4 thoughts on “Hot Seat Case #134: 10 day old M with bloody stools”

1. 
   

   It appears that this is otherwise a healthy newborn, who has a recent onset of hematochezia. The report of large copious amount of frank blood is concerning, though it is unclear who is reporting this (mother or the provider) and quantification of blood is difficult. It is reassuring that the baby is otherwise feeding and growing, and does not have vomiting, fevers, or irritability.

   In history, I would like to know if the baby received vitamin K at birth and if there is any bleeding history in the family. I would also like to know if the baby passed meconium within 24-48 hours of birth, and what is the baseline stooling frequency.

   Vital signs and physical exam are reassuring. I would do a rectal exam to get a sense of whether the stool may be hard, or if there is a frank blood on my finger.
   Based on the presented information, I feel that the dietary protein allergy is the most likely etiology. As the baby is nontoxic, and belly exam is benign, serious conditions are less likely (necrotizing enterocolitis, volvulus, intussusception, Hirschsprung enterocolitis).
   I would do blood work, including CBC and coags for reassurance. If the volume of blood loss is large, and if there is anemia, I would suspect Meckel diverticulum to be relatively high on the differential.

   I would not immediately think to get an x-ray, unless I had a concerns elicited from H&P ( e.g. irritability, poor feeding, vomiting, abdominal distention, decreased bowel sounds). However, now that the xray is obtained and report states that pneumatosis could not be excluded, I feel I would be in a difficult position re: dispo. I would review the images with the radiologist, if possible. Although the chance of pneumatosis is still low, I would probably admit the baby for observation and repeat AXR.

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   1. 
      

      Common things being common, can we get clarification on two other exam points:
      Were there any anal fissures?
      Was there tenderness on abdominal exam?

      NEC although very infrequent, has been described in term NB’s with no risk factors. With that suspicious report, we may need to do perform additional labs, serial exams, bowel rest & place in observation status/admit.

      Another benign consideration is “swallowed maternal blood”. Can we do the Apt test or as part of stool OB testing assess for fetal Hgb? Throwing pathologist a lifeline here!

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2. 
   

   Only because it’s Vahe, I’ll add a different perspective here. While our consultants are great to think deeply about a variety of things, our consultants will come at a problem with their lens on it. Typically, when we consult GI in the ED, we’re already presuming less likely surgical causes and hence the consultant comes to us with what’s likely. However, as ED docs, as Jay alludes to we look at what the worst thing. As I’m sure Shilpa will do soon, her post will include the SPIT DDx (Serious, Possible, Interesting, Treatable) and that’s what we need to do as ED docs.

   My classic story for this is when the cardiologist was presented with abdominal pain and their first thought was it must be myocarditis…Ahh, the lens from which we look.

   Point: Be mindful of the lens from which the consultant sees the patient.

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3. 
   

   Thanks Pavan for the set up and to Jonathan for this great case. I like looking at the DDx using the SPIT lens.

   To restate the case:

   We have a full term, well appearing, thriving 7 day old infant presenting with frankly bloody stools without other systemic symptoms such as vomiting, fever, jaundice, pallor or irritability; with normal vitals and exam but questionable pneumatosis on AXR.

   S (Serious) – It is always important to start with this category to ensure consideration of important ‘not to miss’ diagnoses. As those above have mentioned, necrotizing enterocolitis (NEC) (approximately 10-15% of cases are in full term infants usually in the first week of life), Hirschprung’s with enterocolitis, infectious colitis, sepsis, GI malformations (malrotation with volvulus) or coagulopathy fit in this group. This category does not imply that diagnostic testing is necessary to rule out the above list however it does ensure that the provider considers these causes and is able to justify by history, exam or with testing (if history or exam are not helpful in decision making) that they are less likely. In our case, the baby being well appearing without systemic signs of illness — which removes many of these causes. However we are stuck with an AXR suggesting possible pneumatosis, which would make me want to admit the child for observation.

   P (probable) – Then we move to what is more common and what we think is most likely the cause of the symptoms. Anal fissures (this should be apparent on exam), swallowing maternal blood (however you would not think it would cause copious bleeding as described in this scenario), and allergic colitis (FPIES or food protein induced enterocolitis syndrome). For ex: cow milk protein allergy, however milk protein allergy usually presents slightly later.

   I (interesting) – This is a good category to encourage us to think of less common causes so that we can continue to learn.

   T (treatable) – What can you do today (with minimal risk) to potentially treat a cause. As mentioned above, elimination diet for the mother to remove milk proteins from her diet is a good start. Additionally, think about those items on the serious list that are easily treatable when thinking about this category. Given this I would suggest the following work-up:

   Hemoccult stool — if positive then…
   CBC
   Apt test (to check for swallowed maternal blood)

   These are optional especially given no vomiting — I have to agree with GI, not sure I would have gotten an AXR.

   AXR(to look for free air, pneumatosis, portal venous air)
   US (I read about this briefly in the diagnosis of NEC – if our US folks want to comment)

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