Cecal Hematoma Associated with Suspected Necrotizing Enterocolitis in a Neonate.

Sir,

Cecal hematoma is exceedingly rare entity and usually reported in the elderly as a complication of colonoscopy.[1] This is not reported, to the best of our knowledge, in neonates.

A 4-day-old male neonate, weighing 2.4 kg, presented with a history of delayed passage of meconium, abdominal distention, bilious vomiting, hematochezia, and pallor. The baby passed small amount of meconium on the 2nd day of life and was on mother feed. The abdominal distension developed gradually over the next 2 days and was associated with few episodes of bilious vomiting on the 3rd day of life. On the 4th day of life, the baby passed fresh blood and clots per rectum and also developed pallor. On examination, abdomen was distended and shiny; rectal stimulation showed blood-stained meconium. Laboratory investigations showed hemoglobin of 8.3 g/dl, white blood cell 4000/cc, and C-reactive protein 48; the rest of laboratory tests were normal. X-ray abdomen erect showed dilated bowel loops. Ultrasound abdomen showed dilated bowel loops. On exploration, small bowel was distended, slightly edematous and inflamed, with multiple hemorrhagic patches and large bowel was collapsed. A large mural cecal hematoma [Figure 1] was present which caused the intestinal obstruction. The cecal hematoma was evacuated along with limited right hemicolectomy; ileostomy and mucous fistula were created. Serial biopsies were taken to rule out Hirschsprung's disease (HD).

Figure 1

Huge cecal hematoma

Initial postoperative course was uneventful. His stoma started moving on the 2nd postoperative day and he was started orally on the 4th postoperative day. On the 5th postoperative day, the baby developed whole body edema. Complete blood count showed thrombocytopenia. Prothrombin time and activated partial thromboplastin time were also deranged. C-reactive protein increased to 98 and serum albumin dropped to 2.2 g/dl. Blood culture was negative. Antibiotics were stepped up, and the baby was infused albumin and fresh frozen plasma. Two transfusions of platelets were also given. The patient improved gradually and was discharged on the 17th postoperative day on full feeds. Histopathology showed normal ganglion cells in all samples, and biopsy of ileum/cecum showed edema of lamina propria, submucosa, and muscle coat with infiltration of inflammatory cells.

Cecal hematoma is usually reported after blunt abdominal trauma, colonoscopy, foreign body ingestion, patients on anticoagulation therapy, hemophilia, and occasionally spontaneous in nature.[1234] No case has yet been reported in association with necrotizing enterocolitis (NEC). NEC usually appears in preterm neonates on the 2nd week of their life, but in 10%–15% of cases, it can appear in term neonates and in that case it appears early, within few days after birth.[5] Our suspicion was of HD or NEC, but peroperatively, the hemorrhagic patches were not exactly looking like NEC; that is why we also took serial biopsies to rule out HD. Although histopathologic features of advanced or fully developed NEC were not present, exclusion of HD, presence of bowel wall edema and inflammation, and histopathologic evidence of edema of bowel layers along with infiltration of inflammatory cells may point toward early or developing NEC. As per Bell's classification, our case falls in Stage IB or IIA as no pneumatosis intestinalis was visible. Since our patient deteriorated postoperatively, it can be speculated that the disease process progressed but ultimately settled down; however, we cannot exclude hospital-acquired infection after surgery.

To summarize, NEC can present early in term neonates and occasionally it may be associated with cecal hematoma which was the main reason of sudden pallor in our patient. Surgical intervention to evacuate it, limited right hemicolectomy, and temporary enterostomy proved life-saving in our patient.

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