Bilious Emesis and Dehydration in an Infant

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ESPR208
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Bilious Emesis and Dehydration in an Infant

Chief Complaint: Bilious Emesis

History of Present Illness: 

An 11-month-old ex- 33 and 2/7 week gestation female presented to the emergency department (ED) for evaluation of increasing emesis over the past two days. She had been seen in the ED two days prior for the same concerns. During the index ED visit she had improvement in symptoms and tolerated PO after receiving ondansetron and intravenous fluids.  She was subsequently discharged home.

The patient returned to the ED due to increasing frequency of emesis since discharge and report of new-onset bilious emesis on day of arrival. She was unable to tolerate solids or liquids by mouth throughout the day. Additionally, the parents reported the child had only one wet diaper daily throughout her illness and appeared increasingly more tired today.  Her last bowel movement was two days prior and was soft. She had a diaper rash that had been gradually worsening over the past week for which the mother had been applying a barrier cream. The patient had no fever, symptoms of upper respiratory infection, abdominal pain or pain behavior, abdominal distension, or foul-smelling urine. Parents denied any recent travel or known sick or COVID-19 contacts.

Birth History: 

Patient was born at 33 and 2/7 week gestation to a G3P0-1 mother via vaginal delivery with premature prolonged rupture of membranes. Her birth weight was 1.695kg. Maternal group B streptococcus was positive and mother received latency antibiotics and penicillin prior to delivery. There was also documentation of perinatal hepatitis C exposure. Pregnancy was also complicated by maternal intravenous substance abuse. Child was admitted to the Neonatal Intensive Care Unit and underwent 48-hour sepsis rule-out with empiric antibiotic therapy and was treated for neonatal abstinence syndrome.  Blood and urine cultures had no growth.

Past Medical History: History of MRSA infections of the skin. Normal growth and development reported by parents.

Immunizations: Up to date by history

Allergies: None

Family History: Maternal prenatal history as provided above. Remainder of family history non-contributory.

Physical Examination:

Vital Signs:

Temperature: 37.1 (by temporal thermometer)

Heart Rate: 162

Blood Pressure: 113/86

Respiratory Rate: 34

Oxygen Saturation: 99% on room air

Weight: 9.16kg


General: awake and alert, tired and moderately ill-appearing

HEENT: normocephalic, atraumatic, pupils equal round and reactive to light, lips dry, tacky mucous membranes, no oral lesions or exudates, normal tympanic membranes bilaterally, no drooling

Neck: supple, full range of motion

Lungs: clear to auscultation bilaterally, no grunting, nasal flaring or retractions, no wheezes, rales or rhonchi

Cardiovascular: tachycardic, + S1/S2, no murmurs, rubs or gallops, capillary refill 3 seconds, 2+ femoral pulses bilaterally

GI: soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly, no palpable abdominal mass or hernia

GU: Tanner 1 female, normal external female genitalia, no inguinal hernia

Musculoskeletal: full range of motion x4, no tenderness or deformities

Neurologic: awake, alert, normal tone, no focal motor deficits

Skin: warm, well-perfused, diaper rash with areas of erythema and satellite erythematous maculopapular lesions including inguinal folds


Laboratory Testing: 

Complete Blood Count (CBC):

WBC: 6.2 x 103/μL           Differential:  17%Neut/7% Bands/54%Lymph/19%Mono/1%Eos/2%Baso

Hgb: 12.6 g/dL

Hct: 39.2 %

MCV: 85 fL

Platelet Count: 399 x 103/μL


Basic Metabolic Panel (BMP):

              Sodium: 139 mEq/L

              Chloride: 105 mEq/L

              Potassium: 4.4 mEq/L

              Bicarbonate: 22 mEq/L

              Glucose: 64 mg/dL

              BUN: 19 mg/dL

              Creatinine: 0.2 mg/dL

Urinalysis:

              Color:  Yellow

              Clarity:  Slightly Cloudy

              Bilirubin:  Negative

              Glucose:  0

              Hemoglobin:  Negative

              Ketones:  Large

              Leukocytes:  Negative

              Nitrites:  Negative

              pH:  5.0

              Protein:  Negative

              Specific Gravity:  1.025

              RBC:  0

              WBC:  2

Other:

Influenza A/B PCR:  Negative

SARS-CoV-2 PCR:  Negative


Diagnostic Imaging:

Two-view (Supine and Decubitus) Abdominal X-ray: distal small bowel obstruction with several calcifications in the right flank presumably at the site of obstruction.

Abdominal Ultrasound:   Prominent fluid- and debris-filled bowel loops with decompressed sigmoid colon and rectum consistent with a distal obstruction. Calcifications seen in non-distended viscus in the right flank region. Small to moderate free fluid.

Pelvic Ultrasound with Doppler:  Normal uterus and left ovary with non-visualization of the right ovary. No large mass or cyst was demonstrated.

Computerized tomography (CT) of the Abdomen and Pelvis with Intravenous Contrast: High-grade distal small bowel obstruction with transition point in the lower right flank. Etiology undetermined.


Emergency Department Course:

A nasogastric tube was placed to decompress the abdomen after the X-ray images were reviewed. Upon insertion of the tube approximately 10mL of bilious fluid was extracted. The patient received two 20mL/kg boluses of normal saline followed by initiation of dextrose-containing maintenance fluids. Her repeat blood glucose level by fingerstick was 77.

The patient was seen and evaluated in the ED by the pediatric surgical team and was taken to the operating room for diagnostic laparoscopy.


Final Diagnosis: Congenital peritoneal band with internal hernia and subsequent small bowel obstruction


Discussion:

Post-inflammatory and post-operative intestinal obstructions are common and well-understood occurrences in infants and children. Some bowel obstructions can be caused by congenital bands secondary to described embryologic remnants such as the vitelline vessels and omphalomesenteric duct, while Ladd's bands occur in relation with anomalies of intestinal rotation and fixation [1]. Anomalous congenital bands (ACBs) unrelated to prior abdominal infection, surgery or trauma are rare causes of intestinal obstruction in children.  The exact incidence and etiology are unknown, though studies report percentages between 1-3% [2]. They are not secondary to described embryologic remnants and do not demonstrate an association with a previous intraperitoneal insult.  Therefore, the location of these bands varies in each patient and can occur in multiple areas of the bowel.

ACBs may originate from mesenteric anomalies. Around approximately day 28 of gestation, the dorsal and ventral mesenteries transiently divide the peritoneal cavity into right and left halves. The ventral mesentery disappears except around the liver and in front of the stomach. As the intestines enter into their final positions within the abdominal cavity, their mesenteries become pressed against the posterior wall of the abdomen, fusing with the parietal peritoneum. Thus, an ACB may be due to failure of complete resorption of the ventral mesentery [1]. In the largest case series of ACBs in 14 patients, it is speculated that the ascending colon is the most common location of an ACB. The second most common location being at the ligament of Treitz and the mesentery of the terminal ileum [3].

ACBs typically present as intestinal obstruction in childhood and are extremely rare in adults.   Obstruction is due to intestinal compression by the band or entrapment of an intestinal loop between the band and mesentery [4]. Congenital internal hernias are extremely rare but due to the high risk of bowel strangulation, they can be very dangerous and even lethal if not diagnosed in a timely manner [5]. In newborns, abdominal distension is the key finding as pain may not be detected. Abdominal pain and vomiting are the most common symptoms at presentation. Plain radiographs of the abdomen can help make the diagnosis of a bowel obstruction. CT imaging should be performed to determine the location and type of obstruction. Studies report a sensitivity of 94-100% and specificity of 90-95% of CT in confirming the diagnosis, site, level, and etiology of a small bowel obstruction [6-8].         

Treatment is surgical excision of bands. This can be performed successfully laparoscopically, especially in the setting of a single band obstruction; however, conversion to laparotomy is indicated when bowel necrosis is present, if the site of obstruction cannot be localized, or if the ability to run the bowel is limited [4]. Prognosis is positive for patients undergoing band excision in a timely manner and becomes more complicated when sequelae such as bowel necrosis are present. There are case reports that describe death in children in whom intestinal obstruction due to ACB went unidentified.

In conclusion, though anomalous congenital bands are a rare entity, they should be considered as part of the differential for intestinal obstruction in a child without history of abdominal insult.


References:

  1. Akgur FM, Tanyel FC, Buyukpamukcu N, and Hicsonmez A. Anomalous congenital bands causing intestinal obstruction in children. J Pediat Surg. 27(4):471-473, 1992. 
  2. Maiese A, Bonaccorso L, Dell'Aquila M, Gitto L, Bolino G. Anomalous congenital band and intestinal obstruction: report of a fatal case in a child. Forensic Sci Med Pathol. 9:588–590, 2013. 
  3. Erginel B, Soysal FG, Ozbey H, Keskin E et al. Small bowel obstruction due to anomalous congenital bands in children. Gastroenterol Res Prac. 2016: Article ID 7364329, 2016. https://doi.org/10.1155/2016/7364329
  4. Abdelwahed A, Saber R, Imen BI, et al. A case report of small bowel obstruction secondary to congenital peritoneal band in adult. Int J Surg Case Rep. 30:23-25, 2017. 
  5. Padhy, BP. Congenital internal hernia a rare cause of acute intestinal obstruction. Indian J Surg. 75(2):156–158, 2013.
  6. Mak SYSK, Roach SC, Sukumar SA. Small bowel obstruction: computed tomography features and pitfalls. Curr Probl Diagn Radiol. 35(2):65-74, 2006.
  7. Boudiaf M, Soyer P, Terem C, et al. CT evaluation of small bowel obstruction. Radiographics. 21(3):613-624, 2001.
  8. Yaghmai V, Nikolaidis P, Hammond NA, et al. Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images. Emerg Radiol. 13(2):69-72, 2006.



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Connecticut Children's
UCONN- Connecticut Children's
UCONN- Connecticut Children's

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