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Proctosigmoidoscopy and rectal biopsy in infants and children
December 1976 The Journal o f P E D I A T R I C S
911
Proctosi gmoidoscopy and rectal biopsy in infants and children The medical records o f all patients ages 0 to 21 years who underwent proctosigmoidoscopy and~or rectal biopsy over a 2 7-month period o f time were reviewed to determine the efficacy and salety o f these procedures in pediatric patients. One hundred twenty-one patients underwent proctosigmoidoscopy; 91 of these also had rectal biopsies. Median age was two years," 21% were less than six months and 8% less than one month o f age. Depth o f examination was 10 to 15 cm in most patients > 10 years o f age. Induced friability was the most frequently observed mucosal abnormality. Abnormal findings were almost always present in patients with bloody diarrhea and were quite common in those with rectal bleeding, but less common in those with chronic diarrhea and abdominal pain. Colitis o f various causes was the most common cause of blood in the stool." anal fissures were found in only four o f 23 patients with rectal bleeding. Both proetosigmoidoscopy and rectal biopsy were needed to exclude the presence o f colitis. Morbidity was 0% with proctosigmoidoscopy and 0.34% with rectal suction biopsy.
J o n A. Vanderhoof, M.D.,* and Marvin E. A m e n t , M.D.,** L o s A n g e l e s , Calif.
PROCTOSIGMOIDOSCOPY and rectal biopsy are commonly used in adults to diagnose colorectal tumors and to evaluate patients with diarrhea and rectal bleeding. Both procedures have been described in infants and children, '-~ but a comprehensive evaluation of their efficacy and safety is lacking. We have reviewed our experience with these procedures during a 27-month period of time to obtain this information. PATIENTS
AND METHODS
All patients less than 21 years of age who had proctosigmoidoscopic examination and/or rectal biopsies at the UCLA Center for the Health Sciences from April, 1973, through July, 1975, were included in this retrospective study. The medical records were reviewed and data concerning proctosigmoidoscopy and rectal biopsy were From the Departments o f Pediatrics and Medicine University of California, School of Medicine. Presented at the plenary session, Western Society/br Pediatric Research, Carmel, California February 1976. *Cystic Fibrosis Clinical Research Fellow in Pediatric Gastroenterology. **Reprint address: UCLA School of Medicine, Department o/ Pediatrics, Los Angeles, CA 90024.
compiled and tabulated. All procedures were done by pediatric gastroenterology fellows and supervised by one of the authors (M.E.A.). All proctosigmoidoscopic examinations were performed using Welch-Allyn rigid fiberoptic sigmoidoscopes. Four sizes having the following dimensions were available: 19 mm x 25 cm (standard adult sigmoidoscope), 15 mm • 25 cm, 15 mm x 15 cm, and 11 mm • 10 cm. All procedures were done without cathartic or enema preparation if the patient had diarrhea or was suspected of having colitis. If a polyp was suspected or if the rectum was filled with hard stool, 10 Ounces of magnesium citrate per 1.73 m ~ was given 24 hours before the procedure, followed by a Fleet's enema the night before and the morning of the procedure. Patients between one month and seven years of age were premedicated 75 minutes before the procedure with meperidine, promethazine, and chlorpromazine at a dosage of 2.0 mg/kg, 1.0 mg/kg, and 1.0 mg/kg, respectively. One-half of these amounts was used for neonates and debilitated patients; a maximum of 50 mg of meperidine, 25 mg of promethazine, and 25 mg of chlorpromazinc was never exceeded. If the patient began to move and strain with digital rectal examination, additional sedation with diazepam, 0.2 to 1 mg/kg, was given intravenously slowly oyer a ten-minute interval, thereby avoiding respi-
Vol. 89, No. 6, pp. 9ll-915
9 12
Vanderhoof and Ament
The Journal of Pediatrics December 1976
Table I. Results at rectal biopsy in patients having proctosigmoidoscopy for various indications
Proctosigmoidoscopy
Rectal biospy
Total number
Normal
Abnormal
Normal
Abnormal
Chronic diarrhea
42
25
17
Rectal bleeding
23
6
17
Bloody diarrhea
20
1
19
Abdominal pain alone
12
10
2
Abdominal pain + chronic diarrhea
9
5
4
14 3 1 2 0 0 5 0 2
5 13 1 9 1 18 0 1 1
6 1 4 6 0 1 5 1 2
1
3
0
Abdominal pain + bloody diarrhea
9
1
8
Abdominal pain + rectal bleeding
,3
2
1
0 0 2
1 4 0
0 4 0
1
0
0
3
1
2
1 0
0 2
0 0
Other
ratory depression. Although the procedure could be performed safely in an outpatient setting, careful monitoring by clinic nursing staff was frequently required for four to six hours after the procedure. Patients were positioned on a standard sigmoidoscopy table in the kneeling position, lnfants were placed in the prone position with a rolled sheet beneath their abdomens. Each examination was initiated with visual inspection of the perianal region followed by digital rectal examination. Selection of the proper sigmoidoscope was arbitrary. The 10 c m x 11 mm instrument was usually used in infants less than three months of age, and the 15 cm x 15 mm instrument for children less than two years of age. The mucosa was evaluated for the presence or absence of ramifying blood vessels, spontaneous friability (bleeding prior to being touched with a mucosal swab), induced friability (bleeding following mucosal wiping), ulcers, and polyps. During each examination multiple areas of mucosa were wiped with a large cotton swab by rotating it 360 ~ against the mucosal surface. Erythema after wiping was not considered abnormal. Rectal suction biopsies were taken with the Quinton multipurpose biopsy tube =using a 2.0 mm biopsy port and 3 to 5 mm Hg negative pressure. Occasionally, greater negative pressure (5 to I0 ram) had to be used to obtain tissue. Biopsies were taken 2 to 4 cm cephalad to the mucocutaneous junction, directed posteriorly or laterally to avoid possible perforation into the peritoneal cavity. All biopsies were interpreted by both one of the authors (M.E.A.) and a staff member of the department of pathology.
[ Not done
RESULTS A total of 121 patients had proctosigmoidoscopic examinations; 91 of these also had rectal biopsies. Patients ranged from two days to 20 years of age with a median age of two years. Twenty-one percent were less than six months of age and 8% were less than one month. Weight ranged from 2 to 80 kg with a median of 15 kg. Indications for proctosigmoidoscopy are shown in Table I. The four most common indications were diarrhea of greater than two weeks' duration, abdominal pain of greater than three months' duration which disrupted normal activities, rectal bleeding, and bloody diarrhea. Many patients had abdominal pain in combination with diarrhea and/or rectal bleeding. Thirty-four additional patients had rectal biopsies performed but did not undergo proctosigmoidoscopy; 28 were biopsied to exclude Hirschsprung disease, three had chronic nonspecific diarrhea, and one had acrodermatitis enteropathica, Two patients had clinical histories compatible with cow milk and soy protein intolerance and were biopsied following a trial feeding of these formulas to evaluate their response to a test feeding. The distance the instruments could be manually inserted varied greatly when compared to age and weight. The 10 and t5 cm instruments could often be inserted their entire length, even in the smallest infants. In children older than 10 years, the median depth of examination was 15 cm. Induced friability was the most frequently described mucosal abnormality and was often found in the absence of spontaneous friability (Table 1I). Thirteen patients in whom induced friability was the only abnormality noted
Volume 89 Number 6
also had rectal biopsies performed; colitis was present in 11 of the 13. Friability was diffuse in 74% of patients whose mucosa was friable, a finding which was not specific for any particular cause of colitis. The frequency with which abnormal findings were observed at proctosigmoidoscopy were also tabulated for each of the various indications for which the procedure was performed (Table I). Patients with bloody diarrhea almost always h a d abnormal examinations showing colitis to be present. In patients with rectal bleeding without diarrhea or abdominal pain, the bleeding source was identified in 74% by proctosigmoidoscopy. In patients whose only presenting complaint was chronic abdominal pain, proctosigm0idoscopic examination was not abnormal except for two patients known to have Crohn ileitis. Final diagnoses of study patients are listed in Table IIL Colitis was the most common condition and was found in 70 patients. Twenty-four had idiopathic ulcerative colitis, diagnosed by its characteristic course and presentation. Nineteen had infectious colitis, determined by isolation of an organism known to cause colitis, or by a clinical course typical of an infectious disease. Thirteen had milk or soy protein intolerance, documented in each case by appropriate challenge studies. Proctosigmoidoscopy and rectal biopsy were most valuable in determining the cause of blood in the stool, with colitis being the usual source of bleeding. Of 55 patients who presented with either rectal bleeding (23) or bloody diarrhea (32), three were known.to have ulcerative colitis prior to proctosigmoidoscopy. Of the remaining 52, the source of bleeding was determined in 42 by proctosigmoidoscopy or rectal biopsy. Thirty-five had colitis. Only four of 23 patients with rectal bleeding alone had anal fissures. One had nodular lymphoid hyperplasia, one had a traumatic mucosal tear secondary to anal intercourse, and the last patient had a rectal polyp. Th e etiology of the rectal bleeding in the ten patients not diagnosed by proctosigmoidoscopy or rectal biopsy was later found to be colonic polyps beyond visualization with the sigmoidoscope in two, necrotizing enterolcoitis in two, and segmental colitis (diagnosed by colonoscopy) in one. Five patients remained undiagnosed. Ninety-one patients had both proctosigmoidoscopy and rectal biopsy. There was concordance of diagnosis in 75. Colitis was diagnosed by proctosigmoidoscopy in seven of the remaining 16 patients when rectal biopsy was normal; the colitis was patchy in these patients. Nine of the 16 patients had colitis diagnosed by rectal biopsy alone. Of a total of 58 patients with all types of colitis who had both proctosigmoidoscopy and rectal biopsy, rectal biopsy was abnormal in 51, proctosigmoidoscopy in 49, and both studies in 42. Correlation of rectal biopsy results with
Proctosigmoidoscopy and rectal biopsy
Table II. Findings on proctosigmoidoscopy in patients
9 13
121
NO.
Finding
q['patients
Normal Induced friability Spontaneous friability Loss of ramifying vessels Edema Erythema Granularity Anal fissure Ulceration Pseudomembrane Mucosal laceration Lymphoid hyperplasia Visible parasites Polyp
58 58 40 26 I0 8 4 4 3 3 1 1 1 I
Table III. Final diagnoses in 121 patients undergoing proctosigmoidoscopy Ulcerative colitis Infectious colitis Milk or soy protein intolerance Irritable colon of infancy Chronic recurrent abdominal pain of childhood Small intestinal mucosal disease Crohn disease Drug-induced colitis Anal fissure Nodular lymphoid hyperplasia Colonic polyps Necrotizing enterocolitis Appendiceat abscess Traumatic mucosal tear No diagnosis established
24 19 13 l1 11 9 8 6 4 4 3 2 1 1 5
proctosigmoidoscopy for each of the various indications is presented in Table I. Complications did not occur from either proc~osigmoidoscopy or from sedation for the procedure. Only one significant hemorrhage resulted from rectal suction biopsy in an eight-year-old child, necessitating transfusion. A total of 293 rectal suction biopsies were taken from 121 patients, resulting in a 0.34% morbidity rate per b~opsy. Eight grasp biopsies were taken from four patients without complications. DISCUSSION Proctosigmoidoscopy is not difficult to perform in infants and children provided that (1) the child is adequately sedated, (2) the proper instruments are available, and (3) the physician is trained in performing the
9 14
Vanderhoof and A m e n t
procedure and in making the appropriate observations. Our data demonstrate the safety of performing both procedures, even in very small infants. The importance of adequate sedation cannot be overemphasized. Patient movement during the examination may result in laceration of the mucosa and possible perforation of the colon or may cause the physician to terminate the procedure before an adequate examination can be completed? All infants and preschool children in our study were asleep when proctosigmoidoscopy was begun; the majority required administration of diazepam to allow the procedure to proceed. Proctoscopy using a test tube and penlight has been frequently used by physicians to examine the rectal mucosa in infants. However, this technique provides inadequate visualization of the mucosa for diagnostic purposes and should be avoided. Amoung visual observations to be made at proctosigmoidoscopy, there are three for which interobserver reliability is greater than 80%? ~ These include the presence or absence of induced friability, spontaneous friability, and ramifying blood vessels. Interobserver agreement for edema, hyperemia, wetness, granularity, and pallor is poor. A previous'protosigmoidoscopic study of children with chronic recurrent abdominal pain reported mucosal changes for which interobserver agreement is poor. t~ Our patients with chronic recurrent abdominal pain ~..... all had normal proctosigmoidoscopic examinations. The four most common indications for proctosigmoidoscopy include chronic diarrhea, abdominal pain, rectal bleeding, and bloody diarrhea. Patients with bloody diarrhea usually have colitis. Proctosigmoidoscopy is of value in these patients in assessing the extent and distribution of rectosigmoid involvement, and in following the course of the disease. The presence of a pseudomembrane is suggestive of antibiotic-induced or infectious enterocolitis, 12 and the presence of discrete ulcers may suggest amebiasis. L3 Mucosal wipings may be examined for amebae, providing a more sensitive diagnostic method than stool examination.TM Proctosigmoidoscopy is essential to establish the etiology of rectal bleeding. All too frequently rectal bleeding is attributed to an anal fissure when the source is another lesion. TM ~'~ Proctocolitis was the most common diagnosis in patients with rectal bleeding, with or without diarrhea. Multiple mucos~/1 wipe tests are necessary to exclude colitis by proctosigmoidoscopy, since 18 patients in our study had induced friability in the absence of spontaneous friability. Patients with chronic diarrhea should also undergo proctosigmoidoscopy and rectal biopsy to exclude the diagnosis of colitis. Patients with abdominal
The Journal of Pediatrics December 1976
pain in the absence of other symptoms rarely have abnormal examinations and should have these procedures performed only if their clinical course is consistent with inflammatory bowel disease. Rectal biopsy is useful in pediatric patients in diagnosing or excluding Hirschsprung disease and also functions as an adjunct to proctosigmoidoscopy in excluding or confirming colitis?~-~3 Because inflammatory changes may be patchy rather than diffuse in some patients with Colitis (26% of our patients), blind rectal suction biopsy may retrieve normal tissue. It is always best to take multiple rectal biopsies when colitis is suspected. Rectal suction biopsy is a safe technique when performed properly. Conclusions cannot be drawn from our experience with only eight grasp biopsies. Another report described a morbidity of 3.4% and mortality of 1% using grasp biopsy in infants. TM
REFERENCES
1. Armineki TC, and McLean DW: Proctologic problems in children, JAMA 194:1195, 1965. 2. Turell R: Pediatric proctology: Review with comment, Am J Dis Child 79:510, 1950. 3. Shapiro S: Proctologic conditions in children: A pictorial review, Hospital Medicine, June, 1969, pp 53-72. 4. Paulson M: Rectosigmoidoscopy in infancy and in childhood-a nonsurgical procedure, Am J Dis Child 52:1430, 1936. 5. Shapiro S: The occurrence of proctologic disorders in infancy and childhood, Gastroenterology 15:653, 1950. 6. ShapiroS: Protologic examination of infants and children, J PEDIATR 32:543, 1950. 7. Brandborg LL, Rubin CE, and Quinton WE: A multipurpose instrument for suction biopsy of the esophagus, stomach small bowel, and colon, Gastroenterology 37:1, 1959. 8, BaronJA, Cornell AM, and Leonard Jones JE: Variations between observers in describing mucosal appearances in proctocolitis, Br Med J 1:89, 1964. 9. Watts JM, Thompson H, and Goligher JC: Sigmoidoscopy and cytology in the detection of microscopic disease of the rectal mucosa in ulcerative colitis, Gut 7:288, 1966. 10. Stone RT, and Barbero GJ: Recurrent abdominal pain in children, Pediatrics 45:732, 1970. 11. Apley J: The child with abdominal pain, Oxford, England, 1964, Blackwell Scientific Publications. 12. Groll A, Vlassenbrouck MJ, Ramchaud S, and Valberg LS: Fulminatingnon-infective pseudomembranous colitis, Gastroenterology 58:88, 1970. 13. Curtis KJ, and Sleisinger MH: Infectious and parasitic disease, in Sleisinger MH, and Fordtran JS, editors: Gastrointestinal disease, Philadelphia, 1973, WB Saunders Company, pp 1375. 14. Turner JA, Lewis WP, Hayes M, and Siment I: Amebiasis--a symposium, Calif Med 114:44, 1971. 15. Mentzer CG: Anorectal disease, Pediatr Clin North Am, February, p 113, 1956.
Volume 89 Number 6
16. Ellison FS: Anal fissure occurring in infants and children, Dis Colon Rectum 3:161, 1960. 17. Campbell PE, and Nobler HR: Experience with rectal suction biopsy in the diagnosis of Hirschsprung's disease, J Pediatr Surg 4:410, 1969. i8. Aldridge RT, and Campbell PE: Ganglion cell distribution in the normal rectum and anal canal, J Pediatr Surg 3:475, 1968. 19. Dobbins WO, and Bill AH: Diagnosis of Hirschsprung's disease excluded by suction rectal biopsy, N Engl J Med 272:990, 1965.
Proctosigmoidoscopy and rectal biopsy
20.
9 15
Morson BC: Rectal biopsy in inflammatory bowel disease, N Engl J Med 287:1337, 1972. 21. Gear EV, and Dobbins WO III: Rectal biopsy. A review of its diagnostic usefulness, Gastroenterology 55:522, 1968. 22. Eidelman S, and Lagenoff D: The morphology of the normaI humai~ rectal biopsy, Hum Pathoi 3:389, 1972. 23. Shandling B, and Auldist A: Punch biopsy of the rectum lbr the diagnosis of Hirschsprung's disease, J Pediatr Surg 7"546, 1972.
911
Proctosi gmoidoscopy and rectal biopsy in infants and children The medical records o f all patients ages 0 to 21 years who underwent proctosigmoidoscopy and~or rectal biopsy over a 2 7-month period o f time were reviewed to determine the efficacy and salety o f these procedures in pediatric patients. One hundred twenty-one patients underwent proctosigmoidoscopy; 91 of these also had rectal biopsies. Median age was two years," 21% were less than six months and 8% less than one month o f age. Depth o f examination was 10 to 15 cm in most patients > 10 years o f age. Induced friability was the most frequently observed mucosal abnormality. Abnormal findings were almost always present in patients with bloody diarrhea and were quite common in those with rectal bleeding, but less common in those with chronic diarrhea and abdominal pain. Colitis o f various causes was the most common cause of blood in the stool." anal fissures were found in only four o f 23 patients with rectal bleeding. Both proetosigmoidoscopy and rectal biopsy were needed to exclude the presence o f colitis. Morbidity was 0% with proctosigmoidoscopy and 0.34% with rectal suction biopsy.
J o n A. Vanderhoof, M.D.,* and Marvin E. A m e n t , M.D.,** L o s A n g e l e s , Calif.
PROCTOSIGMOIDOSCOPY and rectal biopsy are commonly used in adults to diagnose colorectal tumors and to evaluate patients with diarrhea and rectal bleeding. Both procedures have been described in infants and children, '-~ but a comprehensive evaluation of their efficacy and safety is lacking. We have reviewed our experience with these procedures during a 27-month period of time to obtain this information. PATIENTS
AND METHODS
All patients less than 21 years of age who had proctosigmoidoscopic examination and/or rectal biopsies at the UCLA Center for the Health Sciences from April, 1973, through July, 1975, were included in this retrospective study. The medical records were reviewed and data concerning proctosigmoidoscopy and rectal biopsy were From the Departments o f Pediatrics and Medicine University of California, School of Medicine. Presented at the plenary session, Western Society/br Pediatric Research, Carmel, California February 1976. *Cystic Fibrosis Clinical Research Fellow in Pediatric Gastroenterology. **Reprint address: UCLA School of Medicine, Department o/ Pediatrics, Los Angeles, CA 90024.
compiled and tabulated. All procedures were done by pediatric gastroenterology fellows and supervised by one of the authors (M.E.A.). All proctosigmoidoscopic examinations were performed using Welch-Allyn rigid fiberoptic sigmoidoscopes. Four sizes having the following dimensions were available: 19 mm x 25 cm (standard adult sigmoidoscope), 15 mm • 25 cm, 15 mm x 15 cm, and 11 mm • 10 cm. All procedures were done without cathartic or enema preparation if the patient had diarrhea or was suspected of having colitis. If a polyp was suspected or if the rectum was filled with hard stool, 10 Ounces of magnesium citrate per 1.73 m ~ was given 24 hours before the procedure, followed by a Fleet's enema the night before and the morning of the procedure. Patients between one month and seven years of age were premedicated 75 minutes before the procedure with meperidine, promethazine, and chlorpromazine at a dosage of 2.0 mg/kg, 1.0 mg/kg, and 1.0 mg/kg, respectively. One-half of these amounts was used for neonates and debilitated patients; a maximum of 50 mg of meperidine, 25 mg of promethazine, and 25 mg of chlorpromazinc was never exceeded. If the patient began to move and strain with digital rectal examination, additional sedation with diazepam, 0.2 to 1 mg/kg, was given intravenously slowly oyer a ten-minute interval, thereby avoiding respi-
Vol. 89, No. 6, pp. 9ll-915
9 12
Vanderhoof and Ament
The Journal of Pediatrics December 1976
Table I. Results at rectal biopsy in patients having proctosigmoidoscopy for various indications
Proctosigmoidoscopy
Rectal biospy
Total number
Normal
Abnormal
Normal
Abnormal
Chronic diarrhea
42
25
17
Rectal bleeding
23
6
17
Bloody diarrhea
20
1
19
Abdominal pain alone
12
10
2
Abdominal pain + chronic diarrhea
9
5
4
14 3 1 2 0 0 5 0 2
5 13 1 9 1 18 0 1 1
6 1 4 6 0 1 5 1 2
1
3
0
Abdominal pain + bloody diarrhea
9
1
8
Abdominal pain + rectal bleeding
,3
2
1
0 0 2
1 4 0
0 4 0
1
0
0
3
1
2
1 0
0 2
0 0
Other
ratory depression. Although the procedure could be performed safely in an outpatient setting, careful monitoring by clinic nursing staff was frequently required for four to six hours after the procedure. Patients were positioned on a standard sigmoidoscopy table in the kneeling position, lnfants were placed in the prone position with a rolled sheet beneath their abdomens. Each examination was initiated with visual inspection of the perianal region followed by digital rectal examination. Selection of the proper sigmoidoscope was arbitrary. The 10 c m x 11 mm instrument was usually used in infants less than three months of age, and the 15 cm x 15 mm instrument for children less than two years of age. The mucosa was evaluated for the presence or absence of ramifying blood vessels, spontaneous friability (bleeding prior to being touched with a mucosal swab), induced friability (bleeding following mucosal wiping), ulcers, and polyps. During each examination multiple areas of mucosa were wiped with a large cotton swab by rotating it 360 ~ against the mucosal surface. Erythema after wiping was not considered abnormal. Rectal suction biopsies were taken with the Quinton multipurpose biopsy tube =using a 2.0 mm biopsy port and 3 to 5 mm Hg negative pressure. Occasionally, greater negative pressure (5 to I0 ram) had to be used to obtain tissue. Biopsies were taken 2 to 4 cm cephalad to the mucocutaneous junction, directed posteriorly or laterally to avoid possible perforation into the peritoneal cavity. All biopsies were interpreted by both one of the authors (M.E.A.) and a staff member of the department of pathology.
[ Not done
RESULTS A total of 121 patients had proctosigmoidoscopic examinations; 91 of these also had rectal biopsies. Patients ranged from two days to 20 years of age with a median age of two years. Twenty-one percent were less than six months of age and 8% were less than one month. Weight ranged from 2 to 80 kg with a median of 15 kg. Indications for proctosigmoidoscopy are shown in Table I. The four most common indications were diarrhea of greater than two weeks' duration, abdominal pain of greater than three months' duration which disrupted normal activities, rectal bleeding, and bloody diarrhea. Many patients had abdominal pain in combination with diarrhea and/or rectal bleeding. Thirty-four additional patients had rectal biopsies performed but did not undergo proctosigmoidoscopy; 28 were biopsied to exclude Hirschsprung disease, three had chronic nonspecific diarrhea, and one had acrodermatitis enteropathica, Two patients had clinical histories compatible with cow milk and soy protein intolerance and were biopsied following a trial feeding of these formulas to evaluate their response to a test feeding. The distance the instruments could be manually inserted varied greatly when compared to age and weight. The 10 and t5 cm instruments could often be inserted their entire length, even in the smallest infants. In children older than 10 years, the median depth of examination was 15 cm. Induced friability was the most frequently described mucosal abnormality and was often found in the absence of spontaneous friability (Table 1I). Thirteen patients in whom induced friability was the only abnormality noted
Volume 89 Number 6
also had rectal biopsies performed; colitis was present in 11 of the 13. Friability was diffuse in 74% of patients whose mucosa was friable, a finding which was not specific for any particular cause of colitis. The frequency with which abnormal findings were observed at proctosigmoidoscopy were also tabulated for each of the various indications for which the procedure was performed (Table I). Patients with bloody diarrhea almost always h a d abnormal examinations showing colitis to be present. In patients with rectal bleeding without diarrhea or abdominal pain, the bleeding source was identified in 74% by proctosigmoidoscopy. In patients whose only presenting complaint was chronic abdominal pain, proctosigm0idoscopic examination was not abnormal except for two patients known to have Crohn ileitis. Final diagnoses of study patients are listed in Table IIL Colitis was the most common condition and was found in 70 patients. Twenty-four had idiopathic ulcerative colitis, diagnosed by its characteristic course and presentation. Nineteen had infectious colitis, determined by isolation of an organism known to cause colitis, or by a clinical course typical of an infectious disease. Thirteen had milk or soy protein intolerance, documented in each case by appropriate challenge studies. Proctosigmoidoscopy and rectal biopsy were most valuable in determining the cause of blood in the stool, with colitis being the usual source of bleeding. Of 55 patients who presented with either rectal bleeding (23) or bloody diarrhea (32), three were known.to have ulcerative colitis prior to proctosigmoidoscopy. Of the remaining 52, the source of bleeding was determined in 42 by proctosigmoidoscopy or rectal biopsy. Thirty-five had colitis. Only four of 23 patients with rectal bleeding alone had anal fissures. One had nodular lymphoid hyperplasia, one had a traumatic mucosal tear secondary to anal intercourse, and the last patient had a rectal polyp. Th e etiology of the rectal bleeding in the ten patients not diagnosed by proctosigmoidoscopy or rectal biopsy was later found to be colonic polyps beyond visualization with the sigmoidoscope in two, necrotizing enterolcoitis in two, and segmental colitis (diagnosed by colonoscopy) in one. Five patients remained undiagnosed. Ninety-one patients had both proctosigmoidoscopy and rectal biopsy. There was concordance of diagnosis in 75. Colitis was diagnosed by proctosigmoidoscopy in seven of the remaining 16 patients when rectal biopsy was normal; the colitis was patchy in these patients. Nine of the 16 patients had colitis diagnosed by rectal biopsy alone. Of a total of 58 patients with all types of colitis who had both proctosigmoidoscopy and rectal biopsy, rectal biopsy was abnormal in 51, proctosigmoidoscopy in 49, and both studies in 42. Correlation of rectal biopsy results with
Proctosigmoidoscopy and rectal biopsy
Table II. Findings on proctosigmoidoscopy in patients
9 13
121
NO.
Finding
q['patients
Normal Induced friability Spontaneous friability Loss of ramifying vessels Edema Erythema Granularity Anal fissure Ulceration Pseudomembrane Mucosal laceration Lymphoid hyperplasia Visible parasites Polyp
58 58 40 26 I0 8 4 4 3 3 1 1 1 I
Table III. Final diagnoses in 121 patients undergoing proctosigmoidoscopy Ulcerative colitis Infectious colitis Milk or soy protein intolerance Irritable colon of infancy Chronic recurrent abdominal pain of childhood Small intestinal mucosal disease Crohn disease Drug-induced colitis Anal fissure Nodular lymphoid hyperplasia Colonic polyps Necrotizing enterocolitis Appendiceat abscess Traumatic mucosal tear No diagnosis established
24 19 13 l1 11 9 8 6 4 4 3 2 1 1 5
proctosigmoidoscopy for each of the various indications is presented in Table I. Complications did not occur from either proc~osigmoidoscopy or from sedation for the procedure. Only one significant hemorrhage resulted from rectal suction biopsy in an eight-year-old child, necessitating transfusion. A total of 293 rectal suction biopsies were taken from 121 patients, resulting in a 0.34% morbidity rate per b~opsy. Eight grasp biopsies were taken from four patients without complications. DISCUSSION Proctosigmoidoscopy is not difficult to perform in infants and children provided that (1) the child is adequately sedated, (2) the proper instruments are available, and (3) the physician is trained in performing the
9 14
Vanderhoof and A m e n t
procedure and in making the appropriate observations. Our data demonstrate the safety of performing both procedures, even in very small infants. The importance of adequate sedation cannot be overemphasized. Patient movement during the examination may result in laceration of the mucosa and possible perforation of the colon or may cause the physician to terminate the procedure before an adequate examination can be completed? All infants and preschool children in our study were asleep when proctosigmoidoscopy was begun; the majority required administration of diazepam to allow the procedure to proceed. Proctoscopy using a test tube and penlight has been frequently used by physicians to examine the rectal mucosa in infants. However, this technique provides inadequate visualization of the mucosa for diagnostic purposes and should be avoided. Amoung visual observations to be made at proctosigmoidoscopy, there are three for which interobserver reliability is greater than 80%? ~ These include the presence or absence of induced friability, spontaneous friability, and ramifying blood vessels. Interobserver agreement for edema, hyperemia, wetness, granularity, and pallor is poor. A previous'protosigmoidoscopic study of children with chronic recurrent abdominal pain reported mucosal changes for which interobserver agreement is poor. t~ Our patients with chronic recurrent abdominal pain ~..... all had normal proctosigmoidoscopic examinations. The four most common indications for proctosigmoidoscopy include chronic diarrhea, abdominal pain, rectal bleeding, and bloody diarrhea. Patients with bloody diarrhea usually have colitis. Proctosigmoidoscopy is of value in these patients in assessing the extent and distribution of rectosigmoid involvement, and in following the course of the disease. The presence of a pseudomembrane is suggestive of antibiotic-induced or infectious enterocolitis, 12 and the presence of discrete ulcers may suggest amebiasis. L3 Mucosal wipings may be examined for amebae, providing a more sensitive diagnostic method than stool examination.TM Proctosigmoidoscopy is essential to establish the etiology of rectal bleeding. All too frequently rectal bleeding is attributed to an anal fissure when the source is another lesion. TM ~'~ Proctocolitis was the most common diagnosis in patients with rectal bleeding, with or without diarrhea. Multiple mucos~/1 wipe tests are necessary to exclude colitis by proctosigmoidoscopy, since 18 patients in our study had induced friability in the absence of spontaneous friability. Patients with chronic diarrhea should also undergo proctosigmoidoscopy and rectal biopsy to exclude the diagnosis of colitis. Patients with abdominal
The Journal of Pediatrics December 1976
pain in the absence of other symptoms rarely have abnormal examinations and should have these procedures performed only if their clinical course is consistent with inflammatory bowel disease. Rectal biopsy is useful in pediatric patients in diagnosing or excluding Hirschsprung disease and also functions as an adjunct to proctosigmoidoscopy in excluding or confirming colitis?~-~3 Because inflammatory changes may be patchy rather than diffuse in some patients with Colitis (26% of our patients), blind rectal suction biopsy may retrieve normal tissue. It is always best to take multiple rectal biopsies when colitis is suspected. Rectal suction biopsy is a safe technique when performed properly. Conclusions cannot be drawn from our experience with only eight grasp biopsies. Another report described a morbidity of 3.4% and mortality of 1% using grasp biopsy in infants. TM
REFERENCES
1. Armineki TC, and McLean DW: Proctologic problems in children, JAMA 194:1195, 1965. 2. Turell R: Pediatric proctology: Review with comment, Am J Dis Child 79:510, 1950. 3. Shapiro S: Proctologic conditions in children: A pictorial review, Hospital Medicine, June, 1969, pp 53-72. 4. Paulson M: Rectosigmoidoscopy in infancy and in childhood-a nonsurgical procedure, Am J Dis Child 52:1430, 1936. 5. Shapiro S: The occurrence of proctologic disorders in infancy and childhood, Gastroenterology 15:653, 1950. 6. ShapiroS: Protologic examination of infants and children, J PEDIATR 32:543, 1950. 7. Brandborg LL, Rubin CE, and Quinton WE: A multipurpose instrument for suction biopsy of the esophagus, stomach small bowel, and colon, Gastroenterology 37:1, 1959. 8, BaronJA, Cornell AM, and Leonard Jones JE: Variations between observers in describing mucosal appearances in proctocolitis, Br Med J 1:89, 1964. 9. Watts JM, Thompson H, and Goligher JC: Sigmoidoscopy and cytology in the detection of microscopic disease of the rectal mucosa in ulcerative colitis, Gut 7:288, 1966. 10. Stone RT, and Barbero GJ: Recurrent abdominal pain in children, Pediatrics 45:732, 1970. 11. Apley J: The child with abdominal pain, Oxford, England, 1964, Blackwell Scientific Publications. 12. Groll A, Vlassenbrouck MJ, Ramchaud S, and Valberg LS: Fulminatingnon-infective pseudomembranous colitis, Gastroenterology 58:88, 1970. 13. Curtis KJ, and Sleisinger MH: Infectious and parasitic disease, in Sleisinger MH, and Fordtran JS, editors: Gastrointestinal disease, Philadelphia, 1973, WB Saunders Company, pp 1375. 14. Turner JA, Lewis WP, Hayes M, and Siment I: Amebiasis--a symposium, Calif Med 114:44, 1971. 15. Mentzer CG: Anorectal disease, Pediatr Clin North Am, February, p 113, 1956.
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16. Ellison FS: Anal fissure occurring in infants and children, Dis Colon Rectum 3:161, 1960. 17. Campbell PE, and Nobler HR: Experience with rectal suction biopsy in the diagnosis of Hirschsprung's disease, J Pediatr Surg 4:410, 1969. i8. Aldridge RT, and Campbell PE: Ganglion cell distribution in the normal rectum and anal canal, J Pediatr Surg 3:475, 1968. 19. Dobbins WO, and Bill AH: Diagnosis of Hirschsprung's disease excluded by suction rectal biopsy, N Engl J Med 272:990, 1965.
Proctosigmoidoscopy and rectal biopsy
20.
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Morson BC: Rectal biopsy in inflammatory bowel disease, N Engl J Med 287:1337, 1972. 21. Gear EV, and Dobbins WO III: Rectal biopsy. A review of its diagnostic usefulness, Gastroenterology 55:522, 1968. 22. Eidelman S, and Lagenoff D: The morphology of the normaI humai~ rectal biopsy, Hum Pathoi 3:389, 1972. 23. Shandling B, and Auldist A: Punch biopsy of the rectum lbr the diagnosis of Hirschsprung's disease, J Pediatr Surg 7"546, 1972.