A 2-year-old girl is brought to the emergency department due to bloody stools. She had a blood-tinged stool last night and has a large amount of bright red blood in her diaper today. The patient has otherwise been well; has been eating and drinking normally; and has no nausea, vomiting, abdominal pain, or diarrhea. Her past medical history is unremarkable. The patient takes no medications, and her vaccinations are up to date. Temperature is 37.2 C (99 F) and pulse is 108/min. Examination shows a soft, nontender, and slightly distended abdomen. Bowel sounds are normal. There is no rebound tenderness or rigidity. Rectal examination shows a normal anus without tears or fissure. A technetium-99 nuclear scan shows an increased uptake in the right lower quadrant of the abdomen. Which of the following is the most likely diagnosis?

Question

A 2-year-old girl is brought to the emergency department due to bloody stools.  She had a blood-tinged stool last night and has a large amount of bright red blood in her diaper today.  The patient has otherwise been well; has been eating and drinking normally; and has no nausea, vomiting, abdominal pain, or diarrhea.  Her past medical history is unremarkable.  The patient takes no medications, and her vaccinations are up to date.  Temperature is 37.2 C (99 F) and pulse is 108/min.  Examination shows a soft, nontender, and slightly distended abdomen.  Bowel sounds are normal.  There is no rebound tenderness or rigidity.  Rectal examination shows a normal anus without tears or fissure.  A technetium-99 nuclear scan shows an increased uptake in the right lower quadrant of the abdomen.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c15a_65f7_8f63_1d635d20832f_MD0005_00 The differential diagnosis for this child's painless hematochezia includes Meckel's diverticulum as well as vascular malformations. Meckel's diverticulum results from a failure of the vitelline duct to obliterate during the first 8 weeks of gestation, leaving behind a blind pouch often containing ectopic gastric tissue. Meckel's diverticulum classically affects children age <2 but can also occur in older children or even adults. Young children are more likely to experience painless bleeding due to mucosal irritation from gastric acid; adolescents and adults are more likely to have signs of obstruction.A technetium-99 nuclear scan will identify the diverticulum, which is usually located in the right lower quadrant of the abdomen within 2 feet of the ileocecal valve. Technetium-99 concentrates in the parietal cells of the diverticulum and stomach. The scan is also known as "Meckel's scan" due to its high specificity. A symptomatic Meckel's diverticulum is generally treated with surgical resection. (Choice A) Appendicitis is not typically associated with hematochezia, and patients with appendicitis have significant right lower-quadrant abdominal pain, anorexia, and vomiting. (Choice B) Inflammatory bowel disease causes abdominal pain, and anal fissures and skin tags. Inflammatory bowel disease would not result in a positive technetium-99 scan. (Choice C) Intestinal lymphangiectasia or other vascular malformations can cause painless hematochezia but would not result in a positive technetium-99 scan. (Choice D) Approximately 10% of intussusceptions have an identifiable lead point that can cause the bowel to invaginate into itself. Meckel's diverticulum is a well-described example of such a point. However, children with intussusception have significant abdominal pain and poor appetite. Educational objective: Meckel's diverticulum can present as painless rectal bleeding in children age <2. A technetium-99 nuclear scan is highly specific for this condition. References: Emergency management of lower gastrointestinal bleed in children. (http://www.ncbi.nlm.nih.gov/pubmed/23355012) Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum. (http://www.ncbi.nlm.nih.gov/pubmed/22595706) Meckel's diverticulum: a review. (http://www.ncbi.nlm.nih.gov/pubmed/21322060)

A 2-Year-Old Girl Is Brought to the Emergency Department Due