Rumbly in the tumbly: Pneumatosis intestinalis and necrotizing enterocolitis

Case presentation

A 10-day-old infant presents to the emergency department with 1 day of fussiness, decreased oral intake, decreased urine output, and three grossly bloody stools. There has been no fever, cough, congestion, vomiting, or rash. The child is breastfed exclusively and the mother denies she has had cracked nipples or bleeding from the breast. She has noted the child is feeding less vigorously today.

The child was born vaginally at 34 weeks and spent 4 days in the hospital to observe feeding and required blow by oxygenation for 24 hours. The mother had excellent prenatal care. Prior to hospital discharge, the patient had normal feeding and stooling.

The child is afebrile with a heart rate of 170 beats per minute, a respiratory rate of 30 breaths per minute, and a pulse oxygenation saturation of 98% on room air. While not in obvious distress, the child is fussy during the examination but otherwise remains quiet, which the parents state is not typical. The physical examination is unremarkable, except for mild abdominal distention without obvious tenderness; rectal examination shows a patent anus and is guaiac positive. Right after the rectal examination, she passes a loose, grossly bloody stool.

Imaging considerations

Pneumatosis discovered on radiography is a sign, rather than a specific diagnosis, which can be associated with either benign or potentially life-threatening conditions.