Case
#43 "Connect the Dots!" by Charlene Babcock Irvin, MD
A 14 y/o boy presents with his dad who
notes: ‘He’s pooping blood!’. He started
feeling sick a few days ago, with abdominal
cramping and nausea. Initially, he had loose
stools that progressed to diarrhea and now
he has bright red blood per rectum (BRBPR).
He felt feverish, but no fevers documented
by a thermometer. Although nauseous, he has
not vomited. He has had decreased appetite
and intake.
PMH: No hospitalizations after delivery.
No medications, no medical problems.
SH: Denies drugs or alcohol or smoking.
He is not sexually active. No recent travel.
FH: Negative for inflammatory bowel
disease. No one else in the family has
diarrhea.
PE: Thin 14 y/o, laying on cot in no
acute distress.
VS: 142/88, p=110, RR=20, Temp=99.0F,
Sat=97% on room air
HEENT: Dry mucus
membranes, otherwise negative
Heart: Tachy, but no murmurs or abnormality
Lungs: Clear bilaterally
Abd: Scaphoid, muscular. Mild diffuse
tenderness to deep palpation in all four
quadrants is present. No guarding or
rigidity. Bowel sounds are hyperactive. No
scars.
GU: Normal testicles, penis. No hernia.
Rectal exam is without fissures. Rectal
digital exam reveals red bloody/stool with
mucus that is guiac positive.
Ext: No rashes
Neurologic: Alert, cooperative, oriented
with nonfocal neurologic exam.
The results of your work up after IV NS 20
cc/kg bolus then maintenance reveals:
BUN= 25 and CR = 3.1
Electrolytes and glucose normal.
CBC reveals a WBC ct of 19 K (80% PMN, no
bands are seen, but schistocytes are noted
on smear), Hbg is 7.8 mg/dl, Platelets =
55K.
Acute abdominal X-rays reveals nonspecific
gas pattern.
1. What are the causes of lower GI
bleeding in this child?
2. What entity ties the elevated Creatinine (CR) with the bloody stools?
3. What additional tests should you add?
And, should you start Antibiotic treatment?
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