1. HPI
An 18 mo infant is brought to her pediatrician because her dad noticed blood in her stool this morning. Dad said the blood appeared dark red (almost black) and was mixed with the stool. The consistency of the stool was normal. Dad said that her next diaper did not have blood that he could see. He denies any vomiting, diarrhea or abdominal distention but stated she felt a little warm yesterday. She has been given Miralax for constipation occasionally. She has not had any fevers or weight loss. According to her father, she had a couple of episodes where she cried very hard and “scrunched” her legs up. They passed after a few minutes and he attributed them to nightmares. She did not vomit or pass blood/stool during these episodes.
List items in the hx that would you help you solve the case:
PMH/SH:
Dev. Hx:
Birth Hx:
Social Hx:
Family Hx:

2. Further History
Past Med/Surg Hx: Otitis Media 2 wks ago tx w/ Amoxicilin/Clavulanate acid. No surgeries
Meds: Miralax PRN, multivitamin w/iron
Allergies: none
Immunizations: Up to date
Birth Hx: Nl vaginal del. Takes breast and cow’s milk.
Dev Hx: Growing appropriately. Meeting all milestones
Family Hx: 3 year old brother with milk allergy
Social Hx: Lives at home with mom, dad, and sib. No sick contacts. No travel outside the country.
Please list at least 3 items on your differential diagnosis 1. 2. 3.

3. DDx Food or Drugs Infectious Diarrhea Meckel’s Diverticulum
Kool-aid, red licorice, ampicillin, beets, red-dyes, iron supplements
Infectious Diarrhea
Meckel’s Diverticulum
Anal Fissure
Milk Allergy (allergic colitis)
Intussusception
Hemolytic Uremic Syndrome
Henoch-Schönlein Purpura
Sexual Assault
Coagulopathy
Beside each diagnosis list items you will look for on physical exam that would support or refute each one.

4. Physical Exam
Vitals: Appropriate for age. Afebrile
Gen: Appears well
Skin: No bruising, jaundice, pallor, rashes or purpura
HEENT: Moist mucosa. No conjunctival pallor
CV: RRR, no murmurs, Cap refill <2sec
Resp: CTA BL
Abd: No masses palpated. Soft, non-distended, non-tender
M/S: No joint tenderness or swelling of hands and feet.
GU: Vaginal patent w/o trauma.
Rectal: Tone appropriate. No sign’s of any tears, fissures, or trauma.
Neuro: CN’s intact, 5/5 strength, Good muscular tone.
What tests/evaluations (not imaging) would you order. (you may add more or use less than the numbers listed) 1. 2. 3. 4. 5. 6. 7. 8. 9.
10.

5. Lab Tests Order any imaging 1. 2. 3. 4. CBC CMP and glucose: wnl
WBC: 14,000 (R: )
HCT: (R: )
Hb: 10.2 (R: )
Plt: 313 (R: )
CMP and glucose: wnl
PT/INR: 13/0.9 (wnl)
Stool culture and fecal leukocytes: negative
Hemoccult: Positive
Urinalysis: normal
Order any imaging 1. 2. 3. 4.

6. Imaging This image is for reference. This patients US was normal.
Study: KUB (kidney, ureters, bladder):
Findings (ABCDE): There is gas/air (black) all the way to the rectum. No bony abnormalities. There are no extra calcifications in the gallbladder or ureters. No air under the diaphragms. Gas is seen in the stomach.
Interpretation: Normal film
Study: Abdominal ultrasound
Findings : Target sign!!!
Interpretation: Intussception
Note: This patient is presenting with PAINLESS bleeding which is less suggestive of Intussusception, but with the hx of the acute episodes it might need to be ruled out if it happens again.
This image is for reference. This patients US was normal.

7. Imaging continued Meckel’s Scan (right) Surgical pathology (left)
This is a nuclear medicine study using the  technetium-99m (99mTc) isotope. This isotope localizes to gastric tissue which is present in ~50% of these diverticula.
Surgical pathology (left)
Like all true diverticula, a Meckel’s contains all 3 layers (mucosa, muscularis, and adventitia)

8. Consider your DDx: DDx Positive Negative Food or Drugs
Takes iron supplement
Ampicillin (not Augmentin) associated with pseudo-rectal bleeding
Infectious (Salmonella, E.coli, shigella)
Anecdotal fever at home.
No diarrhea, no sick contacts or travel. No fever on exam.
Anal Fissure
Constipation
No physical findings. Usually has bright red blood that is not mixed with stool.
Milk Allergy (allergic colitis)
Takes cow’s and breast milk. Brother with allergy
Usually presents younger and resolved by 1 year. True allergy produces vomiting more than bleeding.
Intussuception
Intermittent episodes of pain and pulling of knees to chest.
Usually appear more sick with vomiting and abdominal pain. Blood more often described as currant-jelly.
Hemolytic Uremic Syn.
Rectal bleeding
No previous E.coli infection. No thrombocytopenia or anemia. Normal urine studies. No diarrhea.
Henoch-Schönlein Purpura
Rectal bleeding in ~50%
No abdominal pain, palpable purpura, swollen hands and feet or joint pains.
Sexual Assault
No genitourinary or vaginal trauma. No hx of broken bones.
Coagulopathy
Rectal Bleeding
No excess bruising, No recurrent epistaxis. PT/INR wnl

9. Therapy
If this patient had an intussusception which is more likely given the “lead point” of a Meckel’s the patient would receive an air contrast enema.
A Meckels is removed via laproscopic or open surgical resection.
A colonoscopy may be indicated because the gastric tissue may have created ulcers in the intestine. These may contribute to the bleeding.

10. Final Ddx: Meckel’s Diverticulum
Rule of 2’s:
2% of Population
2 ft from ileocecal valve (on ileum)
Male:Female is 2:1
Most common by age 2
Commonly 2 inches long
2% symptomatic
Failed involution of the vitelline (omphalomesenteric) duct
Meckel’s generally contain ectopic gastric or pancreatic tissue