A Case Report of Hematemesis in a 4-Week-Old Neonate: Clinical Reasoning and Outcome After Empiric Acid Suppression.

Introduction: Neonatal hematemesis is an uncommon presentation with a broad differential diagnosis ranging from benign to life-threatening etiologies, and there are no well-established, evidence-based management guidelines. This case highlights the diagnostic challenges and potential role of empiric acid suppression in a clinically stable neonate. Cases Presentation: A 4-week-old term male with a prior episode of coffee-ground emesis at 3 days of life presented with recurrent hematemesis consisting of bright red blood. He was hemodynamically stable with an unremarkable physical exam. Laboratory evaluation demonstrated stable hemoglobin, mildly elevated bilirubin, and no evidence of coagulopathy. Imaging, including abdominal ultrasound and radiographs, was unremarkable. Infectious and hematologic workups were negative. Esophagogastroduodenoscopy revealed superficial gastric mucosal abrasions without active bleeding, ulcers, or structural abnormalities. The patient was managed initially with intravenous acid suppression and supportive care, and then transitioned to oral lansoprazole. He tolerated feeds without recurrence of hematemesis and was discharged with a 14-day course of proton pump inhibitor therapy. At two-week follow-up, he remained asymptomatic with normal feeding and no further bleeding episodes. Conclusion: This case underscores the importance of systematic evaluation in neonatal hematemesis and suggests that empiric proton pump inhibitor therapy may be a reasonable option in select stable patients with suspected mucosal injury.