PR Bleeding: Advice for Referrers

RHC for Health Professionals
NHS GGC

The causes of PR bleeding vary with age. It can be fresh red blood (generally indicating bleeding from the lower GI tract) or melena (generally indicating bleeding from higher up in the GI tract). In relatively well children (i.e. those not thought to need acute referral to the hospital) consider the following:

  • For infants the main causes to consider are cow’s milk protein allergy and constipation with a small tear. For a breastfeeding infant consider maternal cracked nipples.
  • For older children consider constipation with an anal fissure, infectious enterocolitis, polyps, and inflammatory bowel disease.

It is important to refer acutely if there are any red flag features or concerns regarding acute illness.

Conditions to be concerned about include:

In infants/young children: necrotising enterocolitis, intussusception, volvulus, Meckel’s diverticulum

In older children: inflammatory bowel disease

Any age: infective diarrhoea

Red Flags

  • Concerns about the condition of a child (raised PEWS score): tachycardia, clinically dehydrated, fever
  • Weight loss (acute or chronic)
  • Acute onset of pain or irritability
  • Large blood loss, or red currant jelly stool
  • Melena
  • Acute bloody diarrhoea
  • Bilious, persistent, or large vomits associated with the PR bleeding
  • Abdominal mass that does not feel like impacted faeces
  • Bleeding from other areas (e.g. nose, mouth), bruising or petechiae
  • Any child protection concerns

Please include the following points from the history in the referral letter

  • Does the child have constipation or diarrhoea? Include length of altered stool pattern
  • Stool frequency and type (use the Bristol Stool Chart if possible)
  • Is the blood mixed in with stool, coating the stool, or present on wiping?
  • Is it fresh blood or melena?
  • Any associated symptoms: including abdominal pain or vomiting
  • Growth of the child: are they gaining weight and length/height? Any evidence of faltering growth?
  • Include birth weight if infant
  • Fluid intake and information about diet, any recent changes?
  • If they are breastfed does the mother have cracked nipples?
  • If they are mixed feeding or formula fed – include which formula, volumes, any symptoms of cows milk protein allergy (either IgE-mediated or non-IgE mediated)? See Allergy Referral Guideline
  • Medication history: any medications that cause change in colour of stool e.g. iron causing black stools
  • Family history: any inflammatory bowel disease, polyposis, or coagulopathy
  • Social history: travel history, any contact with animals, farms or another person with diarrhoea
  • Any child protection concerns?

Please include the following points from the clinical examination in the referral letter

  • General examination - any pallor, rashes, oral ulcers
  • Abdominal examination - pain on palpation, any masses
  • If anal inspection undertaken - any fissures or haemorrhoids?
  • Include height and weight measurements

Suggestions for management whilst waiting for outpatient appointment

Useful resources for parents whilst waiting for outpatient appointment

 If the child is constipated:

  • Signpost parents to the ERIC website, and encourage them to read the information and watch the videos
  • Sign post parents to the Bowel and Bladder UK website: https://www.bbuk.org.uk/
  • Ask parents to look at the ‘Bristol Stool Chart’ images available on the internet, and to assess and record the types of stool their child is passing each day

If the mother is breastfeeding and has cracked nipples refer to Infant Feeding Advisors. See Referral Form and information for parents on Breastfeeding Information for Primary Health Care Providers. Families can access resources using the following QR code:

Editorial Information

Last reviewed: 01/08/2024

Next review date: 31/07/2027

Author(s): Dr Rosalind Kelly, Paediatric Trainee; Dr Ruth Bland, Paediatric Consultant.

Approved By: RHC Medical Paediatrics

Reviewer name(s): Ruth Bland.