A 7-year-old boy is brought in by his parents with concern for rectal bleeding. Both parents had gone to the store and left the child with relatives for about 4 hours. While they were away, a neighbor called the parents to say she called an ambulance after the child came to her apartment saying he was hurt. She saw blood on his shorts and underwear and thought there was bleeding from his rectum. He would not say how he got hurt. When questioned by the mother, the boy said he slipped and fell in the bathroom, but he would not give more details. He is otherwise healthy without any medical problems or surgical history. During a focused history, the mom states he is a developmentally normal child without any delays. His review of systems is negative for weight loss, fevers, chills, night sweats, rashes, or pallor.
On exam, he has moderate tachycardia but no tachypnea, fever, hypotension, hypertension, or hypoxia. He is quiet when left alone and lies on his side as a position of comfort. When asked to move around or lay on his back, he complains of pain in his rectal area. He has no pallor. His pulses are strong. His abdominal exam is positive for mild voluntary left lower quadrant (LLQ) guarding. All other quadrants are without pain, guarding, or rebound.
The physical exam is shown next.
What is seen on exam? What is the first priority in his evaluation?
This patient has a rectal laceration. From
the bedside exam, it is not clear how far it extends into the rectum. As with
any trauma or medical
evaluation, the first priority is the ABCs: attention to airway, breathing, and circulation.
In this patient, airway and breathing are stable. A rectal laceration raises concerns about circulation with concerns for hypovolemia, shock, peritonitis, and sepsis. Intravenous access is obtained and a normal saline bolus is infused. Laboratory studies are obtained to assess for anemia.
The physician and social worker asked the patient what had happened. He continued to repeat that he had fallen but without further details. Parents called the aunt who reported she went to the store leaving the patient in the care of his 19- year-old cousin. The cousin denied any trauma. Even without a disclosure, the injury met the criteria of a reasonable suspicion of abuse. The hospital staff made reports to police and child welfare services.
A surgical evaluation determined the need for operative intervention. A forensic evidence collection kit was sent to the operating room with the patient. Collection was obtained while the child was under anesthesia. Parents gave consent for evidence collection.
The rectal laceration was repaired and the patient was discharged home in 5 days. One week after the event, the patient underwent a forensic interview and gave a disclosure consistent with sexual assault by the cousin. He has had no contact with the cousin since the assault.
Sexual assault is a highly traumatic and highly sensitive area of medicine. Child sexual abuse and assault rarely have physical evidence of trauma. The cases often rest on disclosures by children. An unusual traumatic injury with penetrating rectal trauma and lack of disclosure warrants investigation.
In this scenario, it was
appropriate for the medical staff to ask the patient what happened. It is
preferable to do this separate from caretakers, but only if the patient is
willing to separate. Questions should always be non-leading and open-ended.
This gives the opportunity for the patient
to disclose if he
or she wants to but does not introduce any suggestibility. Examples include
“Can you tell me what happened? Can you tell me why you are here? Has anyone hurt you or made you
uncomfortable?” These general questions
are sufficient. One can then ask “Would you like to tell me more?”
If there is a disclosure, the opportunity for disclosure to a trusted adult
should be provided. The interview should be ended if the patient does not
disclose anything with these general questions. Opportunities and resources for
forensic interviews will vary in different regions.
The literature provides evidence that 90%–95% of exams in child sexual abuse/assault are normal, even when there is a history of penetrating trauma. Delayed disclosure is a common reason for this, which can be due to fear, shame, and lack of knowledge. An estimated up to 75% of perpetrators are known to the victim, contrary to popular belief, and 25%–50% of these are relatives.
In this scenario, it was also appropriate for medical staff to have a concern for sexual assault even without a disclosure. The majority of cases have no physical findings, although the presence of a finding is highly significant. Investigation is warranted if an accidental mechanism cannot be explained accurately, clearly, or reliably. The decision to collect forensic evidence is an
important consideration and is time-sensitive. The literature supports evidence collection out to 72 hours from an assault in pre-pubertal and pubertal children and out to 7 days in adolescents and adults.
Keywords: child abuse, abdominal pain
Adams JA, Kellogg ND, Farst KJ, Harper NS et al. Updated guidelines for the medical assessment and care of children who may have been sexually abused. J Ped Adolesc Gynecol 2016;29(2):81–7.Fortin K, Jenny C. Sexual abuse. Pediatr Rev 2012;33(1):19–32.