An 8-year-old boy is brought to the GP by his father for 3 days of painful bowel motions. He has recently switched GPs and in previous records, he has not been brought in to any of his routine appointments. The child is quiet and withdrawn, but states he has been opening his bowels once per day, with no change in frequency or consistency. His father states it started when he fell down onto one of his toys while playing with his sister. On further questioning, he states there has been some fresh red blood on the toilet paper on wiping. He explains he has been afraid to open his bowels as, for the last three days, he has found it very painful to go, but still has managed without straining. He denies abdominal pain, recent change in diet, or loss of appetite.

On examination, observations are unremarkable and his abdomen is soft and non-tender. An attempt at PR exam is abandoned as he finds it incredibly painful.

Which of the following is the best next step in the management of this patient?

Options:
explanation: Topical glyceryl trinitrate (GTN) is given to treat chronic anal fissures in adults, but not children, as it is unlicensed. It is used to relieve pain caused by the fissure and help the external anal sphincter relax, allowing more blood flow to the mucosa, which may further aid the healing process. In children, anal fissures are initially managed by reducing constipation with high-fibre diets, considering use of laxatives, warm baths, and encouragement of drinking plenty of fluids. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
name: Topical glyceryl trinitrate per rectum
label: d
answer: no
explanation: Constipation may be the first sign of Crohn's disease, where the child is opening their bowels less than three times per week. Constipation can cause anal fissures in children, resulting in the symptoms this child is experiencing. Often in Crohn's disease, however, there are other signs such as bloating, diarrhoea (sometimes with blood and mucus), reduced appetite, weight loss, fatigue, and slow growth. If inflammatory bowel disease is suspected, then a faecal calprotectin would be appropriate. The history, however, does not suggest this child is constipated or has any other systemic issues. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse, and raising concern of a sinister cause for his anal fissure. In this case, referral to the safeguarding lead is more pressing
name: Send a faecal calprotectin
label: e
answer: no
explanation: In this scenario, the child's injuries are not consistent with the father's explanation of events. His symptoms fit with an anal fissure/laceration. This can occur commonly with constipation in children, although a low threshold to suspect sexual abuse is required in a child who has an anal laceration where constipation, Crohn's disease, and passing hard stool have been excluded as the cause. He states he is passing stools normally and regularly, but with fresh red PR bleeding and so an anal fissure is the most likely cause and constipation less likely
name: Referral to the GPs safeguarding lead
label: a
answer: yes
explanation: This would be a reasonable option for a child who has developed constipation and subsequent anal tear/fissure, which is deemed unlikely caused by non-accidental injury. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
name: Recommend a high-fibre diet
label: c
answer: no
explanation: This would be a reasonable option for a child who has developed constipation and subsequent anal tear/fissure, which is deemed unlikely caused by non-accidental injury. Usually a trial of high fibre diet would be trialled first, followed by laxatives if unsuccessful. In this case, the more pressing issue is the inconsistency of the story and the child's injury, raising suspicion of possible sexual abuse. In this case, referral to the safeguarding lead is more pressing
name: Prescribe 7 days of laxatives
label: b
answer: no

Correct answer: a


Learning point: A low threshold for suspecting sexual abuse is essential in a child with an anal laceration when other potential causes, such as constipation, Crohn's disease, and passing hard stool, have been ruled out.