For Part 2 of this series, we will look at another infant with vomiting and discuss the RED FLAG signs and symptoms.
Check out Part 1 if you missed it!
Case 2
A 7 month old with 7-8 episodes of vomiting per day for the past week. Initially vomiting was NBNB but presents to the ED after vomiting became green in color. No fever, no diarrhea. In fact, Mom says that the baby has not had a BM in 4 days. Prior diagnosis during this illness of gastroenteritis during which they received IVF and Zofran at another facility.
His vital signs on presentation now in the ED: Temp 37C HR 135 RR 30 BP 90/45 SpO2 100%.
On your exam, he looks well and is well hydrated. His belly is non-distended and soft with no masses.
Certainly this baby looks well on exam with reassuring vitals signs. However, the progression of vomiting to bilious emesis is a RED FLAG.
You decide to obtain labwork. The CBC, BMP, Magnesium, Phosphorus, Amylase, Lipase, and UA are all normal.
Bilious vomiting, in any age group is concerning! You need to pursue a work up for this baby.
The bilious vomiting is concerning for an obstruction. An abdominal X-Ray was first ordered.
AXR shows nonspecific, nonobstructive bowel gas pattern with mild gaseous distention and air-fluid levels.
At this point, it is important to remember that an abdominal x-ray does not rule out a diagnosis such as malrotation. Therefore, if your clinical suspicion is high (which it should be for this patient, due to the bilious vomiting) you should order additional studies.
An Upper GI was ordered on this patient.
Malrotation & Volvulus
This diagnosis usually presents under 1 year of age.
The malrotation occurs when the cecum is abnormally positioned in the right upper quadrant and is fixed to the right lateral abdominal wall by the peritoneum. This predisposes to twisting on the mesentery, causing a volvulus.
Resuscitate this patient with fluids, place an NG tube, and consult surgery to proceed.
References
Fleisher, G. R., & Ludwig, S. (Eds.). (2016). Textbook of pediatric emergency medicine. 7th Edition. Lippincott Williams & Wilkins.
Parashette, K & Croffie, J. (2013). Vomiting. Pediatrics in review, 34(7), 307-321.
Katie Edmunds is a current Pediatric Emergency Medicine Fellow interested in creating PEM 4 all those who are given the responsibility of treating the sickest babies wherever they may be.
