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Presentation of Case
Dr. Akash Gupta (Medicine and Pediatrics): A 6-month-old boy was seen in the emergency department of this hospital because of gastrointestinal bleeding and abdominal pain.
The patient had been in his usual state of health until 2 days before presentation, when his parents noted that he began to have intermittent episodes of abdominal pain. During these episodes, some of which woke the patient from sleep, he cried and pulled his legs up toward his chest while lying on his back. His parents reported that they palpated his abdomen during some of the episodes and it felt rigid; they suspected that he might be having discomfort related to excessive intestinal gas. He continued to eat and drink normally without vomiting. The next day, the patient had two bowel movements, and the stools had reddish discoloration. With the first bowel movement, the redness seemed to be present in a small amount and only on the outside of the stool; with the second bowel movement, the amount of redness increased. The patient’s mother attributed the stool discoloration to beet consumption, since bowel movements with reddish stools had also occurred in the past after the patient had eaten beets. Intermittent episodes of apparent abdominal pain continued, and between the episodes, the patient behaved normally. On the morning of presentation, he had a third bowel movement with reddish stools. His parents took him to day care, where he continued to have occasional periods of crying and pain, followed by a bowel movement that appeared to consist almost entirely of blood, including a large clot. After this bowel movement, he was reportedly pale and diaphoretic. The day care provider called the patient’s mother, who picked him up and took him to the emergency department of another hospital.
On examination at the other hospital, the temperature was 36.5°C, the pulse 178 beats per minute, the blood pressure 95/52 mm Hg, the respiratory rate 24 breaths per minute, and the oxygen saturation 100% while the patient was breathing ambient air. The weight was 9.1 kg. On palpation of the abdomen, there was diffuse tenderness, which was greater on the right side than on the left, and no masses. There were no external anal fissures, and the remainder of the physical...