CLINICAL REVIEW

Management of bloody diarrhoeain children in primary careM Stephen Murphy1,2

Bloody diarrhoea is an uncommon symptom inchildren, and it may indicate the presence of seriousdisease. This review focuses on childrenpresenting in aprimary care setting. The non-specialist should beaware of the likely causes, initial management, andindications for specialist referral. The emphasis is onchildren in the developed world, although travellersdiarrhoea is also considered. The epidemiology andmanagement of this condition are different in thedeveloping world, where infectious causes predomi-nate. In recent years the reported incidence ofinflammatory bowel disease increased greatly in thedeveloped world and important advances have beenmade in its management. This diagnosis should alwaysbe considered carefully.

What are the most likely causes of bloody diarrhoea in

children?

The likely diagnoses vary depending on age (box). Atevery age intestinal bacterial infections are an impor-tant cause. Inflammatory bowel disease may occur atany agebut ismore likely in older children (>1year). Inyoung infants non-specific (perhaps allergic) colitis ismost likely. Other conditions are rarer but should beconsidered as they can be serious and even lifethreatening.

How common is infection compared with inflammatory

bowel disease?

This is an important question because if it is assumedthat bloody diarrhoea is caused by infection theninflammatory bowel disease will bemissed. Because ofthis common assumption, children with inflammatorybowel disease often experience a delay in diagnosis.1

In the United Kingdom, the most likely causativeinfective agents are speciesofCampylobacter,Salmonella,and Yersinia. Much less often, Shigella, types ofEscherichia coli that produce shiga toxin (such as E coli0157:H7), and other organisms are responsible. In thedeveloping world other disorders including bacterial(Shigella) and amoebic (Entamoeba histolytica) dysenteryare important. This should be considered in those whohave recently been overseas.

Determining the incidence of infection as a cause ofbloody diarrhoea is not simple, but an estimate can bemade.A prospective cohort study in theUK found that1:30 people (adults and children) presented to theirgeneral practitioner annually with gastroenteritis.2

Bacterial gastroenteritis was confirmed in a minorityof cases. The annual incidences of specific bacterialisolates (per 1000 population) were Campylobacter 4.14(95% confidence interval 3.34 to 5.13), Salmonella 1.57(1.19 to 2.06), Yersinia 0.58 (0.42 to 0.88), Shigella 0.27(0.16 to 0.47), and E coli 0157:H7 0.03 (0.01 to 0.11).Reports to the UK Health Protection Agencys centrefor infections suggest that about 15% of Campylobacter,30% of Salmonella, and 50% ofYersinia infections are inchildren (www.hpa.org.uk). Thus, in a primary caresetting the annual incidence of these bacterial infec-tions in children may be around 1.5 per 1000. About50-75 per 100 000 of children will develop bloodydiarrhoea with these infections.Bloody diarrhoea is a presenting symptom in about

75% of children with ulcerative colitis and 25% withCrohns disease (table 1). 1 3 A prospective study ofpaediatric inflammatory bowel disease in the UK andIreland reported an annual incidence of 5.2 (4.8 to 5.6)per 100 000. 3 Of these, 27% had ulcerative colitis and60% Crohns disease. The incidence of childrenpresenting with bloody diarrhoea as a result ofinflammatory bowel disease is therefore 2-3 per100 000 population.Thus, in the developed world bloody diarrhoea in

children is 15-20 times more likely to be caused byintestinal infections than by inflammatory boweldisease. In the developing world, although the true

SOURCES ANDSELECTION CRITERIA

I used the Medline database to search for evidence from

the literature. Randomised controlled trials, meta-

analyses, and Cochrane reviewswere usedwhen relevant

and available. Other sources of evidence included large

case series and cohort studies. I obtained information on

the incidence of specific pathogens from the UK Health

Protection Agencys Centre for Infections

1Division of Reproductive andChild Health, Medical School,University of Birmingham,Birmingham B15 2TT2Birmingham Childrens HospitalNHS Foundation Trust,Birmingham B4 6NH

m.s.murphy@bham.ac.uk

BMJ 2008;336:1010-5doi:10.1136/bmj.39542.440417.BE

1010 BMJ | 3 MAY 2008 | VOLUME 336

For the full versions of these articles see bmj.com

incidence of inflammatory bowel disease is unknown,bacterial and amoebic dysentery are muchmore likelyto be the cause.

How should I investigate and manage bloody diarrhoea

in primary care?

An appropriate strategy must take into account theseverity and symptoms or signs of systemic illness orabdominal complications. Figure 1 outlines anapproach to management, with suggested indicationsfor specialist referral.

How should I investigate and manage intestinal

infections?

Table 2 summarises the sources, clinical presentation,diagnosis, and management of various types ofintestinal bacterial infections. Antibiotics are usuallycontraindicated.WithCampylobacter, ameta-analysis of11 randomised controlled trials reported that earlyantibiotics shortened the illness slightly,4 but treatmentis usually reserved for those with severe symptoms orimpaired immunity. ForSalmonella, aCochrane reviewof 12 randomised controlled trials concluded thatantibiotics provided no benefit and that treatmentmayprolong carriage.5 Antibiotics are usually reserved foryoung infants and children with suspected bacterae-mia, extraintestinal spread, or impaired immunity.Patients with Shigella require antibiotic treatment with,for example, ciprofloxacin. For this reason routineantibiotic treatment is given to patients with bloodydiarrhoea in developing countries.

Salmonella infections generally present with diar-rhoea and fever, and it usually settles within days. It isreadily cultured from stool. In some patients, typicallyafter a period of persistent diarrhoea, bloody mucoiddiarrhoea develops as a result of colitis. If the organismis no longer detectable and the symptoms of colitispersist it may be difficult to distinguish from

inflammatory bowel disease (fig 2). Yersinia is mostcommon in children under 5 years. It may cause painand ulceration in the terminal ileum and Crohnsdisease may be wrongly suspected.Haemolytic uraemic syndrome is a rare and life

threatening condition with sudden onset of micro-angiopathic haemolytic anaemia, thrombocytopenia,and renal insufficiency. Most (80%) patients will havehadbloodydiarrhoea for three to 16 days previously. Itis usually caused by shiga toxin producing E coli, often0157:H7.

When should I suspect inflammatory bowel disease?

Inflammatory bowel disease is uncommon in children,but prompt diagnosis is important. The interval fromonset todiagnosis is oftenprolonged, and this can resultin avoidable morbidity.1 3 In a study of childrenpresenting to a tertiary centre, even though 75% of

Causesofbloodydiarrhoea(realorapparent) ininfantsandchildren

Infants aged 1 year

Common causesIntestinal infection

Inflammatory bowel disease

Crohns colitis Ulcerative colitisJuvenile polyp

Less common or rare causesIntestinal ischaemia

Intussusception Malrotation and volvulusMucosal prolapse syndrome

Henoch-Schnlein purpura or other forms of systemicvasculitis

Factitious illness

Persistent (>7days) or recurrent

Acute episode(6 bloody stools/day) or systemic illness:FeverTachycardiaPallor

Urgent referral to paediatric

gastroenterologist

Mild to moderate (

those with ulcerative colitis had persistent or recurrentbloody diarrhoea, the mean time to diagnosis was20 weeks (table 3). 1

Although infection may be the first consideration,the possibility of inflammatory bowel disease shouldnot be dismissed even in young children. Around halfof children with inflammatory bowel disease presentbefore 11 years of age, and the diseasemay occur evenin the first year of life. If any symptoms suggest chronicgastrointestinal disease, inflammatory bowel diseaseshould be considered (table 2). Persistent (more thanseven days) or recurrent bloody diarrhoea are indica-tions for referral to a paediatric gastroenterologist.Other important signs include impaired growth,weight loss, finger clubbing, andin Crohns diseaseoral or perianal abnormalities. Perianal diseaseoccurs in up to 45% of people with Crohns disease.1 3

How should I screen for inflammatory bowel disease?

Screening blood tests can be helpful, but in the contextof bloody diarrhoea their role is limited. In a study ofchildren presenting to a specialist paediatric gastro-enterology clinic with suspected inflammatory boweldisease the simple combination of haemoglobin andplatelet count was useful.7 Using one or both testsabnormal as a positive outcome gave a sensitivity of

92%, a specificity of 80%, and positive and negativepredictive values of 77% and 93% for ulcerative colitis.However, another study found that haemoglobin,albumin, erythrocyte sedimentation rate, and Creactive protein were normal in 19% of childrenpresenting with clinically mild ulcerative colitis.8

Normal blood tests do not rule out inflammatorybowel disease in children with bloody diarrhoea.Moreover, abnormal results may be found in childrenwith bacterial gastroenteritis. In the absence of anidentified stool pathogen, endoscopic evaluation isrequired in children with severe or persistent symp-toms (fig 1).

How can I recognise and manage severe colitis?

Severe bloody diarrhoea (more than five bloody stoolsdaily) requires urgent referral to a paediatric gastro-enterologist. Severe colitis is associated with anincreased risk of non-response to medical treatment,progression to toxic megacolon, and colonic perfora-tion. Early referralmay reduce these risks. Intravenouscorticosteroids or ciclosporin are often effective insevere disease, and children need expert monitoringfor signs of deterioration. In some cases emergencycolectomy may be life saving.

Which diagnoses are most likely in infants?

Infant colitis

Colonoscopy often shows mucosal inflammation andulceration in infants who present with bloody diar-rhoea. Although cows milk allergy is usually sus-pected, the aetiology is often uncertain. Allergy isprobably overdiagnosed.910 Many infants with bloodydiarrhoea are breast fed and have breast milk colitis.In these cases, it has been proposed that small butimmunologically relevant amounts of intact maternaldietary antigensmight be transferred to breast milk viathe mothers bloodstream. However, this hypothesishas not been confirmed. A recent study of 40 infantspresenting with blood in the stool provided a usefulinsight.10 The mean age at presentation was 3 months

Fig 2 | Ulcerative colitis resulting in mucosal inflammation with

spontaneous bleeding. Patients with haemorrhagic colitis

caused by Salmonella or other infections may present with an

identical appearance

UNANSWEREDQUESTIONS

How can the incidence of bacterial intestinal infection be

reduced?

Given the increased incidence of inflammatory bowel

disease in the developed world, what environmental

factors are responsible?

Does bacterial gastroenteritis cause irritable bowel

syndrome in children, as is reported in adults?

Are antibiotics advisable for patients with haemorrhagic

colitis caused by Escherichia coli that produce shiga

toxin?

Whatare theaetiologyandpathogenesisof infant colitis?

Table 1 | Presenting symptoms and signs in inflammatory bowel disease1

Symptoms Crohns disease (%) Ulcerative colitis (%)

Intestinal symptoms

Bloody diarrhoea 22 75

Non-bloody diarrhoea 42 15

Diarrhoea (overall) 64 90

Blood per rectum (no diarrhoea) 1.6 10

Abdominal pain 83 83

Anorexia and weight loss 88 56

Perianal disease 45 0

Constipation 11 0

Extraintestinal manifestations

Clubbing 25 0

Arthralgia 8 4.7

Erythema nodosum 5 0

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1012 BMJ | 3 MAY 2008 | VOLUME 336

(range 1-6). The stools werewatery in 38% andmucoidin 73%. Colonoscopy showed mucosal aphthae (33%),microscopic inflammation (33%), and focal eosinophi-lic infiltration (23%). The infants were randomlyallocated to a cows milk-free diet (n=19) or a normaldiet (n=21), with breastfeeding mothers in the firstgroup adopting a cows milk elimination diet. They

were reviewed at one and 12 months. During follow-up, bleeding was often intermittent, with an averagetime to the final episode of 24 days (range 1-85). All ofthe infants thrived. Cows milk elimination did notaffect the duration of bleeding, and re-challengesupported a diagnosis of cows milk allergy in only18%.Theauthors concluded that infant colitis is usuallya benign self limiting disorder.

Necrotising enterocolitis

Necrotising enterocolitis is a serious disorder, rarelyseen in primary care. It is characterised by diffuse orfocal ulceration and necrosis in the small intestine andcolon, and it may present with rectal bleeding orbloody diarrhoea. Other common features includeabdominal distension, bilious vomiting, and signs ofsepticaemia. It mainly occurs in premature infants inthe neonatal unit, although it can develop at any timeup to 10weeks of age.Moreover, up to 10%of cases arein full term infants.11 In such cases, predisposing factorssuch as cardiac disease may be present.11 12 Whennecrotising enterocolitis does occur in full term infants,the onset is usuallywithin the firstweek of life.11 13 If it issuspected then urgent hospital referral is necessary.Abdominal radiographymay show features to supportthe diagnosis.

Fig 3 | Typical appearance of pedunculated juvenile polyp

identified at colonoscopy in the sigmoid colon. This child was

said to have bloody mucoid diarrhoea

Table 2 | Summary of bacterial intestinal infections that cause bloody diarrhoea

Pathogen SourcesIncubationperiod Clinical presentation Diagnosis Treatment

Campylobacterjejuni

Mainly from farm anddomestic animals andanimal food products,especially undercookedchicken

1-3 days(occasionallyup to 10days)

Fever and diarrhoea;bloody diarrhoea in up to50%; usually lasts lessthan 1 week, with relapsesin up to 25%

Stool culture; selectivegrowth medium needed

Antibiotics reserved forthosewith severe symptomsor impaired immunity4

Salmonellaspecies

Mainly food bornecancause large outbreaks;farm animals (especiallyundercooked poultry); pets(including reptiles); persontoperson transmission lessfrequent; infants (3-5 months) especiallyvulnerable

6-48 hours(occasionallylonger)

Gastroenteritis-like illness,often with fever lasting3-4 days; bloody mucoiddiarrhoea may follow ascolitisdevelops;colitismaypersist for 1-12 weeks

Stool culture; may staypositive for weeks

Antibiotics not usuallybeneficial and may prolongbacterial carriage5;antibiotics reserved foryoung infants, those withsuspected bacteraemia orwith extraintestinal spread,and those with impairedimmunity

Yersiniaenterocolitica

Farm and domesticanimals; epidemics relatedto contaminated milk andice cream

3-7 days Usuallypresentswith fever,abdominal pain, anddiarrhoea; blood present inthe stool in about 30%;illness usually lasts1-3 weeks

Stool culture; organismeasily missed so thelaboratory should beadvised of suspicion

No evidence of benefit withantibiotics, and diagnosis isoften late; antibioticsreserved for those withimpaired immunity orextraintestinal spread

Shiga toxinproducingEscherichiacoli (such asO157 H7)

Often caused by foodscontaminated with bovinefaeces, such asundercooked minced(ground) beef; largeoutbreaks may occur

3-9 days Often presents with waterydiarrhoea, whichprogresses to bloodydiarrhoea; typically lasts3-8 days; haemolyticuraemic syndrome candevelop after 3-16 days

Specialised diagnostictechniques needed

Antibiotics seem to have noclinical benefit and mayincrease the risk ofhaemolytic uraemicsyndrome6

Shigellaspecies

Highly contagious; usuallyperson to persontransmission; occasionaloutbreaks fromcontamination of food orwater; most commonbetween 6 months and5 years of age; more severein adults

1-4 days A few patients present withgastroenteritis-like illness;most experience lowerabdominal pain, bloodymucoid stools, and fever;illness may be lifethreatening, withsepticaemia

Stool microscopy showspus cells and red cells; theorganism is fastidious andrequires promptinoculation intoappropriate medium forculture

Treated with antibiotics (forexample, ciprofloxacin);during outbreaks or in highprevalence areas in thedevelopingworld antibioticsare given presumptively

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Hirschsprungs disease

Hirschsprungs disease (congenital absence of gang-lion cells in the colon) occurs in 1:5000 live births.About 80% of affected children present in the first yearof life. Inmore than 90% of affected infants the passageof meconium is delayed beyond the first 24 hours. Theclassic presentation is with constipation. However,25% of infants present with enterocolitis causingabdominal distension, and severe watery and some-times bloody diarrhoea.14 This may cause hypovolae-mic shock and colonic perforation, and mortality is33% in these patients.15 Early diagnosis is thereforeessential.

What other disorders should I consider?

Anydisorder that leads tomucosal ischaemia can causebloody diarrhoea.

Intestinal infarctiona surgical emergency

Bloody diarrhoea can indicate a major surgicalemergency. Intussusception occurs most often butnot exclusively in the first year of life. The classicpresentation is with episodic abdominal pain, vomit-ing, and the passage of blood and mucous. In somecases bloody diarrhoea is reported.16 In infants andchildren with congenital gut malrotation, midgutvolvulus may result in extensive intestinal gangrene.This catastrophic event typically presents with symp-toms of obstruction including bilious vomiting. Again,however, bloody diarrhoea may be reported.17

Henoch-Schnlein purpura

Henoch-Schnlein purpura is a common form ofidiopathic systemic vasculitis in children. It is asso-ciated with a characteristic rash (easily overlooked),abdominal pain, arthralgia, and overt or microscopichaematuria.18Overt gastrointestinal bleeding occurs in25% of patients and bloody diarrhoea is sometimesseen.19

Is it really bloody diarrhoea?

Juvenile polyps

Juvenile polyps (inflammatory polyps) occur in about1% of children (fig 3). They are usually associated withthepassageofbloodandmucous, butdiarrhoeamaybereported.20 21 Colonoscopy is required for diagnosis.

Mucosal prolapse syndrome and solitary rectal ulcer

syndrome

Childrenwithmucosal prolapse syndromemay reportbloody diarrhoea.22 However, the true symptom maybe tenesmusthe frequent urge to defecate with justthe passage of blood and mucous. In this disorder theanterior rectal mucosa is prone to prolapse, althoughthis is often not reported by the child. The prolapseleads to mucosal injury. In some cases it is associatedwith the development of inflammatory cloacogenicpolyps at the anorectal junction. The polyps may bedetected on digital examination and are seen atendoscopy; they have a characteristic histologicalappearance.23

Solitary rectal ulcer syndrome presents with similarsymptoms. The pathogenesis of this condition isuncertain, but it is probably also caused by mucosalprolapse. At endoscopy, anterior rectal ulceration isseen several centimetres above the anal canal.

Factitious illness and illness induction

Very rarely, diarrhoea and gastrointestinal bleedingmay be falsely reported either by young people or bycarers.24 25 This possibility should be considered if theclinical circumstances are bizarre or if there are otherreasons for concern.

TIPS FORNON-SPECIALISTS

Children with fewer than six stools daily may bemanaged

in primary care if they are not systemically unwell and do

not have an acute abdomen

Evidence of systemic illness includes fever, tachycardia,

pallor, and shock

Evidence of an abdominal surgical emergency includes

severe pain, persistent or bilious vomiting,

haematemesis, distension, tenderness, a palpablemass,

and signs of septicaemia or shock

Consider inflammatory bowel disease in children with

evidence of chronic diseasepersistent or recurrent

bloody diarrhoea or other gastrointestinal symptoms,

weight loss, or poor growth

Severe colitisassociated with severe bloody diarrhoea

is life threatening and requires immediate referral to a

paediatric gastroenterologist

ADDITIONAL EDUCATIONAL RESOURCES

Resources for healthcare professionals

Health ProtectionAgency, Centre for Infections (www.hpa.

org.uk)Provides up to date surveillance information on

the epidemiology of gastrointestinal infections in the UK

Resources for parents

NationalAssociation forColitisandCrohnsdisease(www.

nacc.org.uk)Provides support and information for

patients with ulcerative colitis and Crohns disease

Crohns in Childhood Research Association (www.cicra.

org)Provides support for patients with inflammatory

bowel disease, particularly children and young adults,

and raises funds to support medical research into the

disease

Table 3 | Time interval from first symptoms to diagnosis of inflammatory bowel disease1

Diagnosis Crohns disease (weeks) Ulcerative colitis

Crohns disease 47 4 weeks to 7 years

With diarrhoea 28 4 weeks to 5 years

Without diarrhoea 66 27 weeks to 7 years

Ulcerative colitis 20 2 weeks to 3 years

Indeterminate colitis* 45 2 weeks to 2 years

*Colitis caused by inflammatory bowel disease in which it is not possible to distinguish between ulcerative

colitis and Crohns disease.

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1014 BMJ | 3 MAY 2008 | VOLUME 336

Contributors:MSM is sole author. Olivier Fontaine, of the World Health

Organization (Geneva), kindly reviewed this manuscript and contributed

helpful comments and advice.Competing interests: None declared.Provenance and peer review: Commissioned; externally peer reviewed.

1 Spray C, Debelle GD, Murphy MS. Current diagnosis, managementand morbidity in paediatric inflammatory bowel disease. ActaPaediatr 2001;90:400-5.

2 Wheeler JG,SethiD,Cowden JM,WallPG,RodriguesLC,TompkinsDS,et al. Study of infectious intestinal disease in England: rates in thecommunity, presenting to general practice, and reported to nationalsurveillance. The Infectious Intestinal Disease Study Executive. BMJ1999;318:1046-50.

3 SawczenkoA,SandhuBK. Presenting featuresof inflammatoryboweldisease in Great Britain and Ireland. Arch Dis Child2003;88:995-1000.

4 Ternhag A, Asikainen T, Giesecke J, Ekdahl K. A meta-analysis on theeffects of antibiotic treatment on duration of symptoms caused byinfection with Campylobacter species. Clin Infect Dis2007;44:696-700.

5 Sirinavin S, Garner P. Antibiotics for treating salmonella gutinfections. Cochrane Database Syst Rev 2000;(2):CD001167.

6 Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of thehemolytic-uremic syndrome after antibiotic treatment of Escherichiacoli O157:H7 infections. N Engl J Med 2000;342:1930-6.

7 Cabrera-Abreu JC, Davies P, Matek Z, Murphy MS. Performance ofblood tests indiagnosisof inflammatoryboweldisease inaspecialistclinic. Arch Dis Child 2004;89:69-71.

8 MackDR, Langton C,Markowitz J, LeLeiko N, Griffiths A, Bousvaros A,et al. Laboratory values for children with newly diagnosedinflammatory bowel disease. Pediatrics 2007;119:1113-9.

9 Xanthakos SA, Schwimmer JB, Melin-Aldana H, Rothenberg ME,Witte DP, Cohen MB. Prevalence and outcome of allergic colitis in

healthy infants with rectal bleeding: a prospective cohort study. JPediatr Gastroenterol Nutr 2005;41:16-22.

10 Arvola T, Ruuska T, Keranen J, Hyoty H, Salminen S, Isolauri E. Rectalbleeding in infancy: clinical, allergological, and microbiologicalexamination. Pediatrics 2006;117:e760-8.

11 Ostlie DJ, Spilde TL, St Peter SD, Sexton N, Miller KA, Sharp RJ, et al.Necrotizing enterocolitis in full-term infants. J Pediatr Surg2003;38:1039-42.

12 Siahanidou T,MandylaH, AnagnostakisD, PapandreouE. Twenty-sixfull-term (FT) neonates with necrotizing enterocolitis (NEC). J PediatrSurg 2004;39:791.

13 Maayan-Metzger A, Itzchak A, Mazkereth R, Kuint J. Necrotizingenterocolitis in full-term infants: case-control study and review of theliterature. J Perinatol 2004;24:494-9.

14 Swenson O, Sherman JO, Fisher JH. Diagnosis of congenitalmegacolon: an analysis of 501 patients. J Pediatr Surg1973;8:587-94.

15 Swenson O, Davidson FZ. Similarities of mechanical intestinalobstruction and aganglionic megacolon in the newborn infant: areview of 64 cases. N Engl J Med 1960;262:64-7.

16 Macdonald IA, Beattie TF. Intussusception presenting to a paediatricaccident and emergency department. J Accid Emerg Med1995;12:182-6.

17 Ford EG, Senac MO, Jr, Srikanth MS, Weitzman JJ. Malrotation of theintestine in children. Ann Surg 1992;215:172-8.

18 Aalberse J, Dolman K, Ramnath G, Pereira RR, Davin JC. HenochSchonlein purpura in children: an epidemiological study amongDutchpaediatriciansonincidenceanddiagnosticcriteria.AnnRheumDis 2007;66:1648-50.

19 Uppal SS, Hussain MA, Al Raqum HA, Nampoory MR, Al Saeid K, AlAssousi A, et al. Henoch-Schonleins purpura in adults versuschildren/adolescents: a comparative study. Clin Exp Rheumatol2006;24(2 Suppl 41):S26-30.

20 Ukarapol N, Singhavejakul J, Lertprasertsuk N, Wongsawasdi L.Juvenile polyp in Thai childrenclinical and colonoscopicpresentation.World J Surg 2007;31:395-8.

21 Gupta SK, Fitzgerald JF, Croffie JM, Chong SK, Pfefferkorn MC,Davis MM, et al. Experience with juvenile polyps in North Americanchildren: the need for pancolonoscopy. Am J Gastroenterol2001;96:1695-7.

22 DuBoulayCE, Fairbrother J, IsaacsonPG.Mucosalprolapsesyndromea unifying concept for solitary ulcer syndrome and relateddisorders. J Clin Pathol 1983;36:1264-8.

23 Poon KK, Mills S, Booth IW, Murphy MS. Inflammatory cloacogenicpolyp: an unrecognized cause of hematochezia and tenesmus inchildhood. J Pediatr 1997;130:327-9.

24 MillsRW,BurkeS.Gastrointestinalbleedingina15montholdmale.ApresentationofMunchausenssyndromebyproxy.ClinPediatr (Phila)1990;29:474-7.

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SUMMARY POINTS

Bloody diarrhoea in infancy and childhood often indicates serious gastrointestinal disease

Intestinal bacterial infection is the most common causeCampylobacter, Salmonella, andYersinia are important in the developed world

Bacterial gastroenteritis is usually self limitingantibiotics are needed only in selected cases

Crohns disease and ulcerative colitis often present with bloody diarrhoea and should beconsidered in all ages

Children with severe bloody diarrhoea or signs of systemic illness need urgent specialistreferral, as these symptoms may indicate a life threatening condition

DNR or PEACE?I have huge difficulty in discussing do not resuscitate(DNR) orders with people whose loved ones are close todeath, especially if this is untimely, unexpected, ornon-malignant. This remains the case evenwhenwe knowcardiopulmonary intervention would be futile. Theresponse But, doctor, surely we should give him achance? is all too frequent, and the explanation that thepatient has no chance sounds arrogant, unhelpful, andfinal. Relatives can emerge from such meetings with afeeling that the doctors have decided to stop and that achance, however tiny, has been squandered.We, however, know the truth about futile resuscitation

attempts in patients clearly dying of irreversible illnesses.To be coerced into carrying out theatrical cardiacmassageor attempting to restart the heart of onewhohas just diedofan irreversible organ failure is unpleasant, disrespectful,and wrong. How can we help people understand the truthabout our position, especially whenwe are trying to do theexplaining at a time of their maximal distress?I have come to the conclusion that one reason for our

difficulty lies in the terminology itself. The very word

resuscitate carries with it implications of success.Do you wish your wife/husband/mother/father to beresuscitated? will surely bring the answer yes from anysane personfacing imminent loss of someone close. Donot resuscitate also sounds a bit harsh, a barked militarycommand. Some have tried to soften it by using do notattempt to resuscitate, which, to me, sounds even worse:dont even dare to have a go, this patient is not to survive.And yet there is a general public acceptance that the end

of life must come and would be better if it were dignifiedand calm. Perhaps this is what our terminology shouldemphasise.We should change thenameof theDNRorder.I would suggest patients end of life avoidance ofcardiopulmonary effortsPEACE. We think it is onlyright to leave your loved one in PEACE. Yes, thats it,thats what we are trying to say.

John Crampton consultant physicianWythenshawe Hospital, University Hospital of South ManchesterFoundation Trust, Manchesterj.r.crampton@lineone.net

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