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studies indicate Hirschsprung disease, rectal biopsy is not necessary to confirm
the diagnosis.
In children of all ages, an adequately performed suction mucosal biopsy of the
rectum 2 cm or more above the dentate line can be reliable in diagnosing
Hirschsprung disease. Because of the complicated evaluation and management of
this disease, referral to a pediatric surgeon is recommended.

Duplications
Duplications occur anywhere from the mouth to the anus and produce various
symptoms. In the abdomen, there may be a noncommunicating cyst that gradually
fills up with secretions and compresses the adjacent normal bowel, producing a
palpable abdominal mass or chronic intestinal obstruction. Rarely, a marginal
ulcer resulting from ectopic gastric mucosa may occur, and this produces painless
bleeding. After appropriate radiographic diagnosis, surgery is indicated.

Inflammatory Bowel Disease
The older child or adolescent may develop either Crohn disease or ulcerative
colitis (see Chapter 91 Gastrointestinal Emergencies ), and this must be included
in the differential diagnosis of chronic intestinal obstruction. Usually, the child
has a history of changing bowel habits, with mucus or blood in the stools, chronic
abdominal pain, and weight loss. Chapter 91 Gastrointestinal Emergencies covers
inflammatory bowel disease in detail.

DISEASES THAT PRODUCE RECTAL BLEEDING
Goals of Treatment
Rectal bleeding can be a sign of a serious condition. Clinicians need to identify
generally innocent etiologies from those that can be life-threatening. The primary
goals should be early recognition of hemorrhagic shock and ischemic bowel.
Blood on the outside of a formed stool is likely to originate from the distal large
bowel, rectum, or anus. Blood mixed in the stool is generally from a higher
source of bleeding. Blood associated with diarrhea is common with inflammatory

bowel disease and infectious enteritis. A “tarry” stool suggests a source of
bleeding in the proximal portion of the GI tract, and bright red blood suggests a
more distal origin ( Fig. 116.17 ). All patients with rectal bleeding should have a
rectal examination. Those with significant hemorrhage require flexible
colonoscopy. In some patients, no definite diagnosis may be reached despite
extensive studies. In any patient with significant bleeding, however, surgical
consultation is indicated. Chapters 33 Gastrointestinal Bleeding and 91