A 6 day old infant male vomits a large amount of 
bright red blood at home and is taken to a rural 
emergency department.  The child looks good, but the 
amount of blood on the baby's blanket brought in by his 
mother is very impressive.  The E.D. physician 
estimates it to be 30 to 50 cc's.
     He was born to a 25 year old G7P1 Blood type AB+, 
rubella immune, syphilis negative, hepatitis B negative 
mother at 37 weeks gestation via spontaneous vaginal 
delivery without any risk factors for sepsis.  Apgar 
scores were 8 and 9.  He was circumcised on day 2 of 
life without any complications or excessive bleeding.  
Mother had a history of substance abuse but a drug 
analysis at birth was negative.
     Mother had visited the child's pediatrician once and 
he was assessed as healthy at the time.  He is currently 
breast feeding.  He is passing stools and urinating well.
     In the rural E.D., a guaiac of the red material on the 
blanket that the baby vomited was positive.  The baby 
passed a dark stool in the E.D. that was also guaiac 
positive.  A CBC was drawn and the infant was 
transferred to a children's hospital by ambulance.
     Exam on arrival:  VS T37.3 (rectal), P128, R35, BP 
75/50.  He is alert and active in no distress.  Color is 
pink with minimal jaundice.  Anterior fontanelle flat and 
soft.  TM's within normal limits for age.  No blood in the 
nares.  Oral mucosa pink and moist.  No bleeding or 
mucosal injuries noted.  Conjunctiva pink (no pallor).  
Neck supple.  Heart regular without murmurs.  Lungs 
clear.  Abdomen soft, flat bowel sounds active, without 
hepatosplenomegaly.  The umbilical cord is drying 
without bleeding.  No hernias.  Normal testes.  Healing 
circumcision.  Peripheral pulses good.  Normal visible 
perfusion.  Capillary refill time 1 second.  No petechiae 
or bruising visible.  Stool is guaiac positive.
     An abdominal series is ordered.  In the meantime, 
his mother is observed feeding him with a bottle and he 
is noted to feed very well.  The CBC done at the rural 
E.D. is normal.  His hemoglobin is 17.3, hematocrit 
49.6.  A repeat of his hemogram shows Hgb 17.2, Hct 
50.3.  Coagulation studies are normal.  A urine 
toxicology screen on the infant is negative.  An Apt test 
done on the hematemesis residue on the blanket is 
negative for fetal hemoglobin indicating that the blood 
on the blanket did not come from the infant.
     The abdominal series is cancelled.  However, some 
"positive" neonatal radiographs are shown below.

View Neo abdominal film #1.

     This abdominal radiograph shows radiographic 
evidence of necrotizing enterocolitis (NEC).  The 
presence of air in the intestinal wall (intramural air) is 
known as pneumatosis intestinalis (arrows).  This is 
seen as a double density layering of the intestinal wall 
sometimes called "railroad tracks" as opposed to the 
single layer density of a normal bowel wall.  In 
neonates, pneumatosis intestinalis is highly indicative of 
NEC.
     NEC presents in the neonatal period with signs and 
symptoms that include guaiac positive stool, poor 
feeding, vomiting, hematemesis, abdominal distention, 
abdominal discoloration, abdominal tenderness, bowel 
obstruction, or other findings suggestive of an acute 
abdomen.  Premature infants are at highest risk.  It is 
unlikely to occur in healthy term infants.  This is 
generally not a condition that presents as an outpatient 
to an emergency department.  It is most often 
diagnosed by neonatologists in intensive care level low 
birth weight infants.  Infants with NEC should be 
managed in a neonatal special care unit.  They are at 
risk of sepsis, bowel necrosis and/or perforation and 
may need the expertise of a pediatric surgeon.  Despite 
this, pediatricians and neonatologists may occasionally 
refer outpatient newborns to an emergency department 
to investigate the possibility of NEC in a newborn who 
was previously discharged.  Thus, it is important to 
have seen some of the positive radiographic findings to 
properly assess the radiographs of such infants.

View Neo abdominal film #2.

     This radiograph shows generalized bowel dilation 
suggestive of an obstruction.  The bowel walls appear 
to be smooth (loss of haustrations).  Additionally, this 
radiograph shows another radiographic sign of NEC.  
Note the faint air luncencies over the liver.  This 
indicates the presence of intraportal air which is highly 
indicative of NEC.  This is subtle and is best 
appreciated if you step back away from the monitor, 
lower the room lights, and adjust the contrast on the 
monitor.

View Neo abdominal film #3.

     In addition to bowel dilation suggestive of an 
obstruction, this radiograph shows a more obvious 
case of pneumatosis intestinalis.  A large segment of 
bowel in the patient's left lower region (cigar shaped) 
shows obvious intramural air along its length. 

     Although the physicians involved in our infant's care 
were concerned about the possibility of NEC, it is 
unlikely that NEC would present with bright red 
hematemesis as it did in this instance.
     Benign causes of hematemesis are largely due to 
the ingestion of blood.  An intra-oral or nasal injury 
resulting in some swallowed blood will often be followed 
by hematemesis.  Mothers occasional have breast 
injuries due to epidermal erosions from the intense 
suckling of the newborn infant.  These can hemorrhage.  
The infant can swallow this blood while breast feeding.  
In this patient's case, his mother's nipples were noted to 
be bleeding.  This was felt to be the source of the 
bleeding since the Apt test was negative for fetal 
hemoglobin.  The Apt test is not ordered frequently by 
emergency physicians, but it may be very useful in 
instances such as this to rule out the infant as the 
source of the bleeding.
     Although the rural E.D. physician estimated the 
volume of hematemesis to be 30 to 50 cc's, the actual 
volume of hematemesis was probably only 10 cc's.  
This was determined by spilling some colored liquid 
onto a blanket to reproduce the area of hematemesis 
noted on the infant's blanket.  This accounts for all of 
the infant's findings except for the guaiac positive stool.  
However, a newborn's meconium stool is normally 
guaiac positive.  If the Apt test was done at the rural 
E.D., it is likely that the infant would not have required 
transfer to another hospital.
     Pulmonary hemorrhage may occasionally present 
with hemorrhaging in the mouth that may resemble 
hematemesis.  Pulmonary hemorrhage results in 
respiratory distress and insufficiency usually requiring 
oxygen and/or positive pressure ventilation.
     Mallory-Weiss syndrome has been reported in 
infants.  Forceful or prolonged vomiting results in a 
laceration of the esophagus diagnostically confirmed on 
endoscopy.
     Esophageal varices resulting from portal 
hypertension may be caused by thrombosis, hepatic 
fibrosis, or congenital malformations of the portal 
circulation.  Thrombosis may be a complication of 
exchange transfusion or umbilical vein catheterization.  
Esophageal varices may spontaneously bleed, resulting 
in large amounts of blood loss.
     Gastric and duodenal ulcers may occasionally occur 
in newborns.  In this age group, peptic ulcer disease 
usually presents with hematemesis.

References
     Vanderhoof JA, Zach TL, Adrian TE.  
Gastrointestinal Disease.  In:  Avery GB, Fletcher MA, 
MacDonald MG (eds).  Neonatology Pathophysiology 
and Management of the Newborn, fourth edition.  
Philadelphia, J.B. Lippincott Company, 1994, pp. 
605-629.
     Gryboski J.  The Esophagus.  In:  Gryboski J.  
Gastrointestinal Problems in the Infant.  Philadelphia, 
W.B. Saunders Company, 1975, pp. 48-117.
     Fanaroff AA, Filston HC, Izant RJ.  Selected 
Disorders of the Gastrointestinal Tract.  In:  Klaus MH, 
Fanaroff AA (eds).  Care of the High-Risk Neonate.  
Philadelphia, W.B. Saunders, 1993, pp. 176-188.