March/April 2002 101

QUESTIONS &ANSWERS

(Data on page 88.)

CLINICAL REPORT

Jacquel ine D. Rychnovsky, MSN, RN, CPNP

1. What is the differential diagnosis for a21-month old child with hematochezia?

According to Tunnessen and Roberts(1999), the most common causes of gas-trointestinal bleeding in children arepolyps, anal fissure, infectious diarrheas(amounts of blood passed are generallysmall), swallowed blood (epistaxis),inflammatory bowel disease (ulcerativecolitis and Crohn’s disease), peptic ulcer,Meckel’s diverticulum, and gastritis.Less common disorders to be consid-ered are esophageal varices, presence offoreign bodies, esophagitis, hemolytic-uremic syndrome, and coagulopathies.

2. What laboratory and/or radiologic stud-ies would you order?

Laboratory tests should include a com-plete blood cell count, platelet count,coagulation studies (prothrombin timeand partial thromboplastin time), stooltests for occult blood and fecal leuko-cytes, and a stool culture. If the labora-tory tests do not reveal a coagulationdisorder or infection, a nuclear medi-cine screen should be performed to ruleout Meckel’s diverticulitis.

3. How would you initially manage thispatient?

If anemia is present, Erika should beginto take an iron supplement of 3 to 6 mgelemental iron per kilogram per 24hours, divided, and taken once to threetimes daily (Siberry & Iannone, 2000).Erika’s mother was told to eliminate allproducts containing cow’s milk fromErika’s diet for several weeks because ofthe occasional association of constipa-tion and hematochezia with an allergyto cow’s milk (Gryboski, 1994; Iacono etal., 1994).

Hemacult tests (Laboratory Specia-lists International, Orcutt, Calif) per-formed on 3 consecutive days were pos-

itive for blood in the stool. The hemo-globin level was 10.7, the hematocritlevel was 32.1, and results of coagula-tion studies were within normal lim-its. Erika continued to have intermit-tent “burgundy”-colored blood in herstool. Results of nuclear medicinescreening to rule out Meckel’s diverti-culitis were negative. A pediatric gas-troenterologist was consulted, whobelieved that given Erika’s history andthe presence of the perianal skin tag,the rectal bleeding was most likely theresult of an internal rectal fissure andchronic constipation. Erika was treat-ed with a stool softener (docusate sodi-um), and instructions were providedto see her for a follow-up examinationin 1 to 2 months.

After several months of treatmentwith stool softeners, the bleeding con-tinued. A colonoscopy was performed,and biopsy specimens of the cecumand transverse colon showed chronicactive colitis, which was believed to be

patchy and mild to focally severe withsome erosion. Although specific fea-tures such as granulomas and lym-phoid aggregation were not present,this finding was believed to be mostconsistent with Crohn’s disease con-fined to the large intestine. Becauseonly intermittent hematochezia hadoccurred at this point, mesalamine(Pentasa) was prescribed and Erikacontinued to take iron supplements,with monthly gastroenterology follow-up appointments. Mesalamine exhibitsantiinflammatory activity in the gas-trointestinal tract. In part because ofthe complexity of the inflammatoryresponse, the exact mechanisms of theantiinflammatory effect of mesalaminehave not been fully elucidated, but itappears that several actions may con-tribute to the drug’s activity in inflam-matory bowel disease (IBD) and thatthey are local rather than systemic.Other treatments that may be initiatedby a gastroenterologist for more severesymptoms include systemic steroids orother antiinflammatory drugs, antibi-otics, and/or cyclosporin. Restrictingthe diet of a child with Crohn’s diseaseis avoided because it may lead to inad-equate intake. Referral to a dieticianmay be indicated.

Crohn’s disease is a chronic disorderthat is associated with high morbiditybut low mortality. Despite treatment,symptoms tend to recur. It is impor-tant for the practitioner to pay particu-lar attention to weight loss and growthfailure. Up to 15% of patients with

CDR(s) Jacqueline D. Rychnovsky is a U.S. Navy Nurse Corps Officer currently stationed in San Diego, Calif.

The views expressed in this article are those of the author and do not reflect the official policy or position of theDepartment of the Navy, Department of Defense, or the U.S. government.

Reprint requests: Jacqueline D. Rychnovsky, MSN, RN, CPNP, 1428 Ashford Castle Dr, Chula Vista, CA 91915.

J Pediatr Health Care. (2002). 16, 88, 101-102.

25/8/110912

doi:10.1067/mph.2002.110912

Restricting the diet of a

child with Crohn’s disease

is avoided because it may

lead to inadequate intake.

PHC CLINICAL INSIGHTS Rychnovsky

102 Volume 16 Number 2 JOURNAL OF PEDIATRIC HEALTH CARE

Crohn’s disease who experience earlygrowth retardation have a permanentdecrease in linear growth. Weight lossand growth failure can be improvedwith attention to nutritional needs andtreatment for the extraintestinal mani-festations of the disease such as scleros-ing cholangitis, chronic active hepatitis,pyoderma gangrenosum, and ankylos-ing spondylitis (Nelson, Behrman, Klieg-man, & Arvin, 1996). Growth parame-ters of height and weight should becarefully measured and plotted every 3to 6 months. The practitioner should en-courage the family to allow the child toplay and participate in all age-appro-priate activities as the condition of thechild allows.

Psychosocial issues for pediatric pa-tients with Crohn’s disease include asense of being different, concerns aboutbody image, and family conflict fromthe added stress of the diagnosis andmanagement of a child with a chronicdisease. Counseling for these childrenand their families may be indicated, es-pecially during adolescence. Referral to

local and national support groups forCrohn’s disease and irritable bowel syn-drome is essential. Additional informa-tion can be found at the Web site of theCrohn’s & Colitis Foundation of Ame-rica (www.ccfa.org).

DISCUSSIONAt a very young age, Erika has biopsyfindings suggestive of Crohn’s disease.Although finding evidence of Crohn’sdisease is unusual in a person of thisage and ethnicity, the incidence of IBDhas been increasing in African-Ameri-can children compared with non–Afri-can American children. In a study byOgunbi, Ransom, Sullivan, Schoen, andGold (1998), symptom duration beforediagnosis for African American chil-dren with IBD was shorter (6 months)than that of non–African American chil-dren (10 months). The estimated occur-rence of Crohn’s disease in AfricanAmericans ranged from 7 per 100,000to 12 per 100,000, whereas the incidenceof ulcerative colitis was between 5 and7 per 100,000; thus IBD may be more

common in African-American chil-dren than previously reported. Fur-ther population-based studies are sug-gested to validate findings of this study.Clinicians should keep this increasingtrend in mind when evaluating Afri-can American children with hema-tochezia.

REFERENCESGryboski, J. (1994). Ulcerative colitis in children 10

years old or younger. Journal of Pediatric Gastro-enterology and Nutrition, 17, 24-31.

Iacono, G., Carroccio, A., Cavataio, F., Montalto,G., Cantarero, M., & Notarbartolo, A. (1994).Chronic constipation as a symptom of cow milkallergy. Journal of Pediatrics, 126(1), 34-39.

Nelson, W., Behrman, R., Kliegman, R., & Arvin, A.(1996). Nelson textbook of pediatrics. Philadelphia:W. B. Saunders.

Ogunbi, S. L., Ransom, J. A., Sullivan, K., Schoen,B. T., & Gold, B. D. (1998). Inflammatory boweldisease in African-American children living inGeorgia. Journal of Pediatrics, 133(1), 103-107.

Siberry, G., & Iannone, R. (Eds.). (2000). HarrietLane handbook: A manual for pediatric house officers(p. 744). St. Louis: Mosby.

Tunnessen, W., & Roberts, K. (1999). Signs and symp-toms in pediatrics (3rd ed.). Philadelphia: Lip-pincott Williams & Wilkins.

WANTED:CHILDREN’S DRAWINGS

The Journal is interested in publishing children’s drawings of theirresponses to illness, treatment, or encounters with the health caresystem or personnel. Please enclose the child’s assent/consent andparental consent to have the drawing published and commented onwhen you submit the drawing. Please send the drawing, along withthe child’s age, gender, any pertinent information regarding thechild’s condition, and the written consents, to:

Bobbie Crew Nelms, PhD, RN, CPNP3133 Barbara St

San Pedro, CA 90731