Hot Seat #40: 3 yo with bloody stools
Posted on: June 23, 2014, by : Sonny Tat MD MPH
The Case
by Sonny Tat, Children’s National
with Shilpa Patel, Children’s National
3 year-old previously healthy girl presents to your ER with abdominal pain and bloody stools. The patient had abdominal pain starting yesterday. After a few hours, the patient had a bowel movement with dark red blood, which may have eased the pain. She had two or three more episodes of bloody stool and intermittent abdominal pain yesterday. Today she went to the PMD who sent stool studies and sent her home. She is in the ED today because of persistent abdominal pain that puts her in the fetal position that is temporarily relieved by bowel movements that are associated with dark blood. She has had emesis x 2 today that is non-bloody, non-bilious.
ROS: No fevers, rash, constipation, sick contacts, or change in diet. URI two weeks ago.
Exam: VS Afebrile, HR 119, RR 22. BP 97/57
Well-appearing, active, smiling, no distress
Chest CTAB, heart RR, no murmurs or gallops
Abd ND/NT, no masses. Rectal exam shows gross blood at the anus
Labs/Rad:
Hemoglobin 8.8 WBC 11.7 Platelets 302 MCV 79
Na 139 K 3.4 Cl 106 CO2 22 BUN 11 Cr 0.4
INR 1.1
Ultrasound is negative for intussusception
Questions for you:
Shilpa Patel is on the Hot Seat
How would you approach this case?
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children’s National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
good case! i think it’s super, super important to differentiate painless versus painful rectal bleeding. and make sure it’s actually blood.
typically, PAINLESS rectal bleeding is either juvenile polyp or a Meckels. period. in this patient who has a drop in Hb with normal indices yet is well appearing….sounds like a Meckel’s. and if this were the case, i would admit for a meckel’s scan since the patient is minimally tachycardic with a low Hb and question of active bleeding. always good idea to get a PT and PTT to look for other coagulopathies, although this is not a presentation of acute hemophilia. and never a bad idea to put in an EJ, although probably not necessary if BP is normal and kid looks fine.
now PAINFUL rectal bleeding is different. think about infectious colitis versus inflammatory bowel disease versus vasculitis etc. so send the culture, ESR/CRP. If inflammatory markers are negative, this points more towards anatomic (meckels, polyp). If positive this supports one of these inflammatory or infectious conditions. A better history is needed to look for signs of IBD, although the normal blood indices point against a crohn’s picture although UC is possible. I do like to get an abdominal XR, especially in a 3yo where ingestion of foreign material is possible. One magnet is ok. Two magnets……bad! and have to ask if the kid (or someone else) stuck anything in his bum. rectal obstruction can cause gaseous distention (pain) and bleeding from local trauma. same goes with constipation, although pretty HARD (no pun intended) to get your Hb down so much with constipation/tears.
Every once and a while, you get a patient with abdominal pain (+/- rectal bleeding) and can’t quite figure out why…..then two days later they develop the rash from HSP !!!
Thanks Dave! Here is the link to my response: http://pemfellows.blogspot.com/2014/06/hot-seat-case-40-response-by-shilpa.html