studies indicate Hirschsprung disease, rectal biopsy is not necessary to confirm the diagnosis In children of all ages, an adequately performed suction mucosal biopsy of the rectum cm or more above the dentate line can be reliable in diagnosing Hirschsprung disease Because of the complicated evaluation and management of this disease, referral to a pediatric surgeon is recommended Duplications Duplications occur anywhere from the mouth to the anus and produce various symptoms In the abdomen, there may be a noncommunicating cyst that gradually fills up with secretions and compresses the adjacent normal bowel, producing a palpable abdominal mass or chronic intestinal obstruction Rarely, a marginal ulcer resulting from ectopic gastric mucosa may occur, and this produces painless bleeding After appropriate radiographic diagnosis, surgery is indicated Inflammatory Bowel Disease The older child or adolescent may develop either Crohn disease or ulcerative colitis (see Chapter 91 Gastrointestinal Emergencies ), and this must be included in the differential diagnosis of chronic intestinal obstruction Usually, the child has a history of changing bowel habits, with mucus or blood in the stools, chronic abdominal pain, and weight loss Chapter 91 Gastrointestinal Emergencies covers inflammatory bowel disease in detail DISEASES THAT PRODUCE RECTAL BLEEDING Goals of Treatment Rectal bleeding can be a sign of a serious condition Clinicians need to identify generally innocent etiologies from those that can be life-threatening The primary goals should be early recognition of hemorrhagic shock and ischemic bowel Blood on the outside of a formed stool is likely to originate from the distal large bowel, rectum, or anus Blood mixed in the stool is generally from a higher source of bleeding Blood associated with diarrhea is common with inflammatory bowel disease and infectious enteritis A “tarry” stool suggests a source of bleeding in the proximal portion of the GI tract, and bright red blood suggests a more distal origin ( Fig 116.17 ) All patients with rectal bleeding should have a rectal examination Those with significant hemorrhage require flexible colonoscopy In some patients, no definite diagnosis may be reached despite extensive studies In any patient with significant bleeding, however, surgical consultation is indicated Chapters 33 Gastrointestinal Bleeding and 91