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 
Gastroenterol 1995;90(10):1747-1758.
     West KW, Rescoria FJ, Grosfeld JL, Vane DW.  
Pneumatosis intestinalis in children beyond the 
neonatal period.  J Pediatr Surg 1989;24(8):818-822.

Return to Radiology Cases In Ped Emerg Med Case Selection Page

Return to Univ. Hawaii Dept. Pediatrics Home Page

Web Page Author:
Loren Yamamoto, MD, MPH
Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine