Bloody Diarrhea and Dehydration In a 5-Month Old
Radiology Cases in Pediatric Emergency Medicine
Volume 6, Case 14
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 5-month old male who presented to an
emergency department with emesis. He was assessed
as having gastroenteritis with some mild dehydration.
He was given IV fluids and discharged from the ED on
oral hydration after he was noted to improve clinically.
Two days later, he developed diarrhea which persisted
for the next two days and today he was noted to have
some bloody streaks in the diarrhea. This prompted his
parents to take him to an acute care clinic. He was
noted to be moderately dehydrated and lethargic, but
he did not appear to have an acute abdomen. Some
laboratory studies were drawn, IV fluids were started
and an abdominal series was ordered.
View abdominal series flat and upright views.
Transfer to a children's hospital was arranged and
he was noted to improve clinically just before he was
transferred. Upon arrival at the children's hospital, the
following examination is noted.
Exam: T37.3 (rectal), P122, R26, BP 100/63,
oxygen saturation 100% in room air. He is alert and
active in no acute distress. He is not toxic and not
irritable. His anterior fontanelle is soft and flat and his
neck is supple. His eyes are not sunken and his oral
mucosa is moist. Neck supple. Heart regular without
murmurs. Lungs clear. Abdomen soft, flat, non-tender
with active bowel sounds. No organomegaly or masses
are noted. There are no hernias and his genitalia are
normal. His skin turgor, color and perfusion are good.
He moves his extremities well. His strength and tone
are good. His facial function is good.
Laboratory studies from the acute care clinic are
available for review. CBC WBC 7,200 35% segs, 51%
lymphs, 9% monos, 5% eos, Hgb 14, Hct 41, platelet
count 473,000. Na 141, K 3.9, Cl 109, Bicarb 13, BUN
10, Cr 0.4, glucose 80. Liver function studies are
After reviewing the set of abdominal radiographs
from the acute care clinic, another abdominal series is
View repeat abdominal films flat and upright views.
These radiographs show marked pneumatosis
intestinalis. There is air dissecting through the wall of
the rectum, sigmoid and distal colon. No free air is
noted. An abdominal ultrasound is performed which
shows the presence of microbubbles in the hepatic
portal venous circulation and increased echogenicity of
the liver secondary to trapped microbubbles throughout
the liver. These findings are indicative of bowel
pneumatosis with air entering the mesenteric veins
draining into the portal venous system.
He is evaluated by a pediatric surgeon who feels
that he has necrotizing enterocolitis despite his benign
abdominal examination. He is admitted to the pediatric
intensive care unit for observation because of the risk of
bowel perforation and the development of shock.
Antibiotics are started.
Later in the evening, his abdominal series is
repeated and the degree of pneumatosis is noticeably
decreased. No free air is noted.
His clinical course is benign and he recovers nicely.
Cultures of his blood, urine and stool are all negative.
So signs of hemolytic uremic syndrome or
intussusception are present. He is later restarted on
feedings and does well. A follow-up barium enema is
negative for any bowel strictures.
Pneumatosis intestinalis is most notably associated
with necrotizing enterocolitis (NEC) in neonates, a
serious condition often associated with very ill
premature neonates. NEC frequently results in sepsis,
bowel perforation, bowel gangrene, and bowel
Pneumatosis intestinalis in older infants and children
is uncommon. It is associated with a variety of
conditions such as short gut syndrome, pyloric stenosis,
bowel ischemia, congenital heart disease,
bronchopulmonary dysplasia, corticosteroid therapy,
chemotherapy and immunosuppression. In many
instances, no etiology other than gastroenteritis can be
determined. Pneumatosis intestinalis in older infants
and children does not carry as high a morbidity as it
does in premature neonates, but this finding is often
associated with a surgical abdominal emergency.
Adults with obstructive pulmonary disease will
sometimes manifest pneumatosis intestinalis and these
cases are usually benign.
Heng Y, Schuffler MD, Haggit RC, Rohrmann CA.
Pneumatosis intestinalis: A review. Am J
West KW, Rescoria FJ, Grosfeld JL, Vane DW.
Pneumatosis intestinalis in children beyond the
neonatal period. J Pediatr Surg 1989;24(8):818-822.
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