Visual Diagnosis: Melena in a 13-month-old Girl

Malinda Wu; Meghan Kessler; Brett W. Engbrecht; Mark Tulchinsky; Michael M. Moore; Chandran P. Alexander

doi:10.1542/pir.2017-0253

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Malinda Wu, MD*
Meghan Kessler, MD^†
Brett W. Engbrecht, MD, MPH^‡
Mark Tulchinsky, MD^§
Michael M. Moore, MD^§
Chandran P. Alexander, MBBS, MD*

^*Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA
^†Department of Pathology, Penn State Hershey Medical Center, Hershey, PA
^‡Department of Pediatric Surgery, Penn State Hershey Children’s Hospital, Hershey, PA
^§Department of Radiology, Penn State Hershey Children’s Hospital, Hershey, PA

AUTHOR DISCLOSURE
Drs Wu, Kessler, Engbrecht, Tulchinsky, Moore, and Alexander have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A previously healthy 13-month-old girl presents to the emergency department after a bowel movement with copious dark maroon blood with clots (Fig 1). She is fussy during the bowel movement, which is typical for her, and becomes pale thereafter. She does not have a history of constipation. On physical examination she is afebrile, mildly tachycardic, normotensive, and oxygenating well on room air. She is nontoxic appearing, pale, has a soft and flat abdomen that is nontender, without masses, and there is no anal fissure. She has a congenital nevus on her lower back.

Figure 1.

Patient’s initial maroon-colored stool with clots.

Laboratory tests in the emergency department are notable for an elevated blood urea nitrogen level (24 mg/dL [8.57 mmol/L]) with a normal serum creatinine concentration (0.36 mg/dL [31.8 µmol/L]) and glomerular filtration rate (101 mL/min/1.73 m²), microcytic anemia (hemoglobin level, 8 g/dL [80 g/L]; hematocrit, 24.7%; mean corpuscular volume, 69 fL), and unremarkable coagulation studies. Supine and lateral decubitus plain films demonstrate an unusual air-filled, mildly dilated bowel loop with some wall thickening in the middle abdomen. Ultrasonography of the abdomen demonstrates focally dilated loops of bowel in the right lower quadrant containing stool but no evidence of intussusception. A Meckel scan performed 6 hours after intravenous administration of ranitidine (2 mg/kg) shows abnormal small-bowel uptake in the …