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Virtual Pediatric Patients
Donna M. D'Alessandro M.D., Tamra E. Takle M2
Peer Review Status: Internally Peer Reviewed
"I'd like you to meet my son Jamie who is a week old today. Jamie and I, and his 2-1/2 year-old brother Jason live with my mother in a house in a small Iowa town. Jamie's father works at a car wash and I stay home to take care of the boys."
The Problem / Clinical Presentation
"My story with Jamie started one week ago on a Wednesday when I went into labor. I had a normal pregnancy with no complications except that I got the hiccups a lot. My doctor had delivered my son Jason and he is really good. My doctor was going out of town when the baby was supposed to be due, so I chose to be induced so he could deliver the baby. As it turned out, I started going into labor two weeks before I was due and they helped the labor with the Pitocin. I was in labor for 15 hours, which was different from my first child who only took six hours. That night, my beautiful little baby was born."
"When I first fed him with the bottle an hour or so after he was born, he threw up. I thought maybe he swallowed a lot of phlegm. The next few times I fed him on Thursday, everything came right back up. He started getting a little better at keeping his food down late Thursday. On Friday, when I got released, the pediatrician told me Jamie would have to stay another day. If the vomiting slowed down, Jamie could come home Saturday. The pediatrician told me I was probably feeding Jamie too much, but I don't think I was feeding him any more than my first child"
"I called on Friday night and Saturday morning and was surprised to hear that Jamie was still vomiting. While I was visiting him on Saturday afternoon, he vomited a lot of bright greenish-yellow fluid. At this point the pediatrician ordered x-rays, and later decided to send him to the University of Iowa. When the pediatrician told me this, I had tears streaming down my face. Until then, I didn't really believe there was anything wrong with him."
"When we got to the University of Iowa, I was initially told that he may not need surgery, but late Sunday night they took him to the operating room."
Clinical Physical Exam
Jamie was a vigorous and well-appearing infant with a weight of 2780 grams. Vital signs were stable. His abdominal evaluation showed a soft, non-tender, non-distended abdomen with good bowel sounds. There were no masses and no hepatosplenomegaly. Genitourinary examination showed a circumcised male with bilateral descended testes and no hernias noted. The rest of his physical examination was normal.
Clinical Differential Diagnosis
The differential diagnosis for a 3 day old with bilious emesis would include:
CBC differential was unremarkable. His electrolytes were Na=144 mEq/l, K=3.5 mEq/l, Cl=107 mEq/l, CO2=23 mEq/l , BUN=6 mg/dl, Creatinine=0.8 mg/dl and Glucose=78 mg/dl (within normal limits for age). Total bilirubin was 5.1 mg/dl and direct bilirubin was 0.6 mg/dl (within normal limits).
Laboratory Differential Diagnosis
These findings indicate that Jamie had normal physiologic parameters but does not change the differential diagnosis.
Abdominal radiograph was unremarkable. An upper GI series showed that the duodenal-jejunal junction was abnormally located to the right of the spine. At this point, there was an abrupt narrowing of the duodenum with a fine thread of contrast extending inferiorly in a "corkscrew"-like appearance. Abdominal ultrasound with color Doppler showed the superior mesenteric vein coursing around the superior mesenteric artery with a swirl-like appearance.
Imaging Differential Diagnosis
Malrotation with midgut volvulus resulting in partial small bowel obstruction
The patient was taken to the operating room and explored through a midline incision. Malrotation with midgut volvulus was confirmed. A Ladd's procedure was performed, placing the colon in the left side of the abdomen and the small bowel in the right side of the abdomen. An appendectomy was also performed.
Treatment Course, Prognosis and Follow-up
"The doctor came out of the operating room and said he removed Jamie's appendix. I asked what was wrong with his appendix, and the doctor said it was on the wrong side. So I guess there was a little more to it than just mucus. It wasn't until a couple of days later that I understood that his intestines were all turned around."
"It was really unexpected, the local doctors didn't catch it on the x-rays. It wasn't until they made Jamie swallow the barium that they knew what was wrong with him. It was hard to believe anything was wrong. He even had a few bowel movements in the hospital. When I called the local nurses and told them he had surgery, they were really surprised."
"It's a long story for a week-old baby. I wondered if it was my fault, if I didn't take my vitamins enough or eat the right foods. But I know it's not my fault, and I'm a lot closer to him already. He's my little blessing."
"Now we're finally on our way home. We've packed his Barney doll, a present from Jason, and the football and boxing glove from his dad. Dad calls him his little fighter."
Emesis is the forceful ejection of the stomach contents through the mouth. Regurgitation is the effortless bringing up of a small amount of food without discomfort or distress. For a layperson, these can be hard to separate.
The differential diagnosis is very extensive and the most common problems vary with the age of the child. Congenital anomalies and inborn metabolic errors along with feeding difficulties are more common in infancy with infectious and systemic disease become more common in childhood. Adolescence adds the problems such as eating disorders, drug use and pregnancy. Potentially, any of the problems listed may be seen at any time.
In infancy (see also Childhood and Adolescence)
- Ingestion of maternal blood or mucus
- Gastroesophageal reflux
- Esophageal incoordination
- Excessive crying
- Non-organic causes - solid food feeding before the child is ready, anxiety, excitement, imitation, attention seeking behavior, motion sickness
- Food allergies
- Inborn errors of metabolism - Phenylketonuria, galactosemia, and many more
- Congenital adrenal hyperplasia
- Infections such as otitis media, urinary tract infection, CNS infection, sepsis
- Munchausen syndrome by proxy
- Atresia/stenosis and webbing of the GI tract
- Other obstruction of GI Tract - duplications, annular pancreas, meconium ileus, functional ileus, meconium plug syndrome, vascular rings, tumors, bezoars
- Pyloric stenosis
- Testicular torsion
- Esophageal atresia
- Urethral obstruction
Childhood (see also infancy and adolescence)
- Strep Throat
- Diabetes Mellitus
- Ketotic Hypoglycemia
- CNS related problems such as migraine, tumors, intracranial bleeding, epilepsy
- Reye's Syndrome
- Familial Dysautonomia
- Gall bladder disease
- Ovarian cysts
Adolescence (see also infancy and childhood)
- Drugs and alcohol
- Eating Disorders
- Pelvic Inflammatory Disease
- no additional specific causes in adolescence
History and Physical
A complete history should be taken from the patient and/or family. Attention should be paid to the timing of the emesis in association with eating, any associated pain or discomfort, changes in eating and elimination patterns, whether eating or eliminating improves or worsens the emesis, characteristics of the stool and urine, any trauma or systemic problems such as changes in mentation or weight loss, and fever.
The physical examination should emphasize the abdominal examination, but other areas such as the respiratory, and genitourinary systems should be closely examined. Additionally, other systemic signs should be looked for including skin changes and an erythematous pharynx.
A careful history and physical examination guides all laboratory and radiographic evaluations. Depending on the age of the patient and the differential diagnosis, radiographic procedures such as plain films, ultrasound and contrast studies may be ordered and help elucidate anatomic problems. If a surgical problem is being considered, then early consultation with a surgeon should be considered.
Laboratory evaluation helps to find systemic and infectious diseases and can help determine secondary problems such as electrolyte abnormalities caused by copious emesis. Considerations for the initial laboratory evaluation can include:
The classic case of malrotation with midgut volvulus is a newborn <1 month old with bilious vomiting. However, malrotation with midgut volvulus may present as intermittent abdominal pain and/or vomiting. Malrotation is also associated with other congenital anomalies such as diaphragmatic hernia, omphalocele and gastroschisis.
Malrotation with midgut volvulus is the failure of the developing bowel to undergo the usual counterclockwise rotation in the 4th to 10th week of embryogenesis. Peritoneal bands (which normally attach the bowel to the central body axis posteriorly) compress the duodenum, partially obstructing it. Because the mesentery is not well attached, patients are at risk for developing a midgut volvulus.
The term volvulus comes from the Latin word volvere, meaning to turn or roll. Volvulus refers to complete twisting of a loop of bowel around its mesenteric attachment, which results in intestinal obstruction. The superior mesenteric artery can be compressed leading to ischemia of its distribution, the small bowel from the duodenal-jejunal junction to mid-transverse colon.
Electrolyte imbalances may occur secondary to emesis, but there is no specific laboratory test to confirm the diagnosis of malrotation with midgut volvulus.
The abdominal plain radiograph is usually unremarkable, although classically it can demonstrate duodenal or small bowel obstruction. The upper GI exam is the diagnostic test of choice. The normal position of the duodenal-jejunal junction (DJJ) is at the level of the duodenal bulb, overlying the left pedicle of the spine or to the left of the spine. Any other position should be considered to be abnormal (a low-lying DJJ or a DJJ positioned to the right of the spine) and demonstrative of malrotation. Volvulus classically appears on the upper GI as a spiral corkscrew of the duodenum. Volvulus can also be seen on abdominal ultrasound where the volvulized small bowel has a "whirled" appearance.
Malrotation with midgut volvulus is a surgical emergency, because ischemia can lead to small bowel infarction. To relieve the obstruction, the peritoneal bands (also known as Ladd bands) around the duodenum are divided. The colon is placed on the left and the duodenum on the right to broaden the mesentery. An appendectomy is performed to avoid future confusion if the child has abdominal pain. This surgical procedure is known as Ladd's procedure.
Return of intestinal function varies with the degree of ischemia. Children who undergo treatment before development of bowel infarction usually regain normal function within a few days. For patients with a bowel infarction, return of normal function may be delayed depending on the length of infarcted small bowel that must be resected. Resection of a large section of the small bowel leads to a poor prognosis.
Berkowitz, Carol D, Pediatrics A Primary Care Approach. W.B. Saunders and Co. Philadelphia, PA, 1996. pp. 330-334.
Davenport M. Surgically Correctable Causes of Vomiting in Infancy. British Medical Journal 1996: 312, 236-9.
Illingworth, RS, Common Symptoms of Disease in Children. Blackwell Scientific Publications. 1988. pp. 69-83 Ross AJ. Intestinal Obstruction in the Newborn. Pediatrics in Review 1994: 15(9), 338-347.
Sheldon, Stephen H. and Levy, Howard B. Pediatric Differential
Diagnosis. Raven Press. New York, 1985. pp. 167-176.
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