Visible blood in the stool in a neonatal intensive care unit

Abstract. Background: Visible blood in the stool (VBS) and the appearance of gas within the bowel wall on radiographs, pneumatosis intestinalis, are the two major signs used to diagnose necrotizing enterocolitis (NEC). We experienced a four-fold increase in the incidence of VBS that was not associated with additional morbidities. Objective: To identify three new different diagnostic entities that would have been otherwise labeled as NEC. Methods: In this retrospective study we collected data on all neonates recognized with VBS; all of them had abdominal radiographs. Neonates were classified into three groups; 1) Benign pneumatosis coli (Pcoli) group (n = 46): included neonates with VBS and pneumatosis intestinalis on radiographs but no other clinical or laboratory abnormalities, 2) Classic NEC group (n = 39): included neonates with VBS and pneumatosis intestinalis, that was associated with clinical instability and/or laboratory abnormalities, and 3) Isolated VBS group (n = 46): included neonates with VBS without radiographic pneumatosis, clinical signs, or laboratory abnormalities. Results: Group 1 infants were of older gestational age when compared to Group 2 infants; the majority (89%) of the Benign Pcoli neonates was ≥34 weeks, whereas the majority (79%) of Classic NEC neonates was ≤33 weeks. The median postnatal age at the time of VBS was 7, 13 and 8 days for the three groups, respectively. Surgery (n = 13) and death (n = 6) were reported only in Classic NEC group. In the Isolated VBS group, the recognized blood was attributed to viral gastroenteritis (n = 3), anal fissure (n = 6), swallowed maternal blood (n = 9), and milk protein intolerance (n = 9), while the etiology was undetermined in 19 neonates. Conclusion: Although risk for surgery and mortality were high in Classic NEC, all neonates who presented with Benign Pneumatosis Coli or Isolated VBS had benign course and they all survived. Clinical and laboratory findings at the time of presentation of VBS are essential to differentiate these three diagnostic entities, and could possibly help avoidance of prolonged fasting and use of antibiotics.