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Morning Report
Elisabeth Kaza, MD
August 3, 2012
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You are in the ED...
2 mo old term female with severerecurrent vomiting and dehydration
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HPI
3 wks ago (at 5 wks of life): first emesis Emesis:
Non bloody, non bilious
More forceful and frequent over time Seen by PCP numerous times, tried on:
Soy formula, Alimentum, Nutramigen
Anti-reflux meds
Would tolerate new formula for ~ 24hrs Past 2 days: not waking up, decreased
UOP, only smears of stool for past wk
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PMH/SH/FH
Birth history: 39 wks to 30 y/o G3P2002 via NSVD
Resuscitation: dry & stim, Apgars 8/9
SH: UT Parents and 2 siblings (7 and 9 y/a)
FOB smokes at home
FH: not contributory
Medications: none currently
ROS: lethargy, decreased UOP, pallor
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VS/PE
VS: T 37.1, HR 129, RR 28, BP 90/55, SaO2 92% on RAWeight: 3.6kg (Birth Weight: 3.054kg)
Height: 52.8 cm
Physical Exam:
Gen: no acute distress, appeared ill, slightly lethargic
HEENT: anterior fontanelle sunken, PERRL, drymucous membranes
Resp: clear to auscultation, no wheezing/crackles
CV: RRR, cap refill 3 sec, femoral pulses 2+
Abdomen: soft, mildly distended, NT, no HSM
Neuro: moves all extremities, Moro/suck wnl
Skin: cool, no rashes or jaundice
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Differential Diagnosis ??
2 mo old term female with severerecurrent vomiting and dehydration
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Vomiting in Children:
Reassurance, Red flag, Referral?
Gastrointestinal Neurologic Renal Endocrine
-Esophagus:
stricture, web, TEF, atresia
-Stomach:
pyloric stenosis, web, ulcer
GERD
-Intestine:
duodenal atresia, malrotation,
intussusception, volvulus,
duplication, NEC
-Colon:
Hirschsprung, imperforate anus
-Acute gastroenteritis
-H. pylori infection
-Parasitic infections-Appendicitis
-Celiac disease
-Milk/soy protein allergy
-Inflammatory bowel disease
-Pancreatitis
-Cholecystitis
-Hepatitis
-Peritonitis
-Trauma: duodenal hematoma
-Tumor
-Cyst
-Hematoma
-Cerebral edema
-Hydrocephalus
-Pseudotumor cerebri
-Migraine headache
-Abdominal migraine
-Seizure
-Meningitis
-Obstructive uropathy
-UPJ obstruction
-Nephrolithiasis
-Renal insufficiency
-GN
-UTI
-RTA
-Diabetic ketoacidosis
-Adrenal insufficiency
Metabolic Miscellaneous
-Galactosemia-Hereditary fructosemia
-Amino acidopathy
-Organic acidopathy
-Urea cycle defects
-Lactic acidosis
-Lysosomal storage
disorder
-Peroxisomal disorders
-Sepsis-Pregnancy
-Bulimia
-Psychogenic
-Cyclic vomiting
-Overfeeding
-Medication toxicity
-SMA syndrome
-Child abuse
-PNA
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Age-related DD of Vomiting in
Children Younger Than 12 Mo
Age Common Causes Type of Vomiting Associated Features
Newborn - Intestinal atresia/web
- Meconium ileus
- Hirschsprungs
- NEC- Inborn errors of metabolism
Bilious, depending on lesion
Bilious
Bilious or nonbilious
Bilious or nonbiliousBilious or nonbilious
Esophagus, duodenum, jejunum
Ass with CF
Suction rectal surgery
KUB pneumatosisMay have acidosis/hypoglycemia
0-3 mo - Pyloric stenosis
- Malrotation, midgut volvulus
- Inborn errors of metabolism
- Milk/soy protein allergy
- GERD
- Child abuse
Nonbilious
Bilious
Bilious or nonbilious
Bilious or nonbilious, bloody
Nonbilious, bloody
Nonbilious
Hypochloremic metabolic alkalosis
Emergent surgical consultation
Abnormal newborn screen
Hx extreme fussiness
Emesis within 30min of feeding
CNS imaging studies
3-12 mo - Gastroenteritis
- Intussusception
- Child Abuse
- Intracranial mass
Nonbilious initially
Bilious
Nonbilious
Nonbilious
Consider stool studies
Abdominal distention
Anterior fontanelle fullness
CNS imaging
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Age-related DD of Vomiting in
Children Younger Than 12 Mo
Age Common Causes Type of Vomiting Associated Features
Newborn - Intestinal atresia/web
- Meconium ileus
- Hirschsprungs
- NEC- Inborn errors of metabolism
Bilious, depending on lesion
Bilious
Bilious or nonbilious
Bilious or nonbiliousBilious or nonbilious
Esophagus, duodenum, jejunum
Ass with CF
Suction rectal surgery
KUB pneumatosisMay have acidosis/hypoglycemia
0-3 mo - Pyloric stenosis
- Malrotation, midgut volvulus
- Inborn errors of metabolism
- Milk/soy protein allergy
- GERD
- Child abuse
Nonbilious
Bilious
Bilious or nonbilious
Bilious or nonbilious, bloody
Nonbilious, bloody
Nonbilious
Hypochloremic metabolic alkalosis
Emergent surgical consultation
Abnormal newborn screen
Hx extreme fussiness
Emesis within 30min of feeding
CNS imaging studies
3-12 mo - Gastroenteritis
- Intussusception
- Child Abuse
- Intracranial mass
Nonbilious initially
Bilious
Nonbilious
Nonbilious
Consider stool studies
Abdominal distention
Anterior fontanelle fullness
CNS imaging
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PYLORIC STENOSIS
Hernanz-Schulman M Radiology 2003;227:319-331
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Laboratory Evaluation
CBG: 7.59/62.2/58/59.7/BE unable toreport
BMP:
Anion Gap: 31
CBC:
CRP: 2.6
iCa: 1.17, Mg: 2.2, Phos: 3.9
124 53 40
2.6 >40 0.59104
11.7 488
39.3
9%B
36%N
33%L
22%MI/T: 0.19
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Abdominal UltrasoundMarked thickening of pyloric mm and elongation of pyloric channel
Unilateral wall thickness: 5mm Channel length: 25mm
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History
Harald Hirschsprung
(1830-1916)
German Pediatric
Congress inWiesbaden in 1887
2 infant girls with
pathologically
proven IHPS
Hernanz-Schulman M Radiology 2003;227:319-331
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Symptoms
Persistent non-bilious vomitingAround 2-6 weeks of age
Usually forceful and projectile
Clear or curdled milk
Tends to occur within 30-60 min of feeding
Males, especially firstborn
Incidence: 3 per 1000 live births
Exact cause unclear Erythromycin interacts + motilin receptors
(gastric/pyloric contractions/hypertrophy)
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Dx and Treatment
History, PE (palpable olive)
Laboratory:
hypochloremic hypokalemic metabolic
alkalosis
U/S of pyloric mm:
Sensitivity of 85-100%
Mm thickness of > 4mm Mm length of 14 mm
Surgical pyloromyotomy
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Can you feel an olive?
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Surgical Criteria
Good hydration status
Normalization of acid-base status and
electrolyte
Chloride > 100
Bicarb < 28 which she reached on day 3