Blood in urine/Blood in

stool/Blood from any

site
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-Dr. Bhavesh khandhar
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Blood in urine

 Presence of RBCs in urine. It may be seen by naked eye or

microscopic seen.
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How to ask and what to observe

 Recent vigorous exercise or trauma. (See "Exercise-induced

hematuria".)

 History of new onset of incontinence, dysuria, frequency, or

urgency suggests urinary tract infection (UTI) as a possible
cause.

 History of unilateral flank pain that may radiate to the groin

suggests obstruction caused by a calculus or blood clot.
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How to ask and what to observe

 flank pain without radiation but with fever, dysuria, and

frequency and/or urgency is suggestive of acute pyelonephritis

 The timing of hematuria during micturition may suggest an

etiology. As an example, initial hematuria (onset of urination)
usually suggests urethral bleeding; continuous bleeding
throughout urination may occur from bleeding in the bladder,
ureter or kidneys; and terminal bleeding (at the end of urination)
is indicative of bladder disease.
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 The color of urine may distinguish glomerular bleeding from

extraglomerular bleeding. Glomerulonephritis is associated with
brown urine. Bleeding from the lower urinary tract is suggested
by pink or red urine and may be accompanied by blood clots.

 history of pharyngitis or impetigo (two or three weeks prior to

onset of hematuria) suggests poststreptococcal
glomerulonephritis, although a recent upper respiratory (one or
two days prior to onset of hematuria) infection can be
associated with immunoglobulin A
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 history of predisposing clinical conditions such as sickle cell

disease or trait or coagulopathy such as severe hemophilia.

 Exposure to medications that can cause hemorrhagic cystitis

(such as cyclophosphamide), eosinophilic cystitis (nonsteroidal
anti-inflammatory drug or antihistamines) or interstitial nephritis
(such as nonsteroidal anti-inflammatory drug [ibuprofen] or
penicillins
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Causes

 Urinary tract infections(cystitis, bacterial, viral(adenovirus),

urolithiasis, hydronephrosis, urethritis, foreign body,TB)

 Systemic infection(henoch-scholein purpura, SLE, HUS,

Bacterial endocarditis)

 Glomerular(PSGN, MSGN, MPGN, RPGN, IgA nephropathy)

 Vascular(Trauma, sickel cell disease, renal artery thrombosis, A-

V malformatiom, hemangioma, exercised induced, Nutcraker
syndrome)
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Causes

 Neoplastic(wilms tumor, renal cell carcinoma, rhabdoid tumors,

uroepithelial tumors,angiomyolipoma)
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Blood in stool

 Blood from gastro-intestinal tract. It may be from upper

GI(proximal to ligament treitz) tract or lower GI tract(distal to
ligament treitz)

 Upper GI tract also called melena and lower GI tract also called
hematochezia
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How to ask and what to observe

 Duration and amount of bleeding – (The patient or family can

estimate the amount of blood, but this is often inaccurate. Asking
whether there is enough blood to color the toilet water, if so how
red, and if clots are present, can help to convey the amount of
bleeding observed)

 Color of the blood – (Bright red blood is most consistent with a

lower gastrointestinal source, hemorrhoid, or anal fissure.
However, UGIB should be considered in infants or any child with
evidence of hemodynamic instability or with risk factors for UGI
bleeding)
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 Consistency of accompanying stool – Accompanying diarrhea

suggests the possibility of colitis (eg, food protein-induced colitis
in an infant, hemolytic-uremic syndrome (HUS) or
immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura
[HSP]) in a young child, inflammatory bowel disease (IBD) in
older children and adolescents, or infectious colitis in all age
groups).

 blood that is primarily on the outside of a formed stool(anal

fissure, hemorrhoid, or polyp)
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 Typical features are small recurrent rectal bleeding, often with

constipation and/or anal symptoms.(Anal fissure)

 Typical features are small to moderate bleeding, often with mucous in

stool, with or without abdominal pain and diarrhea(milk or soy protein
colitis)

 Typical features are normal appearing stool, often with recurrent

bleeding(juvenile polyp)

 Diarrhea with abdominal pain – (Suggests colitis (milk- or soy-induced

in an infant; infectious colitis or IBD in older children), or HUS)
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 Associated with Fever – Suggests infectious colitis, possibly

Hirschsprung-associated enterocolitis in a young infant, or
occasionally IBD.

 Associate with Weight loss and fatigue, delayed puberty –

Suggest underlying systemic disease, especially IBD.

 History of epistaxis

 Recent use of nonsteroidal antiinflammatory drugs (NSAIDs) or

any other medications – (NSAIDs can cause UGIB due to peptic
ulcers, or exacerbate LGIB due to anti-platelet effects)
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Causes

Neonatal period

 Swallowed maternal blood

 ●Anorectal fissures
 ●Necrotizing enterocolitis
 ●Malrotation with midgut volvulus
 ●Hirschsprung disease with enterocolitis
 ●Coagulopathy
 ●Brisk upper gastrointestinal (GI) bleeding

 ●Vascular malformations
 ●Gastric or duodenal ulcer

 ●Gastrointestinal duplication cyst

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Infant and toddler period

 Anal fissures (especially around the introduction of solid food or cow's milk)
 ●Milk or soy protein-induced colitis (allergic colitis)
 ●Intussusception
 ●Infectious colitis
 ●Meckel's diverticulum
 ●Lymphonodular hyperplasia
 ●Gastrointestinal duplication cyst
 ●Coagulopathy
 ●Eosinophilic gastrointestinal disease (EGID)
 ●Infantile and very early onset inflammatory bowel disease (VEO-IBD)
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Pre school age and school age group

 nfectious colitis

 ●Hemolytic-uremic syndrome (HUS)

 ●Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura [HSP])

 ●Juvenile polyps

 ●Very early onset inflammatory bowel disease (VEO-IBD)

 ●Solitary rectal ulcer syndrome (SRUS)

 Inflammatory bowel disease

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Blood from any site

 Blood from other sites than urine and stool are from
ear(trauma,infection, foreign body, head injury,rupture ear
drum), any body part injury(history traumatic injury), oral
cavity(traumatic injury, vitamin deficiency,ulcer,
candiasis,leukemic infiltrate,herpes virus infection), nasal
cavity(nasal dryness, foreign object, allergic reaction, URTI,
picking nose, repeated sneezing,chemical irritant), eye(retinal
hemorrhage, traumatic injury, head injury), Head injury
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Thank you