Hematemesis in a 6-Day Old Infant
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 14
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
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 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
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
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.
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.
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.
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