Pediatric Hospitalist Case

[Freezer]

alright all you gunners... batter up...

2 day old newborn who presents with bloody, heme positive, stool soon after delivery. Prenatal u/s normal. Abdominal U/S normal. CBCs normal. Vitals normal. Stool, still bloody.

Go!

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[Rumalum]

do the test to see if it's maternal vs. fetal blood

 

[Freezer]

do the test to see if it's maternal vs. fetal blood

Great thought! We were thinking the same thing. Got an Apt test and it was all fetal HgB. Also, it was a clean delivery and mom does not report any bloody milk production

 

[Cytarabine]

Great thought! We were thinking the same thing. Got an Apt test and it was all fetal HgB. Also, it was a clean delivery and mom does not report any bloody milk production

FHx of coagulopathy?
WGA / birthweight?
Good antenatal / postpartum care?
Epistaxis?
Breast or bottle feeding? Maternal meds? Tolerating feeds?
BRBPR or melena? Intermittent blood or every stool is bloody? Passed meconium?
Crying w/defecation?

Normal nasal exam / no signs of recent bleed?
Benign abdomen?
Anal fissure?

Also want coags

 

[Freezer]

FHx of coagulopathy? Incomplete, mom adopted
WGA / birthweight? AGA for 41w
Good antenatal / postpartum care? Yes
Epistaxis? No
Breast or bottle feeding? Breast
Maternal meds? I was interested in the same thing. Mom was on cefdinir prior to delivery for an AOM but we feel it is unrelated as the stool is truely heme positive
Tolerating feeds? Yes, advancing appropriately
BRBPR or melena? Initial stool had gross blood. Following stools could be passed off for meconium if we were not already suspicious for a bleed.
Intermittent blood or every stool is bloody? Every
Passed meconium? Yes
Crying w/defecation? No

Normal nasal exam / no signs of recent bleed? wnl
Benign abdomen? wnl
Anal fissure? No

Also want coags - me too but the sample keeps clotting before making it to the lab

Perfect questions by the way!

Meckles Scan was Negative.

 

[Cytarabine]

Boy or a girl?

My next move would probably be peripheral smear and platelet function assay +/- factor assay, but I think I'm going down the wrong track. Think the clotting in the coag tube is big hint, but I'm not sure exactly where to go with it!

 

[Psai]

did he get vitamin k at birth?

what does the umbilicus and the gu exam look like? i'd like to look for umbilical and inguinal hernia maybe hes incarcerated

babygram to look for volvulus even though ultrasound was negative. also for nec to see if he has portal vein air or pneumatosis intestinalis although he's wasn't premature. maybe he has intussusception

can you do a ristocetin cofactor assay

 

[Cytarabine]

did he get vitamin k at birth?

what does the umbilicus and the gu exam look like? i'd like to look for umbilical and inguinal hernia maybe hes incarcerated

babygram to look for volvulus even though ultrasound was negative. also for nec to see if he has portal vein air or pneumatosis intestinalis although he's wasn't premature. maybe he has intussusception

can you do a ristocetin cofactor assay

Good postpartum care I'm assuming means he got a vit K injection. I had meant to about the relative utility of US/xray in diagosing/ruling out NEC, but AGA/term doesn't fit and an otherwise healthy baby tolerating feeds doesn't really fit; same for volvulus/strangulation. Unless there are weird presentations of these I don't know of

 

[Freezer]

I love the NEC idea. Given that NEC doesnt show up radiographically until the disease has had time to progress, we empirically made her NPO and started Amp/gent(our area still has great Gent coverage). The coagulation studies are all great thoughts as well. All in all, you both came up with an extremely well thought out differential! We just got a diagnosis today... the big reveal. Turns out Cytarabine had a great question regarding epistaxis. When I first saw your question, I immediately thought of vasculitities and AVMs but also simpler etiologies which may have been something you were thinking all along. At delivery, turns out, a suction catheter was passed down the nares to help clear the airway. The catheter appears to have made a big ole gash in the nasal pharynx which was seen using a mirror in the oropharynx. Healing up well now. Althoguh the hemoccult studies are still positive, even trace microscopic blood will turn those things positive. HgB remains stable and she is feeding well. Kind of a boring Dx. Was hoping for an interesting zebra and instead I got trauma from management. You all did great and you are going to be great docs in your career!

 

[Cytarabine]

Thanks for posting the case, theyre always appreciated!

 

[mvenus929]

Good postpartum care I'm assuming means he got a vit K injection. I had meant to about the relative utility of US/xray in diagosing/ruling out NEC, but AGA/term doesn't fit and an otherwise healthy baby tolerating feeds doesn't really fit; same for volvulus/strangulation. Unless there are weird presentations of these I don't know of

I've seen several term, otherwise well infants present with NEC. We had one go home and show up to clinic with grossly bloody stools. Volvulus is weird without vomiting, but I wouldn't rule out NEC just because she was 'tolerating' feeds.

 

[Cytarabine]

I've seen several term, otherwise well infants present with NEC. We had one go home and show up to clinic with grossly bloody stools. Volvulus is weird without vomiting, but I wouldn't rule out NEC just because she was 'tolerating' feeds.

Normal vitals / cbc / only notable positive blood in stool? Was there pneumatosis?

 

[mvenus929]

Normal vitals / cbc / only notable positive blood in stool? Was there pneumatosis?

Oh, no, the CBC was abnormal (I:T of 0.7), but he was acting a little more tired, took a little less than he normally did for feeds. Vitals were all fine. KUB was read as the hedging call 'stool, but pneumatosis cannot be excluded'. He progressed pretty quickly after that, but all the same.... and the only abnormality on the CBC was the differential. WBC count and H/H were normal. Given that I've had many a kid sent to my hospital from an outside ED with no differential on the CBC, I could see it slipping through the cracks. I had a term kid last time I was on NICU that developed NEC, but I think he had some vitals abnormalities, and then had a rapid change in the color of his abdomen. I think he ended up having a fixed loop, and went to surgery because of that, not because of any pneumatosis. Of course, as you mentioned, I'm not sure what an abdominal ultrasound would show in NEC.

Point being that while it's rare for term kids that don't have any underlying issues to have NEC, if you see enough babies, you'll find a couple of them. And since NEC can present in a wide variety of ways, I think it was worthwhile keeping it on the differential in this case, though if it genuinely were NEC, it would progress and show something other than the bloody stool after initial workup.