With the fever and vomiting an "infectious enterocolitis" is still
(-) points would be the absence of diarrheal stool and mucous. Also
melena generally suggests bleeding above the ligament of treitz which
would be unusual with a colitis.
IBD (UC or Crohns) can present like this especially if the patient has
had abdominal pains, fever, weight loss in his past medical history.
Crohns can involve the upper GI tract too. =20
A negative NG aspirate does not rule out an upper GI bleed above the
ligament of Treitz. I would consider H. Pylori or viral gastritis or
Meckel's diverticulitis can be a concurrent diagnosis. However, fever,
vomiting and pain go against it.
I have seen malrotation with intermittent volvulus as well as
intussusception present in an infant like this. If the emesis is =
I would definitely pursue this route aggressively. Points against would
be the age as I said, and the presence of fever. However,
intussusception may be precipitated by an infectious illness (
presumably due to swelling of the Peyer's patches????).=20
1. Look at the fresh stool under microscopy for fecal leucocytes. This
will quickly sort out the infectious from non infectious causes of
blood. Sounds simple but could save the patient a lot of grief! Send =
a stool culture too.
2. ESR to screen for IBD
3. Abdominal radiographs to rule out the worst yet less likely scenario
of bowel obstruction.
If above is negative=20
IVF, hydrate and observe. Follow serial hematocrits. Consider upper
endoscopy if melena is persistent. Some may begin with a lower GI
contrast study to rule out IBD.
My working diagnosis: Infectious enterocolitis
Hope that helps
PLEASE LET US KNOW THE FOLLOW UP. Also why did you do Protein C? =20
> I've just seen a 12 year old boy at our E.D. that started with high
> fever (39,5=BAC-40,0=BAC), vomiting and abdominal cramps two days =
> has been on ibuprofen and acetominophenIn. the night before admission
> he had a profuse dejection of black stools (no mucus). He had no =
> complaints. He has been healty until now and he lives in suburban =
> in a midclass neighborhood. He hasn=B4t done any travel abroad
> At our E.D. he apears a well developed boy although prostratred, =
> on bed.
> No signs of anemia or moderate dehydratation.
> Good peripheral perfusion.=20
> No skin rashes, bruises or petequia. No conjunctival findings.
> No meningeal signs.
> Vital signs OK (except temparture of 39,3=BAC).=20
> Normal ear drums and canals
> Normal nasopharynx
> Normal oropharynx
> Lungs normal
> Heart normal
> Abdomen: mild discomfort on palpation with no signs of peritoneal
> irritation;bowel sounds perhaps increased; no palpable masses; liver
> or spleen not enlarged=A0
> Rectal exam: not painful; no masses and no stools palpable; glove =
> black fecal material (melena)=A0
> Initial work up: complete blood count, Na+, K+, BUN, glucose, protein
> C, blood culture, coagulation studies, Widal, stool culture=20
> Nasogastric drainage - no fluid or blood recovered
> Intravenous fluids (dextrose 3,3% + 0,45% NaCl)=A0
> Results available by now:
> * CBC: WBC - 3,6 x10^9/L (differential: N - 71%; L-21%);
> hemoglobin: 13,5 g/dl; platelets - 169 x10^9/L=20
> * Protein C - 8 mg/l (Normal 0 - 9 mg/L)=20
> * Na+, K+, BUN, glucose - all normal
> What would be your initial work up ?
> What diagnosis would you give?
> What treatment would you give?
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