Hot Seat #219: Gut-sy Decisions
Posted on: November 27, 2023, by : Brandon Ho
Case by Brandon Ho, CNH PEM Fellow
It is a wonderful Saturday evening in the ED when an 11-month-old female presents with 3 days of projectile vomiting after every feed. Vomiting occurs 4-5 times a day and is described as occasionally yellow-green. Parents note that her stomach is very hard after feeding but becomes soft again after she vomits. She appears more fussy but is consolable, especially after episodes of vomit. Per her parents, she has also been constipated and has not had a bowel movement in the last two days but continues to pass gas. She has had normal UOP (6-7x/day).
She was born at 40 weeks and had no problems after birth. She has been otherwise well and gaining weight appropriately. Denies fever, cough, congestion, diarrhea, rash. No sick contacts. Immunizations are up-to-date.
T37, HR 128, RR 26, BP 102/68, 99% on RA. FLACC 0
General: Appears tired. Irritable but consolable and interactive
Skin: Warm, dry, no rashes
Head: Normocephalic, atraumatic.
Eye: PERRL, EOMI, Normal conjunctiva
Ears, nose, mouth and throat: No pharyngeal erythema or exudate. Moist mucosal membranes
Cardiovascular: RRR, No murmurs/rubs/gallops, <2 sec capillary refill
Respiratory: CTAB. Good aeration bilaterally. No increased WOB.
Gastrointestinal: Soft, non-tender, mild distension, no guarding or rebound. No palpable masses. No hepatosplenomegaly.
Neurological: No focal neurologic deficits
An abdominal x-ray was obtained which showed gaseous distention of the stomach and possibly the proximal duodenum. Findings may be seen in the setting of possible gastric outlet/proximal small bowel obstruction in the appropriate clinical setting. No evidence of large volume free air.
The patient was made NPO and received an NSB and mIVF. CMP was obtained and was unremarkable. Surgery was consulted and felt that obstruction was unlikely given patient was well-appearing and was passing gas. Felt symptoms were more likely due to viral ileus vs gastroenteritis. Recommended an upper GI to further evaluate. However, it is now 8 pm and Radiology is unable to perform an upper GI as they are no longer in-house. Radiology recommends CT abdomen with oral contrast or an upper GI study in the morning. Surgery felt that the patient was stable to wait till morning as clinical suspicion was low. Hospitalist was called and recommended an abdominal ultrasound.
An ultrasound examination is an interesting suggestion by the Hospital Medicine service, as that is something I don’t generally consider when assessing for bowel obstruction (outside of pyloric stenosis which typically occurs in infants between 2-8 weeks of age, but could be considered up to 6 months). Was the Hospitalist looking to r/o malrotation by assessing for an inverted SMA/SMV position? If, on the other hand, they were trying to r/o pyloric stenosis with an US, that would be quite interesting as I’ve never heard of pyloric stenosis in an 11-month old. Also, outside of ruling out secondary causes of small bowel obstruction (such as abdominal mass, appendicitis, or cholecystitis), I think US is less helpful in assessing primary intestinal causes of a SBO.
My differential includes malrotation with intermittent mid-gut volvulus (which is something no-one should sit on) and gastric volvulus. I would definitely get an abdominal CT with oral contrast (as STAT as possible) to assess for these. Also, if not already obtained, a lactate (to assess for dead gut) and lipase (to r/o pancreatitis).
Going to disagree with my esteemed colleague Dr. Agrawal. US is quick, safe, cheap, and very good for detecting malrotation and volvulus, the latter of which is a true emergency and in the differential here. (also good for intussusception, lower down on the differential here). If negative, then contrast CT but that could take all night…
See similar case here: https://appliedradiology.com/articles/ultrasound-diagnosis-of-midgut-volvulus.
My thoughts are that — this doesn’t sit well with my gut — so I have to do SOMETHING. Surgery’s suggestion that obstruction is unlikely may be true — but we are a specialty ER of many zebras, so what is unlikely is LIKELY to walk in our doors. I wouldn’t oppose the US – I think it can either help or not be useful at all. Lab work may also be helpful (that lactate may help you as Dewesh pointed out). I always like to think through my diagnostic AND therapeutic plans in situations where an immediate answer to the patient’s issue is not readily available (ie no upper GI study at this time). If I can’t solve the answer to what is causing the patient’s problems (diagnosis), then I can at least do no harm (therapy). So, I would reiterate to everyone that this patient is NPO, IVF, and we need to be vigilant with UOP and abdominal exam. Hopefully the US and/or labs have some indicators to light a fire under surgery or radiology. This case has the “feels” of a surgical vs medical issue — so not sure how the Hospitalists were engaged (if not for a “vague” admission request). All of this history is concerning — so trending vital signs, getting updates from parents on signs of increased fussiness and documenting reassessments is key. Surgery may not be wrong is suggesting that this might be able to wait until morning….. but it should not be signed out and forgotten about — for sure.
Dewesh 1: Dave 1
To add to the Vim on US to look for SBO, would offer up that US is still user-dependent and availability in the community still depends on where you are practicing. 🙂
If just interested in malro, would study vessels with an IV con CT study which can be relatively quick, (though many rads would prefer PO con for SBO). Our rads would be called in for UGI if high suspicion.
Over the years I’ve diagnosed a few children with incidental malro without volvulus, and an adult presenting with volvulus, so must keep it on a differential for intermittent abdominal pain even beyond the typical age of presentation.
Our surgeons approach SBO due to adhesions non-surgically with oral gastrograffin.