An Infant’s Episode of Bright Bloody Stool
A ten-month-old male presented with one large episode of bright-red bloody stool. He had 3 episodes of non-bloody, non-bilious vomiting following the bloody stool.
The parents denied any fevers, lethargy, weight loss, cough, congestion, abdominal pain, diarrhea, constipation, decreased urination, rash, changes in mental status or other symptoms. They denied any similar episodes like this in the past.
The patient had no documented medical history and was born without any complications. He had been growing well, with no developmental delays. The infant had no previous surgeries or hospitalizations and was not taking any medications. His vital signs during a physical exam were stable. He was alert, active and in no distress.
The rest of child’s physical exam was noncontributory, except for some paleness noted of the inner eyelids and skin. The patient had a regular heart rate and rhythm, his lungs were clear, and his abdominal exam was normal, with no tenderness or distension. His laboratory work showed white blood cells of 16.9, hemoglobin 8.2 g/dL, hematocrit 25.2, and platelets 279. The patient’s electrolytes were normal, but blood urea nitrogen (BUN) was 14 mg/dL and creatinine 0.11 mg/dL. Stool occult blood was positive. Imaging studies included normal kidneys, ureter, and bladder (KUB), and a normal abdominal ultrasound. The patient also underwent nuclear diagnostic imaging.
What caused the infant’s bloody stool?
(Answer and discussion on next page)
Answer: Meckel’s diverticulum
A Meckel’s scan yielded a positive result. Repeat hemoglobin was 6.9 g/dL, and the patient was given a transfusion of packed red blood cells (PRBC). The next day, he underwent laparoscopic Meckel’s diverticulum resection along with appendectomy. The young child tolerated the procedure well, with no complications. He was placed on antibiotics and PPN during recovery and discharged home with no major complications during his stay.
Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract. It is caused by incomplete obliteration of the vitelline duct, leaving a true diverticulum containing all the layers of the small bowel.1 It is usually 2 feet proximal to the ileocecal valve and is 2 cm to 3 cm in length. It is said to occur in approximately 2% of the population and is 2 times more common in males.
_______________________________________________________________________________________________________________________________________
Related Content
Red-Colored Stool
An Infant With Abdominal Distention, Pain, and Bloody Stools
______________________________________________________________________________________________________________________________________
Two to four percent of cases may develop a complication in their lifetime. Malignancy rates range from 0.5% to 4.9%. Meckel’s diverticulum is usually silent but can present with obstruction, painless gastrointestinal bleeding, or intussusception. Other signs and symptoms may include abdominal distention, nausea, or vomiting.2
It is important to have Meckel’s diverticulum as part of the differential diagnosis in any patient presenting with painless GI bleeding, symptoms of intussusception, appendicitis, volvulus or abdominal wall hernia.3 Patients will typically have a negative abdominal exam but can have some tenderness. Laboratory values may be consistent with volume depletion and anemia.
Diagnosis is made with a Meckel’s scan, which is a nuclear medicine study. It uses 99m-technetium pertechnetate, which has affinity for gastric mucosa, so it will only identify those diverticula containing ectopic gastric mucosa. Sensitivity of the Meckel’s scan is 85% to 90%, with 95% specificity.
Initial management of these patients should focus on fluid resuscitation and abdominal decompression with nasogastric tube. Proton pump inhibitors or transfusions may be considered in cases of GI bleed. Resection is recommended for symptomatic patients. Death from Meckel’s diverticulum is rare at only 0.001%.
Rhonda Graham, DO, is a postgraduate pediatrics resident at Palms West Hospital in Loxahatchee, Florida.
References
- Rabinowitz S. Pediatric Meckel diverticulum. Medscape. http://emedicine.medscape.com/article/931229-overview. Accessed March 5, 2014.
- Javid P, Pauli EM. Meckel’s diverticulum.” UpToDate. http://www.uptodate.com/contents/meckels-diverticulum. Accessed March 5, 2014.
- Squires RH. Gastrointestinal bleeding. Pediatr Rev. 1999;20:95-101. http://pedsinreview.aappublications.org/content/22/11/394.extract. Accessed March 5, 2014.