Hematemesis and Pyloric Stenosis

Abstract

An 11-week-old male infant was brought to an outside emergency department (ED) with the chief complaint of coffee ground emesis. He was vomiting about half of his feeds, 2 to 3 times a day for the last 2 days. On the day of presentation to the ED, he had 8 episodes of emesis over a 2-hour period, all of which were described by the mother as coffee ground and projectile. He usually drank 4 oz of Similac with iron every 2 to 3 hours, but his mother reported that it had decreased to 2 oz every 3 hours over the last 2 days. He had no fever or diarrhea. He did not have a bowel movement for the last 2 days. Prior to that, his bowel movements were normal without blood or melena. His mother had not noticed any abdominal distension or increased fussiness. There was no history of trauma or bleeding reported from other sites. He was born at term by normal vaginal delivery without any complications. There was no history of bleeding diathesis in the family.At the community ED, he was noted to be active, alert, hemodynamically stable and had a normal physical examination. A complete blood count (CBC) and coagulation studies were reported to be normal. X-ray of the abdomen revealed mild gastric distension but was otherwise normal. He received a normal saline bolus 20 cm 3 /kg. A nasogastric (NG) tube was placed that returned blood-tinged stomach contents, and he was transferred to our ED for further care.Physical examination at our ED revealed an alert, well-appearing vigorous infant with a temperature of 37.5°F, heart rate of 142 beats per minute, respiratory rate of 32 breaths per minute, and a blood pressure of 115/79 mm Hg. He had no pallor or scleral icterus. Anterior fontanelle was soft and level. His NG tube was in place with return of blood-tinged gastric contents. There was no active bleeding noted from anywhere else. His capillary refill was less than 2 seconds. He was breathing comfortably, and his lungs were clear to auscultation. His abdomen was soft and nontender, with no organomegaly or palpable masses and with normal bowel sounds. His skin had no petechiae, bruises, or ecchymoses. Rectal examination showed soft stool that was hem occult negative.

Bilious Vomiting Does Not Rule Out Infantile Hypertrophic Pyloric Stenosis

“…In contrast, bilious emesis in infants with HPS has not been widely described. After an extensive literature search, we found multiple authors describing the vomit of IHPS as nonbilious, 7,10,11,16,17,19-24 but found only 1 case report, written in Hebrew, that suggests that bilious vomiting can be a presenting symptom. 26 Physiologically, bilious vomiting should not occur in a hypertrophied pylorus that prevents backflow of bile into the stomach.…”

“…[6][7][8]17,18 The description of the vomit seen in IHPS is commonly described as never containing bile, and when bilious vomiting is present, IHPS can be excluded from the differential diagnosis of the vomiting infant. 7,10,11,16,17,[19][20][21][22][23][24] There are a few reports of hematemesis being associated with IHPS, but the frequency of hematemesis is low. 3,10,20 Although bilious emesis has been described in the context of concomitant gastrointestinal malrotation, 25 there is only 1 case report of bilious emesis being described in IHPS without additional gastrointestinal pathology.…”

Hematemesis in a 5-Month-Old Girl: A Tale of Double Whammy

“…Common causes of hematemesis during infancy include gastritis, esophagitis, stress ulcer, vascular malformation, and pyloric stenosis. 8 It is rare for congenital duodenal obstruction to present with acute gastrointestinal bleeding. 9 On review of the literature, there have been less than 10 cases of incomplete duodenal obstruction with hematemesis in early life reported in the English literature; even fewer cases of duodenal web with hematemesis.…”