Gastrointestinal bleeding — branching viva

Opening — framing the problem

The examiner begins: an 18-month-old boy passes a large amount of bright red blood per rectum with no pain and looks well. What is your first framework for thinking about this? ^[1]

My first framework is the upper versus lower split at the ligament of Treitz and the age of the child. Bright red blood per rectum usually means a lower tract source, and in a well toddler with no pain a Meckel diverticulum and a juvenile polyp head the differential, with an anal fissure excluded by the perianal exam. I would first confirm he is haemodynamically stable, because even a painless bleed can be large. ^{[1] [3]}