THE CASE
An 8-year-old girl is brought to the emergency department by her mother with a complaint of 5 days of worsening constipation and rectal bleeding. For the past week, the girl has had small stools 3 or 4 times a day and crampy abdominal pain. Yesterday, her stools were streaked with a small amount of blood. The mother notes that her daughter spends up to an hour in the bathroom with each bowel movement. In addition, the mother remarks that the girl has a rash in the rectal area and along the inner thighs. The patient complains of pain in this area. The mother also reports that her daughter has been walking oddly for the past few days and crying.
The patient has no fever, vomiting, or dysuria; however, her oral intake and activity level have been decreased, and her sleep has been poor. She has also had occasional pains in her ankles and hands. There is no disclosure or reported history of abuse.
She has a history of chronic constipation that began when she was about 3 weeks old. The constipation has been treated with over-the-counter fiber supplements with varying success. She takes no other medications. An MRI scan of the abdomen performed at age 3 years to evaluate her constipation was reportedly normal. There is a family history of hypertension but no family history of GI disorders.
The patient, her mother, and her 3 brothers recently moved to the area from Texas. The patient's father did not move with the family and had reportedly been abducted while he was in Mexico.
On physical examination, the child is uncomfortable and appears anxious. She weighs 23 kg (50.6 lb). Distention is noted in the lower left and upper left quadrants; there is diffuse abdominal tenderness with decreased bowel sounds but no hernias. The abdominal radiograph is as shown (Figure 1). Genitourinary examination reveals a very painful erythematous, papular rash in the perianal region and extending to the bilateral buttocks and medial thighs (Figure 2). Stool coats the entire groin area, and a possible fissure is seen near the anus.
