Hot Seat Case # 110: 3 year old male with bloody emesis
Posted on: March 27, 2018, by : Monica Prieto MD
Monica Prieto, MD Children’s National Medical Center
with Christina Lindgren, MD Children’s National Medical Center
3 year old male who is brought in by grandmother with a chief complaint of bloody emesis for 1 month. The vomiting has been occurring 2-3 times per day, every day. Grandmother reports that the emesis is frequently bloody, never bilious. There is no associated diarrhea. No blood in the stool. Patient’s oral intake of liquids and solid food is unchanged. Normal urine output.
She reports that the emesis looks like “red cool-aid”. She shows you multiple pictures that she has taken on her phone of drinking glasses filled with red liquid and says “like this, doctor. This is his vomit”.
Grandmother reports that the patient has been seen 4 times over the last month for these symptoms, once in this emergency department and twice at other emergency departments in the community. She says that the patient has had blood-work, chest and abdominal X-rays, and stool studies. She is unable to provide you with the details or results of these tests, but she states that she is “frustrated because something is wrong, but everyone says he’s fine.”
ROS:
Constitutional symptoms: No fever, fatigue or weight loss.
Skin symptoms: No rashes or pallor.
ENMT symptoms: No nasal congestion, sore throat or mouth ulcers.
Respiratory symptoms: No cough or respiratory distress.
Gastrointestinal symptoms: Bloody emesis. No abdominal pain, diarrhea, constipation, blood in stool or rectal fissures.
Genitourinary symptoms: No hematuria, increased urgency or increased frequency
Hematology: No petechiae, bruising or mucosal bleeding.
PMHx: No previous illnesses or surgeries
FHx: No family history of malignancy, inflammatory bowel disease, thyroid disorders, or disorders of bleeding or clotting.
SHx: Maternal grandmother is patient’s legal guardian. Patient lives with grandmother, 13 year old female cousin and 7 year old sister. Patient’s father is incarcerated and patient’s mother passed away soon after his birth in a motor vehicle accident. No recent travel, no recent antibiotics, no animal exposures. No known TB exposures, and patient does not have contact with his father.
Physical Exam:
VS: Wt. 14.8kg (60th percentile), Ht. 97cm (67th percentile), T. 37.2, HR 119, RR 22, BP 95/68
General: Well-nourished playful child running around exam room.
Skin: Warm and dry. No rashes, petechiae, bruising or pallor.
EENT: No conjunctival or mucosal pallor. Oral mucosa moist, no intraoral lesions or bleeding. No pharyngeal erythema or exudates. No nasal discharge, bleeding or masses.
Cardiovascular: Regular rate and rhythm. No murmur or gallop. Distal pulses 2+ and equal bilaterally. Capillary refill <2 secs.
Respiratory: Non-labored respirations. Lungs are clear to auscultation. No coughing.
Gastrointestinal: Abdomen is soft, nontender and nondistended. Normal bowel sounds. No organomegaly. No peri-anal or rectal lesions.
Genitourinary: Normal genitalia for age.
Neurological: Normal gait, symmetric strength bilaterally. No focal deficits observed.
You review your colleagues note from 3 weeks ago and note a laboratory work-up with CBC, CMP, PT and PTT all normal for age. You note a diagnosis of gastritis with likely Mallory-Weiss tear, successful oral challenge in the ED, and discharge home with supportive care. Multiple stool studies (resulted after discharge) were normal and did not reveal an infectious etiology.
You defer imaging, but you repeat the CBC, PT and PTT and add a CMP, lipase and stool occult blood. The results are:
WBC 8.2, Hgb 12.1, Hct 34.5, Plts 360
PT: 12.9 secs, pTT 30 secs
CMP: Normal
Lipase: Normal
Stool Occult Blood: Negative
Stool cultures: Pending
The patient has eaten and drank fluids in the emergency department without emesis. He remains well-appearing with age-appropriate vital signs. You inform the grandmother that his laboratory evaluation is within normal limits. She becomes visibly upset and says “Are you telling me that I’m crazy? My therapist says I’m not crazy because I take my medicines! He is bleeding.” You speak calmly and reassure the grandmother of your commitment to the care of her grandson, de-escalating the interaction. The grandmother calmly states: “There’s something wrong. I know there’s something wrong and no one can find it. What now, doctor?”
Ultimately, you are concerned that the grandparent has a plausible but untrue delusion about the symptoms the patient has, and on multiple hospital evaluations the child is healthy.
In the “Comments” section below, please feel free to comment further on:
- What responsibilities does the pediatric ED have when it comes to figuring out whether the caregiver needs a mental health evaluation and how to go about it?
- How do you ensure the safety of the patient, including patient disposition?
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I think you’re making this too complicated. If the kid is vomiting 2-3 times/day with “blood” and the hemoccult is negative (and there isn’t melena), then something is fishy. Don’t do any tests in this non-tacyhcardic child. Just admit (or keep in observation) until the kid vomits and do a gastro-cult test. Seems like a decent story for munchausen by proxy. If the kid does vomit blood than he buys an upper scope to see if its esophageal or gastric. But that’s not going to happen. I think an extended social history and inquiry would be a better bet when this child doesn’t vomit after 48 hrs on the floor. 3 years old should be old enough to at least do a little questioning of the child with the parent out of the room to screen for other weirdness or injuries that could put the child at risk. It’s harder when the child is <2.5yo.
One thing that strikes me as very unusual about this story is that bloody emesis rarely looks like Kool Aid and if it is truly bright red it often implies rapid bleeding, which should result in melanotic stool.
I think the most important part of this case is that the child is very well appearing and growing. While the kid has had three negative work ups thus far, I think obtaining some labs would be helpful to build a case. I would obtain a CBC, hemoccult and a gastroccult, recognizing that you likely will not be able to obtain the gastroccult or hemoccult ER. In terms of imaging, I am not sure what imaging we could do that will help, especially given that he looks so well. If we are concerned about UGI bleeding, the most important imaging would be an endoscopy.
Ultimately, despite this child being well appearing and not meeting admission criteria, I think that you have to admit him to determine if this is in fact Muchausen by proxy, which may require inpatient video surveillance. At this point, unless the grandmother is posing an immediate harm to the child, I do not think that we need to consult psych nor can we obligate her to speak with psych. If she allows you, it may be helpful to speak with her psychiatrist directly or one of her other family members to get a sense of what has been going on. In the ER, I would consult SW to determine if there are other family/social concerns and I would contact the pediatrician to see if they have noticed any other red flags.
I would lean heavily on PCP if available. They may have results of complete workups previously done, and provide insights re other red flags (missed appointments etc., changes in growth – seems unlikely based on values you provided). I think making a CPS referral for something like Munchausen is rarely going to be something for the ED to take on, and requires serial exams/much more background context. So if I cannot hear from PCP, or there is anything else suspicious on exam, I would have low threshold to admit for obs.