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

A 5-month-old girl presented to the emergency department with 3 episodes of hematemesis. Her symptom started on day of admission. The medical history was significant for gastroesophageal reflux diagnosed at 1 month of life after she presented to her pediatrician with episodes of spitting up and fussiness after each feed. She was started on ranitidine but her parents report minimal relief of symptoms. Family history included a maternal history of duodenal atresia repaired at birth, and maternal aunt with gallbladder agenesis and partial small bowel obstruction repaired as an infant. On admission, her growth parameters were normal and physical examination was unremarkable. She had an episode of coffee-ground emesis witnessed by the medical team and visual inspection of the stool was consistent with description of melena. Laboratory evaluation included a hemoglobin of 11.7 mg/dL and a positive fecal occult blood. Pediatric surgery and gastroenterology team were consulted on admission and she underwent an upper gastrointestinal (UGI) series, which demonstrated severely dilated duodenum and paucity of passage of contrast concerning for small bowel obstruction (Figure 1).