Chapter 43

1. Problem. A newborn infant has passed a bloody stool. This is generally a benign and self-limiting disorder. In a large majority of patients, the cause is unknown.

2. Immediate questions

1. Is it grossly bloody? This finding is usually an ominous sign; an exception is a bloody stool as a result of swallowed maternal blood, which is a benign condition. A grossly bloody stool usually occurs in infants with a lesion in the ileum or the colon or with massive upper gastrointestinal tract bleeding. Necrotizing enterocolitis (NEC) is the most common cause of bloody stool in premature infants and should be strongly suspected. It is seen in 25% of patients with NEC.

1. Is the stool otherwise normal in color but with streaks of blood? This is more characteristic of a lesion in the anal canal, such as anal fissure. Anal fissure is the most common cause of bleeding in well infants.

1. Is the stool positive only for occult blood? Occult blood often signifies that the blood is from the upper gastrointestinal tract (proximal to the ligament of Treitz). Nasogastric trauma and swallowed maternal blood are common causes. Microscopic blood as an isolated finding is usually not significant. Tests for occult blood are very sensitive and can be positive with repeated rectal temperatures.

1. Was the infant given vitamin K at birth? Hemorrhagic disease of the newborn or any coagulopathy may present with bloody stools.

1. What medications are the mother and infant on? Certain medications can cause bleeding. If the mother was on aspirin, cephalothin, or phenobarbital, these can cross the placenta and cause coagulation abnormalities in the infant. If the infant has been given nonsteroidal anti-inflammatory drugs, heparin, tolazoline, indomethacin, or dexamethasone, these are all associated with bleeding.

3. Differential diagnosis

1. Occult blood only, no visible blood

1. Swallowing of maternal blood (accounts for 30% of bleeding) during delivery or breast-feeding (secondary to cracked nipples) may be the cause. Swallowed blood usually appears in the stool on the second or third day of life.

1. Nasogastric tube trauma.

1. Necrotizing enterocolitis.

1. Formula intolerance. Milk protein sensitivity is secondary to cow's milk or soybean formula, and symptoms of blood in the stool usually occur in the second or third week of life. One study found that cow's milk allergy was diagnosed in 18% of patients with rectal bleeding.

1. Gastritis or stress ulcer (common cause and can be secondary to certain medications). Erosions of the esophageal, duodenal, and gastric mucosa are a common cause of bleeding. Stress ulcers may occur in the stomach or the duodenum and are associated with prolonged, severe illness. Steroid therapy, especially prolonged, is associated with ulcers. Hemorrhagic gastritis can occur from tolazoline and theophylline therapy.

1. Unknown cause. Many cases of bloody stool in an infant have no identifiable cause.

1. Streaks of visible blood in the stool

1. Anal fissure (tear) can be secondary to straining.

1. Rectal trauma is often secondary to temperature probes.

1. Grossly bloody stool

1. Necrotizing enterocolitis.

1. Disseminated intravascular coagulation (DIC). There is usually bleeding from other sites and may be ...

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