March Week 1: Vomiting
Malrotation and Volvulus in Infancy and Childhood. Millar, Rode, and Cywes. Seminars in Pediatric Surgery, Vol 12, No 4. 2003.
Infantile Hypertrophic Pyloric Stenosis: Epidemiology, Genetics, and Clinical Update. Ranells, Carver, and Kirby. Advances in Pediatrics. 2011.
You are the pediatrician on call at a community hospital. You are called to see a 4-week-old baby in the ER for dehydration. The baby was born at full term, and was previously healthy until 1 week ago when he started spitting up. Parents changed the formula, but he still vomits. The emesis is non-bilious and happens shortly after feeds. It is getting worse every day until today when he vomited all the feeds. He seems to be hungry all the time too.
On physical exam, his HR 190, RR 54, BP 86/53, SPO2 100%. His cap refill is 3 seconds, his anterior fontanelle is slightly sunken, and his lips are slightly dry. You get some labs and find the following abnormalities: pH 7.5, Chloride 84, Potassium 2.2.
1. What is the most likely diagnosis?
2. What is the first thing that you want to do for this patient?
3. What will you look for on physical exam that will aid in diagnosing this condition?
4. Which consultant would you like to call?
5. Is the baby going to be ok?
You are the resident on ‘mommy call.’ You get a call from a mother who is distressed because her baby vomited. The baby is 3 days old, born at full term and mom took him home yesterday. He was well until this morning. His abdomen has become progressively more distended, he is irritable, and looks pale. When you ask mom the color of the vomit, she tells you that it is green. You instruct her to go straight to the emergency room for admission to the hospital.
1. How concerned are you about this baby?
2. What are 3 causes of bilious emesis in the newborn baby?
3. What test are you going to do as soon as this baby is admitted? What if they tell you that this test cannot be done in the middle of the night, and ask if you can wait until the morning?
4. What is the pathophysiology behind intestinal malrotation and midgut volvulus?
5. What is the immediate treatment for this baby?
6. What is the definitive treatment for this baby?
Cases by Dr. Farias-Moeller