Written by Andy Brigg, DO and Edited by Van Wall, DO

HPI: 4 day old Male born at 38 weeks with no complications, who presents to the ED with a four day history of large volume, non-bilious emesis with nearly every feeding. Was seen at PCP’s office and noted to have jaundice with 0.5 Kg weight loss since birth, and was sent to the ED for further evaluation. While in the ED, he had another episode of emesis with oxygen desaturation, which required supplement O2.

No PMHx, PSHx, Meds or allergies.

Vitals: HR: 152 RR: 40 T: 99.6 SPO2: 99% RA

PE:

General Appearance:  Jaundice, crying with exam

Head:  Normocephalic and atraumatic

Eyes:   Scleral icterus

ENT:   Dry mucus membranes

Neck:  Supple

Chest:  Clear to auscultation, no wheezes, rales, or rhonchi, no tachypnea, retractions, or cyanosis

CV:  RRR, no murmurs, normal S1 & S2, capillary refill less than 2 seconds

Abdomen:  Abdomen is soft without significant tenderness, masses, organomegaly or guarding. Hypoactive bowel tones

Anus:   Normal position

Genitourinary:  No hernias, no masses

Extremities:  No gross abnormality

Neurological:  Normal without focal findings

Skin:    Jaundiced

Labs: 

Bili neonatal total 22.5 (HH) 1.0-12.0 mg/dL
Bili conjugated(dir) 0.6 <1.0 mg/dL
Collection Time: 06/23/16  9:17 PM
Value Ref Range
Na 148 (H) 135-145 mmol/L
K 4.0 3.6-5.3 mmol/L
Cl 105 98-109 mmol/L
CO2 16 (L) 18-26 mmol/L
Anion gap w/o K 27 (H) 7-15
BUN 26 (H) 4-15 mg/dL
Creatinine 0.64 (H) 0.2-0.6 mg/dL
Glucose 64 60-105 mg/dL
SGOT/AST 28 5-40 IU/L
Alk Phos 89 75-316 IU/L
SGPT/ALT 6 6-60 IU/L
Bilirubin total 22.5 (HH) 1.0-12.0 mg/dL
Protein 6.5 4.3-6.9 g/dL
Albumin 3.8 3.2-5.0 g/dL
Globulin (calc) 2.7 2.0-4.5 g/dL
A:G Ratio 1.4 >1.0
Calcium (LL) 8.5-10.5 mg/dL
<2.0

KUB:

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IMPRESSION:

A distended gas-filled stomach is noted with the remainder of the bowel decompressed including the duodenum. Underlying gastric outlet obstruction is suspected.
UGI:

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IMPRESSION:

There is gastric dilatation and opacification of the duodenal bulb, second duodenal segment, and proximal to mid third duodenal segment. Contrast abruptly ends at the proximal to mid third duodenal segment and does not cross the entire spine. There is proximal upstream duodenal dilatation. There is a paucity of distal gas.

DDx in vomiting neonate:

  • Duodenal Atresia (usually have bilious vomiting)
  • Midgut volvulus
  • Pyloric Stenosis (unusual in this age)

Diagnosis: Malrotation with  Midgut volvulus

The patient went immediately to the OR, had mutliple Ladd bands lysed and bowel was detorsed with viable bowel. He is recovering well.

Key points:

  1. Present in about 1 to 200-500 people.
  2. Over 50 percent of children with malrotation present before one month of age with the life-threatening complication of volvulus.
  3. Vomiting may or may not be bilious. With volvulus, you can frequently see a “corkscrew” appearance of the duodenum.
  4. Vomiting occurring within first 48 hours of  life is a Red Flag.  Also, the mother presented to clinic not specifically for vomiting, but also for jaundice (This patient’s hyperbili was not obstructive although some cases of hyperbili with malrotation are.)

**This patient was seen by Dr. Sakata, who helped provide key points, and Dr. Brigg.  Initially, IR did not want to come in after hours, and stated that this “could probably wait till morning”.  Dr. Sakata continued to advocate for the patient and refused to get off the phone until the radiologist agreed to come see the patient.  She wanted to emphasize that “time is bowel” in these situations.

Additional References:

http://pedemmorsels.com/malrotation/

Vomiting from noodles, or are we missing something?

 

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