Case 3-2012

Dr. Rebecca C. Bell (Pediatrics): A 6-day-old boy was admitted to this hospital because of vomiting, diarrhea, and abdominal distention. The patient was born at another hospital to a teenaged primigravida by vaginal delivery after a full-term, uncomplicated gestation. The mother had received prenatal care; she had no history of sexually transmitted infections, and prenatal screening tests were negative. Meconium was present at delivery. The patient’s birth weight was 4.3 kg (95th percentile), and the 1-minute and 5-minute Apgar scores were 7 and 9, respectively. Breast-feeding was initiated. The newborn passed two stools on the second day (the first at 30 hours of age). The next day, he reportedly had one loose, green stool. He was discharged home at 50 hours of age. He lived with his mother and her parents. When he was 3 and 4 days of age, he vomited yellow-green emesis on several occasions. He was otherwise well and breastfeeding regularly. At 3 a.m. on the day of admission, he became fussy and did not complete his normal feeding. Between 3 a.m. and 9 a.m., approximately six episodes of vomiting (initially breast milk, followed by mucus) occurred, with increasingly foul-smelling emesis. Diarrhea developed, and urine output decreased. Later that morning, he became less active; abdominal distention developed, and he stopped voiding. He was taken to a clinic affiliated with this hospital. On examination, he appeared tired, with intermittent grunting. The rectal temperature was 38.0°C. The abdomen was distended and tender, with hypoactive bowel sounds; stool was positive for occult blood. He was transported by ambulance to the emergency department of this hospital. On examination, the patient appeared alert and slightly uncomfortable. The temperature was 37.2°C, the pulse 160 beats per minute, the respiratory rate 30 breaths per minute, and the oxygen saturation 100% while he was breathing ambient air. The weight was 3.9 kg. The abdomen was distended, soft, and tympanic, with decreased bowel sounds. There were small, bilateral noncommunicating hydroceles. The remainder of the examination was normal. A stool specimen showed no occult blood. Urinalysis revealed clear orange urine, with a specific gravity greater than 1.030, pH 6.5, nitrites, 1+ urobilinogen, 3+ bilirubin, 2+ albumin, and trace white cells, blood, glucose, and ketones. Urinalysis also revealed 0 to 2 red cells, 3 to 5 white