months after the age of 4 months to assess the time to tolerance of CMP. Ongoing FPIAP CMP was defined as RB, behavioral change, diarrhea, and vomiting. Tolerance was defined as CMP daily without symptoms.Only 31% of the cohort failed OFC at initial diagnostic challenge, meaning that over two-thirds of infants who initially responded to CMP exclusion did not have return of symptoms on rechallenge just weeks later. Of the patients confirmed to have FPIAP CMP, the median age of tolerance was determined to be 6.8 months, with >75% of the cohort tolerant by 10 months. Infants with a first-degree family history of atopic disease developed tolerance later (8.9 months versus 5.1 months).In this work, it was confirmed that the majority of RB in infants is likely not related to FPIAP CMP. This study also revealed that the time to resolution might be earlier than previously thought.Although there are no solid guidelines on introduction of CMP in presumed FPIAP CMP, the majority of patients exclude CMP until approximately 1 year. In this study, it was found that only one-third of RB before 4 months was due to FPIAP. Of those with FPIAP, CMP could be challenged earlier and at more frequent intervals depending on family wishes. A major limitation of this study is that exclusively breastfed infants were excluded and the lack of information on maternal diet in those who were nursing.

Feeding-based treatment of allergic proctocolitis and associated clinical outcomes

Allergic colitis (AC) is one of the most common etiologies of rectal bleeding in infants aged one to six months. The aim of this study is to apply step-by-step dietary restrictions in the mother's diet or change of infant formula fed thereby, to evaluate the subsequent clinical response. Sixty healthy infants whose clinical and evaluation results indicated proctocolitis in our outpatient gastroenterology clinic were included in this. They were divided into three groups according to the type of feeding; group 1 were exclusively breast fed, group 2 were exclusively formula fed and group 3 were fed with combination of both. In breast feeding women, discontinuation was allergenic food was studied in four stages; cow-related dairy products, soy, sesame and fast food (stage A), egg (stage B), corn, nuts and fish (stage C) and wheat (stage D). Sixty newborns with age at symptom onset 3 days-20 days participated in the study. Up to the time of our initial evaluation, the mean age and weight of infants was 73.34±1.00 day and 3292.71±367.93g, respectively. There was no significant difference in sex and the type of labor between the groups. Thirty-three infants had a history of eczema and the parents of 47 infants had a history of allergy, with the greatest prevalence in group one. Rectal bleeding in 50% of infants was halted after the elimination of allergenic feed in mother (15 in stage A, 8 in stage B and 7 in stage C). Ten infants needed extensive hydrolyzed formula and 20 needed amino acid-based formulas. There is no need for immediate use of amino acid or extensive hydrolyzed formulas in the first stage of blood in stool, perhaps discontinuing allergenic food in mothers could be the primary measure.

Allerjik Proktokolit Öngörüsünde Hematolojik Parametrelerin Kullanımı

Aim: Allergic proctocolitis (AP) is a common cause of rectal bleeding in infants. There is no diagnostic tool specific to the disease. The aim of the study was to evaluate hemogram parameters as a marker of inflammation in patients with AP.Material and Methods: The files of patients who were exclusively breastfed and diagnosed as food protein induced AP were examined retrospectively. A hundred and fifty patients diagnosed with AP were included in the study. The same number of healthy babies formed the control group. Parameters in complete blood count were compared between patient and control groups. Rectosigmoidoscopic examination was performed to confirm the diagnosis in patients who could not achieve complete improvement with diet therapy, and hemogram parameters were evaluated according to eosinophilic infiltration in biopsies.Results: The mean platelet volume (MPV) values (p&amp;lt;0.001) and eosinophil percentages (p=0.001) of the AP group were higher than the control group. The mean hemoglobin values of the AP group were statistically significantly lower than the control group (p&amp;lt;0.001). No statistically significant difference was found between patient and control groups in terms of white blood cell (WBC) count, platelet count, platelet distribution width (PDW) and neutrophil/lymphocyte ratio (NLR). WBC count, platelet count, hemoglobin, MPV and C-reactive protein (CRP) values were similar between groups of patients according to the number of eosinophils in colon biopsies.Conclusion: We observed a significantly higher MPV values and eosinophil percentages in patients with AP. These parameters maybe helpful in diagnosis of AP.

Allergic Proctocolitis Is a Risk Factor for Functional Gastrointestinal Disorders in Children

To test the hypothesis that allergic proctocolitis, a cause of self-limiting rectal bleeding in infants, can predispose to the development of functional gastrointestinal disorders (FGIDs) later in childhood. We studied a cohort of 80 consecutive patients diagnosed with allergic proctocolitis. Their sibling or matched children presenting to the same hospital for minor trauma served as controls. Parents of the patients with allergic proctocolitis and controls participated in a telephone interview every 12 months until the child was at least 4 years old. At that time, they were asked to complete the parental Questionnaire on Pediatric Gastrointestinal Symptoms, Rome III version. Sixteen of the 160 subjects (10.0%) included in the study met the Rome III criteria for FGIDs. Among the 80 patients with allergic proctocolitis, 12 (15.0%) reported FGIDs, compared with 4 of 80 (5.0%) controls (P = .035). After adjustment for age and sex, the OR for FGIDs in allergic proctocolitis group was 4.39 (95% CI, 1.03-18.68). FGIDs were significantly associated with iron deficiency anemia, duration of hematochezia, and younger age at presentation. In a multivariate analysis, only the duration of hematochezia was significantly associated with the development of FGIDs (OR, 3.14; 95% CI,1.72-5.74). We have identified allergic proctocolitis as a new risk factor for the development of FGIDs in children. Our data suggest that not only infection, but also a transient early-life allergic inflammatory trigger may induce persistent digestive symptoms, supporting the existence of "postinflammatory" FGIDs.

Single and multiple food allergies in infants with proctocolitis

BackgroundFood protein-induced allergic proctocolitis is a frequent cause of rectal bleeding in infants. Characteristics of infants with multiple food allergies have not been defined. ObjectiveThis study aimed to identify characteristics of infants with proctocolitis and compare infants with single and multiple food allergies. MethodsA total of 132 infants with proctocolitis were evaluated retrospectively. All of the infants were diagnosed by a paediatric allergist and/or a paediatric gastroenterologist according to guidelines. Clinical features of the infants, as well as results of a complete blood count, skin prick test, specific immunoglobulin E, and stool examinations or colonoscopy were recorded. ResultsCow's milk (97.7%) was the most common allergen, followed by egg (22%). Forty-five (34.1%) infants had allergies to more than one food. Infants with multiple food allergies had a higher eosinophil count (613±631.2 vs. 375±291.9) and a higher frequency of positive specific IgE and/or positive skin prick test results than that of patients with a single food allergy. Most of the patients whose symptoms persisted after two years of age had multiple food allergies. ConclusionsThere is no difference in clinical presentations between infants with single and multiple food allergies. However, infants with multiple food allergies have a high blood total eosinophil count and are more likely to have a positive skin prick test and/or positive specific IgE results.

Iron Requirements for Infants with Cow Milk Protein Allergy

H istorically, cow milk has been used as a major source of protein and balanced nutrition for infants and children in resource-rich and resource-constrained countries. It is a rich source of energy, protein, and calcium. It is also an important source of fat; many of its fatty acids are readily metabolized to essential omega-3 fatty acids. Regular consumption of milk during childhood has been shown to enhance bone density later in life. However, reliance upon whole pasteurized cow milk as the sole or major source of nutrition for infants during the first year of life can increase the risk for iron deficiency and, in extreme cases, iron-deficient anemia (IDA) for a number of reasons. In 1972, Woodruff et al showed that 7 of 12 infants (ages 7-17 months) with IDA who ingested between 720 and 1920 mL whole milk daily had higher albumin turnover rates than a group of 5 normal infants. Parenteral iron had no effect on albumin turnover, but replacing whole milk with reconstituted evaporated milk or soy formula decreased the high albumin turnover rates to normal levels, suggesting that large amounts of cow milk protein could result in iron and protein loss in the gastrointestinal tract. Cow milk contains low levels of ascorbic acid, a factor that increases iron absorption, and certain proteins that negatively impact iron absorption. Cow milk contains about 4 times more calcium than human milk, and calcium negatively impacts iron absorption. Furthermore, cow milk has a higher protein concentration than human milk, and ingestion of large amounts can lead to metabolic and fluid imbalances, particularly in children with febrile illnesses. Thus, several entities have recommended against whole cow milk ingestion until 9-12 months and then, only when given in moderate amounts in conjunction with appropriate complementary foods.

Non–IgE-mediated gastrointestinal food allergy

Non-IgE-mediated gastrointestinal food-induced allergic disorders (non-IgE-GI-FAs) account for an unknown proportion of food allergies and include food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), and food protein-induced enteropathy (FPE). Non-IgE-GI-FAs are separate clinical entities but have many overlapping clinical and histologic features among themselves and with eosinophilic gastroenteropathies. Over the past decade, FPIES has emerged as the most actively studied non-IgE-GI-FA, potentially because of acute and distinct clinical features. FPIAP remains among the common causes of rectal bleeding in infants, while classic infantile FPE is rarely diagnosed. The overall most common allergens are cow's milk and soy; in patients with FPIES, rice and oat are also common. The most prominent clinical features of FPIES are repetitive emesis, pallor, and lethargy; chronic FPIES can lead to failure to thrive. FPIAP manifests with bloody stools in well-appearing young breast-fed or formula-fed infants. Features of FPE are nonbloody diarrhea, malabsorption, protein-losing enteropathy, hypoalbuminemia, and failure to thrive. Non-IgE-GI-FAs have a favorable prognosis; the majority resolve by 1 year in patients with FPIAP, 1 to 3 years in patients with FPE, and 1 to 5 years in patients with FPIES, with significant differences regarding specific foods. There is an urgent need to better define the natural history of FPIES and the pathophysiology of non-IgE-GI-FAs to develop biomarkers and novel therapies.

Food intolerance and mucosal inflammation

Most infants are immunologically active and are able to develop a tolerance to oligoclonal antigens by producing IgA, along with activation of regulatory T cells, in early infancy. Cytokines and their signaling molecules are important mediators in the intestine, regulating both oral tolerance and mucosal inflammation. This system works efficiently in most individuals, but for an as yet undefined reason, some people react to food and other proteins as though they were pathogens, with induction of chronic inflammation in the mucosa. The adverse reaction caused by ingested foods is defined as food intolerance. The clinical features of food intolerance include vomiting, diarrhea, bloody stool, eczema, failure to thrive, and a protean range of other symptoms. Intolerance can be divided into two categories depending on whether or not they are immunologically mediated. Food intolerance and mucosal inflammation are deeply related because tolerance cannot be established when there is an inflammation in the intestinal mucosa. Mast cells, eosinophils, mucosal lymphocytes, and epithelial cells are deeply involved and related to each other in the development of mucosal inflammation. Meanwhile, rectal bleeding in infancy is related to lymphoid hyperplasia with eosinophil infiltration into the colonic mucosa facilitated by C-C motif ligand 11 (CCL11, known as eotaxin-1) and C-X-C motif chemokine ligand 13 (CXCL13). Rectal bleeding in infancy may not be simply caused by allergic reactions against specific antigens, but may be due to migrated lymphocytes developing immunological tolerance; including IgA synthesizing, in the intestinal mucosa.

Outcome of infants presenting rectal bleeding: a retrospective study in a single institution.

Although rectal bleeding in infancy (RBI) is not a rare phenomenon, the clinical course of RBI is not fully understood. To investigate the outcome and pathogenesis of RBI, especially when concomitant with food-protein-induced proctocolitis (FPIP) and neonatal transient eosinophilic colitis (NTEC), 22 neonates with rectal bleeding with FPIP and NTEC from January 2008 to June 2012 were enrolled and their clinical course and mechanisms of inflammation were examined. Thirteen infants showed rectal bleeding after feeding and were diagnosed with FPIP, and nine infants showed rectal bleeding before feeding and were diagnosed with NTEC. Elevated peripheral white blood cell (12,685 ± 3754/μl and 30,978 ± 16,166/μl) and eosinophil (1084 ± 816/μl and 4456 ± 3341/μl) were confirmed in FPIP and NTEC, respectively. Colonoscopy revealed nodular lymphoid hyperplasia, a pale mucosal surface and oozing with diffuse infiltration of neutrophils, lymphocytes, and eosinophils in both groups. Reverse transcription polymerase chain reaction analysis revealed enhanced expression of the interleukin-6, CCL11, and CXCL13 genes, where CXCL13 expression was more prominent in FPIP. Mucosal infiltration by CD3- and immunoglobulin-A- but not immunoglobulin-E-positive cells was confirmed. Among them, only one infant with FPIP developed milk allergy, whereas none with NTEC had developed milk allergy at the age of 1 year. FPIP in infancy and NTEC are similar diseases and interleukin-6, CCL11, and CXCL13 may play a major role in the pathogenesis of rectal bleeding. Although the involvement of allergic reaction is possible, milk allergy was not a common outcome after 1 year of follow up.

Cow's milk associated rectal bleeding: a population based prospective study

Isolated rectal bleeding in infants is often attributed to the consumption of cow's milk. However, the prevalence of this condition has not been described, and its preferred diagnostic methods and management are controversial. In a prospective population-based study following 13,019 children from birth, 21 infants with isolated rectal bleeding attributed to cow's milk protein consumption were identified. Following evaluation, parents were encouraged to resume cow's milk protein and infants were followed for reappearance of symptoms and thereafter for 6 yr. In addition, infants with rectal bleeding were compared to a control group of healthy infants. The prevalence of isolated rectal bleeding attributed to cow's milk consumption was 0.16%. All infants were asymptomatic within days of dietary modifications. Eleven of the 14 infants (78.5%) whose parents reintroduced cow's milk protein to their diet following our evaluation tolerated it with no adverse effects. Those 11 infants were significantly younger at initial consumption of cow's milk protein (6.7 ± 1.6 months) compared to those who continued elimination diet (17.7 ± 9.2 months), (p = 0.002) while their 1-yr hemoglobin levels were comparable (p = 0.98). No risk factors for rectal bleeding were identified. The prevalence of isolated rectal bleeding attributed to cow' milk is low. The condition is generally benign and resolves quickly with elimination diet. Reintroduction of cow's milk following resolution of symptoms is often well tolerated and is recommended for confirming the diagnosis and avoiding prolonged unnecessary elimination diets.

Rectal Bleeding in Infancy: Clinical, Allergological, and Microbiological Examination

Rectal Bleeding in Infancy: Clinical, Allergological, and Microbiological Examination

Prevalence and Outcome of Allergic Colitis in Healthy Infants with Rectal Bleeding: A Prospective Cohort Study

Allergic colitis is often diagnosed clinically in healthy infants with rectal bleeding and often treated with costly hypoallergenic formula. The true prevalence of allergic colitis is unknown. We tested the hypothesis that allergic colitis is overdiagnosed in healthy infants with rectal bleeding. The authors also determined whether rectal bleeding in infants without allergic colitis would resolve without diet change. For the purposes of this study, allergic colitis was defined histologically as colonic mucosa with >or= 6 eosinophils per high power field and/or eosinophils in colonic crypts or muscularis mucosae. We surveyed all 56 Ohio NASPGHAN members to determine standard practice regarding the evaluation of rectal bleeding in infants. In addition, infants <or= 6 months old with rectal bleeding were recruited from the referral area of Cincinnati Children's Hospital Medical Center. All infants underwent flexible sigmoidoscopy with biopsies at 5, 10 and 15 cm. Formula or maternal diet was changed only for infants with histologic findings of allergic colitis as defined. Study subjects were followed for 9 weeks. In the survey of NASPGHAN members, 84% indicated they would empirically change the diet of an infant with rectal bleeding to treat presumed allergic colitis. In our study population, however, only 14 of 22 (64%; 95% confidence interval, 41-83) infants with rectal bleeding had allergic colitis. Five (23%) had normal biopsies and three (14%) had nonspecific colitis. Rectal bleeding in all infants with normal biopsies or nonspecific colitis resolved without diet change except for 1 infant subsequently diagnosed with infantile inflammatory bowel disease. A significant proportion of infants with rectal bleeding may not have allergic colitis and may undergo unnecessary, expensive formula or maternal diet changes that may discourage breast-feeding.

53 Infantile Allergic Colitis: A Heterogenous T-Helper Type 1/ T-Helper Type 2 Food Mediated Mucosal Inflammation?

Background: Allergic colitis (AC) is a well recognised cause of rectal bleeding in infancy. Dietary antigens have been clinically implicated, in particular, cow's milk protein (CMP). The underlying immune mechanism remains elusive. The aim of the study is to characterise the systemic and gut mucosal T-helper type1/ type 2 (Th1/Th2) cytokine profile in infants with allergic colitis and, to correlate the clinical CMP sensitivity with in vitro response.

Intussusception in a Young Adult With Bloody Diarrhoea

Bloody diarrhoea is a common presenting symptom in acute surgery, medicine and also in out-patient clinics. Intussusception, although a common cause of small bowel obstruction and rectal bleeding in infants, is rare in adults. In contrast to paediatric cases, where the majority can be treated by pneumatic or hydrostatic reduction, the vast majority of adult cases of intussusception are due to a tumour of some kind and will require operation and resection. Diagnostically plain radiology, CT, ultrasound and endoscopy are useful since the clinical picture is often unclear. We present a case of a young man who presented with acute bloody diarrhoea. The diagnosis was made colonoscopically and he was treated surgically. The case underlines the need for surgeon to maintain an open mind when investigating unexceptional symptoms.

Clinical Quiz

A 4-year-old girl had a 3-month history of passing red blood per rectum and lower abdominal pain. Colonoscopy revealed erythematous rectal and distal sigmoid colon mucosa with a chronic nonspecific inflammatory cell infiltrate in the biopsy tissue specimen. Hemoglobin, leukocyte count, platelet count, and C-reactive protein were all normal. The symptoms recurred after 2 years, when colonscopy and rectal mucosal biopsy findings were unchanged. Hydrocortisone enemas were again prescribed. Follow-up was unsatisfactory, and the family failed to attend several hospital appointments. The patient was referred again at 14 years of age with a 2-year history of a dull ache in the lower abdomen that became worse after a bowel movement, especially if she was moving around. She also reported tenesmus. She would strain for half an hour and pass a small amount of stool and red blood. The blood would continue to drip for a couple of hours after a bowel movement. Menarche occurred when the patient was aged 12 years, with periods that were regular but heavy and associated with flooding and dysmenorrhea. The rectal bleeding showed no cyclical fluctuation but worsened after menarche. Investigation revealed hemoglobin of 7.2 g/dl, mean corpuscular volume of 74 fl, leukocyte count of 14 × 109/l, and erythrocyte sedimentation rate 29 mm/hr. Prothrombin time and partial thromboplastin time were normal. The colonoscopy examination showed erythematous rectal and distal sigmoid mucosa with dilated tortuous vessels (Fig. 1). There were several raised, flat-topped, bluish mucosal lesions in the proximal sigmoid and descending colon. There were crypt abscesses, chronic inflammatory cell infiltration, and fibrosis of lamina propria seen in rectal mucosal tissue specimens. Sigmoid and descending colon biopsy specimens were histologically normal. The patient was treated with senna and oral iron. Mesenteric angiography was normal but a technetium 99–labeled erythrocyte scan showed an abnormal focus of uptake in the abdomen.FIG. 1.A: What is the diagnosis? B: What further investigations should be conducted? Answer: The patient had extensive low-flow venous malformations of the rectum and distal colon. Ultrasound examination showed dilated venous channels around the rectum and uterus that were confirmed by computed tomographic scan (Fig. 2A). Magnetic resonance imaging showed widespread serpiginous varices within the pelvis surrounding the uterus and bladder adnexa extending toward the rectum (Fig. 2B). The wall was thick with prominent vessels in the rectum and perianal area.FIG. 2.Figure 2: ContinuedComment: Venous malformations of the rectum are uncommon lesions that present complex management problems (1). Most lesions become symptomatic with rectal bleeding in infancy or childhood. Many of these patients are treated for colitis for years before the correct diagnosis is made. The usual symptom is painless bleeding per rectum and occasional tenesmus or abdominal pain. These patients may have chronic constipation and rectal prolapse. Occasionally, venous malformations affect the sigmoid and descending colon in addition to the rectum. Venous malformations of the rectum have been described as “diffuse cavernous hemangiomas.” Mulliken et al. divided vascular lesions into pediatric hemangiomas and vascular malformations. Unlike hemangiomas, vascular malformations do not proliferate in the first few months of life, and growth is commensurate with that of the child. They may contain a combination of venous, lymphatic, capillary, or arterial components. This patient had extensive low-flow venous malformations. Several treatment options have been tried in such patients, including sclerotherapy, surgery, and radiation therapy. These are associated with significant morbidity and mortality and should be reserved for patients unable to maintain hemoglobin above 10 g/dl when treated with iron therapy and stool softeners.

Cow's milk enteropathy: Surgical pitfalls

Background: Cow's milk-induced intestinal bleeding is a well-recognized cause of rectal bleeding in infancy. The authors report on 5 older children who presented with either visible rectal bleeding or profound anemia associated with occult intestinal bleeding secondary to cow's milk enteropathy. Methods: Five children (3 boys and 2 girls) aged between 20 months and 9 years were referred for further investigation of gastrointestinal bleeding. Two had been investigated previously on multiple occasions, and both had undergone laparotomies with negative results. Further investigations showed evidence of allergic colitis in 3 detected only on proximal colonic biopsy findings. Results: In all cases, bleeding resolved completely after instituting a cow's milk-free diet. Two of the patients subsequently have undergone a cow's milk challenge leading to prompt recurrence of symptoms, which again resolved after simple dietary manipulation. Conclusions: Cow's milk enteropathy may cause overt rectal bleeding or profound anemia from occult intestinal bleeding even in older children. Histological abnormalities in such cases may be confined to the proximal colon. After appropriate investigation, a trial of cow's milk exclusion should always be considered before laparotomy for obscure, chronic gastrointestinal bleeding in children.

Allergic proctocolitis in infants: A prospective clinicopathologic biopsy study

Allergic proctocolitis is a major cause of rectal bleeding in infants, but its clinical features and laboratory results are often nonspecific. Our previous retrospective study demonstrated that large numbers of eosinophils in colonic mucosal biopsy specimens were highly associated with cases of allergic proctocolitis. Therefore, we prospectively examined 60 colonic mucosal biopsy specimens from the same sites (4, 8, and 12 cm from the anal verge) in 20 infants with clinically confirmed allergic proctocolitis to validate this morphologic feature, to characterize its distribution, and to correlate these data with the clinical information. The patients (age range, 4 to 304 days) were fed breast milk or a variety of formulas and all presented with rectal bleeding. Sigmoidoscopic examination was abnormal in 19 cases, typically characterized by focal areas of mucosal erythema. The major histologic finding was a strikingly focal increase in the number of eosinophils in all mucosal compartments, with a predilection to aggregate in close association with lymphoid nodules. Eosinophilic infiltration varied not only between biopsies at different sites, but also within individual biopsy specimens. Only 12 of 20 patients (60%) had all three of their biopsy specimens categorized as abnormal; in the remainder, only one (four patients) or two (four patients) of the three biopsy specimens were abnormal. The average number of eosinophils per high-power field of lamina propria for all cases was 15.6. No significant correlation was identified between the number of eosinophils in the mucosa and the patient's age, length of illness, endoscopic appearance, or type of inciting formula. In summary, eosinophils appear to be an excellent marker for infantile allergic proctocolitis. Given the focal distribution of the eosinophils, multiple mucosal biopsy specimens should be obtained and several levels of each examined to confirm the diagnosis.

Rectal bleeding in infants and children

In 408 children from 1978 to 1988 rectal bleeding was evaluated in relation to sex, age, etiology and laboratory examinations. Anal fissures and juvenile polyps were the most common causes, invagination and parasitic infections the next. The different possibilities of treatment are analysed.