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Fissures
An anal fissure is probably the most common cause of bleeding, especially in
infants. However, fissures may occur at any age. The child usually has a history
of passing a large, hard stool with anal discomfort. Often, the child has a history
of chronic constipation with progressive reluctance to pass stool because of the
associated discomfort. If bleeding occurs, it usually involves streaking of bright
red blood on the outside of the stool or red blood on the toilet tissues. The
diagnosis can easily be made by inspection or anoscopic examination and
appropriate measures taken to relieve the chronic constipation (see Chapter 18
Constipation ). Rarely does a child require hospitalization or surgery.

Juvenile Polyps
Older infants and children can develop either single or multiple retention polyps.
Usually, the polyps occur in the lower portion of the colon and can often be
palpated on rectal examination. Polyps bleed, but they rarely cause massive
hemorrhage. They may intermittently prolapse at the anus or on occasion come
free and be passed as a fecal mass associated with bleeding. Colonic polyps may
be lead points for intussusception. Usually, however, polyps are asymptomatic
except for the associated bleeding. These are not premalignant lesions, and they
tend to be self-limiting ( Fig. 116.18 ) although they can be easily removed by
colonoscopy.