What’s That in the Diaper?

Bloody stools in a neonate can be from a variety of etiologies such as benign anal fissures or milk protein allergy, or from more life-threatening etiologies such as volvulus, infectious colitis, or necrotizing enterocolitis (NEC). Older children may have bloody stools associated with intussusception, usually diagnosed with ultrasound, and treated with contrast enema or Meckel’s diverticulum diagnosed with a technetium scintigraphy. NEC is most commonly seen in premature infants but must be excluded in infants presenting to the Emergency Department with bloody stools. An abdominal radiograph is the initial imaging modality of choice for the diagnosis of NEC. Pathognomonic features of NEC seen on x-ray include pneumatosis intestinalis (air within the bowel wall), portal vein air, or pneumoperitoneum from intestinal perforation. NEC should be managed with IV fluids, bowel rest with gastric decompression, IV antibiotics, and surgical consultation.