Case 3: Abdominal Distention and Bloody Stools in a 2-week-old Term Neonate.

Abstract

A 2-week-old female neonate is born via cesarean section at 39 2/7 weeks to a 34-year-old gravida 3, para 2 woman with adequate prenatal care and negative serologic findings. During pregnancy, the mother develops gestational diabetes that was both diet and insulin controlled. The infant is exclusively breastfeeding at home. At 17 days of age, the infant is brought to the emergency department (ED) with acute onset of bloody stools that occurred once, along with lime-yellow vomitus concerning for bilious emesis. The mother reports that the infant had been fussy the previous day with increased vomiting and nasal mucous discharge requiring bulb suction. She calls the pediatrician who recommends obtaining a rectal temperature, which is 98.6°F (37°C). Two hours later, the infant develops the rectal bleeding episode (Fig 1) and is brought to the ED at our institution. Figure 1. Bright red blood in the diaper of the patient. In the ED, the physical examination findings are significant for increased fussiness on abdominal palpation, moderately distended firm abdomen, increased tympany, absence of bowel sounds, bright red blood in the diaper, and no anal fissures. Admission vital signs include a temperature of 99.3°F (37.4°C), heart rate of 152 beats/min, respiratory rate of 48 breaths/min, and oxygen saturation of 100% in room air. Complete blood cell count in the ED shows no evidence of leukocytosis, bandemia, or eosinophilia (white blood cell count of 16,000/μL [16×109/L] with 1 band, platelets of 477×103/μL [477×109/L]). Coagulation profile is within normal limits (prothrombin time 12.6 seconds, partial thromboplastin time 28 seconds, international normalized ratio 1.0). Abdominal radiography in the ED shows “abnormal dilated bowel, without free air or pneumatosis. Ileus, necrotizing enterocolitis (NEC), and enteritis should be considered. The appearance is less consistent with malrotation; however, upper gastrointestinal (GI) endoscopy is recommended …