Management of a 44-Day-Old Male Infant with Hematuria, Bloody Stool, and Abdominal Tenderness
Immediate Recognition and Urgent Surgical Evaluation
This clinical presentation—hematuria, bloody stool, and abdominal tenderness in a 44-day-old infant—is highly concerning for necrotizing enterocolitis (NEC) or midgut volvulus secondary to malrotation, both of which are surgical emergencies requiring immediate evaluation and intervention. 1
Initial Stabilization and Resuscitation
Hemodynamic Support
- Establish intravenous access immediately and initiate aggressive fluid resuscitation to restore intravascular volume and maintain adequate perfusion, as infants with NEC or volvulus can rapidly develop shock from third-spacing, bowel ischemia, and sepsis. 1
- Monitor vital signs continuously, including heart rate, blood pressure, respiratory rate, and oxygen saturation, to assess hemodynamic stability and guide resuscitation. 2
- Administer supplemental oxygen or provide mechanical ventilation if respiratory distress or hypoxemia develops. 1
Bowel Decompression
- Insert a nasogastric or orogastric tube immediately to decompress the stomach and bowel, which reduces the risk of perforation and aspiration in cases of obstruction or NEC. 1
Urgent Diagnostic Evaluation
Laboratory Studies
- Obtain a complete blood count with differential to assess for leukocytosis, neutropenia, or thrombocytopenia, which are markers of sepsis and NEC. 1
- Measure serum electrolytes, blood urea nitrogen, creatinine, and glucose to evaluate metabolic derangements and renal function. 1
- Perform blood cultures before initiating antibiotics to identify causative organisms in suspected sepsis. 1
- Obtain arterial or venous blood gas to assess for metabolic acidosis, which indicates tissue hypoperfusion and bowel ischemia. 1
Imaging
- Order an immediate abdominal radiograph (supine and left lateral decubitus or cross-table lateral views) to evaluate for pneumatosis intestinalis, portal venous gas, free intraperitoneal air (indicating perforation), or dilated bowel loops with air-fluid levels (suggesting obstruction or volvulus). 1
- If malrotation with volvulus is suspected and plain films are equivocal, proceed urgently to upper gastrointestinal contrast study to assess for abnormal positioning of the duodenojejunal junction and the classic "corkscrew" appearance of midgut volvulus. 1
- Abdominal ultrasound may be considered to evaluate for intussusception (though uncommon in the first 3 months of life) or other structural abnormalities, but should not delay surgical consultation if clinical suspicion for NEC or volvulus is high. 1
Empiric Broad-Spectrum Antibiotic Therapy
Initiate intravenous broad-spectrum antibiotics immediately after obtaining blood cultures, as both NEC and bowel ischemia from volvulus carry high risks of bacterial translocation and sepsis. 1
Recommended Antibiotic Regimens for Neonates
- Ampicillin (50 mg/kg IV every 12 hours for infants <7 days old; 50 mg/kg IV every 8 hours for infants ≥7 days old) PLUS gentamicin (4–5 mg/kg IV every 24 hours) PLUS metronidazole (7.5 mg/kg IV every 12 hours) provides coverage against gram-positive cocci, gram-negative enteric organisms, and anaerobes. 1
- Alternatively, ampicillin PLUS cefotaxime (50 mg/kg IV every 12 hours for infants <7 days old; 50 mg/kg IV every 8 hours for infants ≥7 days old) PLUS metronidazole can be used if aminoglycoside toxicity is a concern. 1
- Meropenem (20 mg/kg IV every 8 hours) is an acceptable single-agent alternative that provides broad-spectrum coverage, including anaerobes. 1
- If methicillin-resistant Staphylococcus aureus (MRSA) or ampicillin-resistant enterococcal infection is suspected, substitute vancomycin (15 mg/kg IV every 12 hours for infants <7 days old; 15 mg/kg IV every 8 hours for infants ≥7 days old) for ampicillin. 1
Urgent Surgical Consultation
Contact pediatric surgery immediately upon recognition of this clinical triad, as both NEC with perforation and malrotation with volvulus require emergent operative intervention. 1
Indications for Emergent Surgery
- Radiographic evidence of free intraperitoneal air (pneumoperitoneum) indicates bowel perforation and mandates urgent laparotomy or peritoneal drainage. 1
- Clinical deterioration despite maximal medical management, including worsening acidosis, hemodynamic instability, or progressive abdominal distension, suggests bowel necrosis and requires surgical exploration. 1
- Suspected midgut volvulus is a surgical emergency requiring immediate laparotomy to detorse the bowel and perform a Ladd procedure to prevent recurrence. 1
Role of Peritoneal Drainage
- In very low birth weight or critically unstable neonates with NEC and perforation, percutaneous peritoneal drainage may be used as a temporizing measure before definitive laparotomy, though some surgeons advocate drainage as sole therapy in select cases. 1
Differential Diagnosis and Key Pitfalls
Necrotizing Enterocolitis (NEC)
- NEC typically presents with abdominal distension, bloody stools, bilious emesis, and signs of sepsis in premature or term infants with risk factors such as prematurity, formula feeding, or perinatal stress. 1
- Radiographic findings include pneumatosis intestinalis, portal venous gas, and free air if perforation has occurred. 1
Malrotation with Midgut Volvulus
- Malrotation most commonly presents in the first week of life but can occur at any age, with bilious vomiting being the hallmark symptom. 1
- Bloody stools and abdominal tenderness indicate bowel ischemia from volvulus, which progresses rapidly to necrosis and perforation if not surgically corrected. 1
- Upper GI contrast study showing abnormal positioning of the duodenojejunal junction or a "corkscrew" sign confirms the diagnosis. 1
Intussusception
- Intussusception is unusual in the first 3 months of life but can present with crampy abdominal pain, bloody "currant jelly" stools, and lethargy. 1
- Ultrasound showing a "target sign" or "pseudokidney sign" confirms the diagnosis, and air or contrast enema may be both diagnostic and therapeutic. 1
Other Considerations
- Neonatal appendicitis, gastric volvulus, and trauma are rare but should be considered if the clinical picture does not fit NEC or malrotation. 1
- Sepsis, enteritis, and metabolic disorders can mimic surgical emergencies and should be evaluated concurrently. 1
Common Pitfalls to Avoid
- Do not delay surgical consultation while awaiting imaging results if clinical suspicion for NEC with perforation or volvulus is high, as delays beyond hours can result in irreversible bowel necrosis and death. 1
- Do not attribute bloody stools solely to benign causes (e.g., anal fissure, milk protein allergy) in an infant with abdominal tenderness and systemic signs, as this can lead to catastrophic delays in diagnosis. 1
- Do not rely on a single abdominal radiograph if clinical suspicion remains high; serial films or advanced imaging (upper GI series) may be necessary to detect evolving pathology. 1
- Do not withhold antibiotics pending culture results, as bacterial translocation and sepsis develop rapidly in NEC and bowel ischemia. 1
Summary Algorithm
- Recognize the emergency: Hematuria + bloody stool + abdominal tenderness in a 44-day-old = NEC or volvulus until proven otherwise.
- Stabilize immediately: IV access, fluid resuscitation, bowel decompression (NG tube), oxygen/ventilation as needed.
- Obtain urgent labs: CBC, electrolytes, blood gas, blood cultures.
- Image immediately: Abdominal radiograph (supine + decubitus); if equivocal and volvulus suspected, proceed to upper GI series.
- Start broad-spectrum antibiotics: Ampicillin + gentamicin + metronidazole (or meropenem).
- Call pediatric surgery stat: Do not delay for imaging if perforation or volvulus is clinically evident.
- Prepare for emergent surgery: Laparotomy for perforation or volvulus; peritoneal drainage may temporize in unstable neonates.