The Case: Dr. Patel said it beautifully: “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.”

Here’s how you answered the questions:

Discussion:

Ahh the classic infant doing funny things….in this case bloody stools. The age old question remains, do nothing because he has a reassuring history and exam?? Or do everything because he is an infant and infants cannot be trusted??

Some cowboys would provide reassurance, ensure good follow up and send this baby home. However, knowing that this is a hot seat case and because we have been burned by well appearing babies before, most would do something. Many commenters and those in the audience asked about exam findings such as anal fissures, abdominal tenderness, rectal exam, hemoccult testing, or Apt testing to help guide additional, more in depth, work up.

As for common things being common, many (including our GI colleague Dr. Badalyan) would highly suspect milk protein allergy. While a common diagnosis in infants, there are a few features that don’t quite fit, which Dr. Patel astutely mentioned, including age (it takes at least 7-10 days for the allergy to develop so this infant is the youngest possible age for presentation) and usually results in blood streaking, rather than grossly bloody stools.

In her comment, Dr. Patel very nicely reminded us of the serious, “can’t miss,” diagnoses. While an AXR is not essential for making the diagnosis of these (colitis, coagulopathy, malrotation), we find ourselves stuck with pneumatosis on the AXR. What to do? Dr. Lindgren raised the great point that our surgical colleagues are much more used to dealing with NEC in neonates and reaching out for their input on management would be valuable. Most agreed that sending this normal appearing baby home given abnormal imaging findings was risky and would opt for a period of observation, if not admission.

Denouement:

Repeat X-ray was obtained:

FINDINGS: Supine AP view of the abdomen was obtained. The bowel gas pattern is nonobstructive. Pneumatosis is present within the left abdomen. No free air or pneumobilia is observed.

IMPRESSION: Positive for pneumatosis. Once Pneumatosis was confirmed, patient was taken directly to NICU.

Initial Labs:  WBC: 11.97, H/H:  13.8/38.5, Plt: 474

CMP unremarkable, CRP: 0<0.1. Blood Culture negative 5 days.

NPO, and antibiotics started (Vancomycin, Gentamicin, Zosyn)

Repeat Abd films obtained. Subsequent films 12-24 hours later showed no pneumatosis. The infant underwent a 72 hour rule out after which, we reintroduced AA formulae and mom eliminated dairy. He was discharged after 7 days with GI follow up.

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