Binita M. Kamath, MBBChir; Robin Kaye, MD; Petar Mamula, MD Series Editors: David A. Piccoli, MD; Petar Mamula, MD


December 28, 2004

Case Presentation

A 14-month-old boy presented to the emergency department with a 3-day history of dark red blood in his stool. There was no associated abdominal pain, emesis, or fevers. Prior to the onset of these symptoms he had a viral upper respiratory tract infection and was given ibuprofen for 2 days by his mother. She did not exceed the recommended dose.

Previously, the child had been entirely fit and well. Growth and development were normal, and there was no history of weight loss. His birth had been unremarkable and he had no prior medical problems, hospitalizations, or surgery. He had been circumcised at birth without complications. There was no relevant family history of gastrointestinal disease. The family was Mennonite. The patient was an only child. There was no history of allergy to any medication.

Vital signs were normal and the patient was afebrile. He appeared healthy and was well developed. There was no lymphadenopathy. Respiratory and cardiac examinations were normal. The abdomen was soft and nontender, with no masses or organomegaly. There was no edema, spider angiomata, or palmar erythema. The rectal examination revealed no masses but contained soft stool, which was positive on heme testing.

Laboratory studies were obtained and revealed a low hemoglobin at 7.6 g/dL. The remainder of the laboratory evaluation, including chemistry panel, liver function tests, and clotting studies, were normal.

Results of a Meckel's scan were negative. The patient then underwent an upper endoscopy, which revealed erythema in the antrum and minimal inflammatory changes on biopsy. The patient was therefore initiated on intravenous ranitidine. He received a blood transfusion, with a posttherapy hemoglobin level of 12 g/dL. He was discharged home with a presumptive diagnosis of bleeding due to gastritis secondary to nonsteroidal anti-inflammatory drug use.

Within 24 hours of discharge, the patient was readmitted to hospital with further dark red blood in the stool. His hemoglobin level was 9 g/dL. The patient underwent a full colonoscopy to the terminal ileum, which revealed lymphoid hyperplasia visually and on histology. Subsequently, a tagged red cell bleeding scan was negative. The patient remained in hospital for a further 48 hours for observation. There were no episodes of hematochezia during this time and he was discharged.

Within 48 hours the patient had further bleeding per rectum and was admitted once again. His hemoglobin level was 11.8 g/dL, with normal differential, chemistry panel, and clotting studies. His liver function tests were unremarkable except for a low serum albumin of 2.7 g/dL.

The patient underwent a series of radiologic examinations to determine the source of the bleeding. He had a computed tomography (CT) scan with oral and intravenous contrast, a repeat Meckel's scan with ranitidine, and an upper gastrointestinal and small bowel follow-through barium study, all of which were unremarkable. A repeat upper endoscopy was then performed and revealed pooling of fresh blood in the duodenum and possible oozing of blood from the ampulla of Vater.

How do you interpret the results of the investigations so far?

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