Case Presentation

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Case Presentation

• Rashida Saif
• St Josephs Childrens Hospital

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Chief Complaint

• 8 month old girl with vomiting for one day

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History of present illness

• Diarrhea
• Fever
• Vomiting
• Rhinorrhea and nasal congestion
• Decreased oral intake
• Decreased urine output
• Irritability

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History of present illness

• No h/o cough
• No h/o sick contact
• No h/o going to daycare
• No h/o eating unusual food
• No h/o recent travel
• No h/o taking any medications

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Emergency Room - SJHMC

• Pulse 150/min
• Respiratory Rate 40/min
• Temperature 100.5 F
• Course
• Intolerance to PO liquids
• Continues to vomit
• Normal saline bolus X 2

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Laboratory Tests
CBC
SMA 7
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Laboratory Tests
Urine Analysis
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Past medical history

• Maternal
• Premature contractions which required terbutaline
  infusion
• Birth history
• Normal spontaneous vaginal delivery
• 37 weeks gestation
• Birth weight 3.14 Kgs
• Feeding
• Similac 16 oz every 6 8 hrs
• Gerber baby food
• Development
• Waves bye bye
• Says ma ma da da
• Sits by herself
• Pull to stand

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Past medical history

• Allergies None
• Illnesses
• Eczema
• Hospitalizations
• Neonatal hyperbilirubinemia
• Immunizations
• HBV 4 doses
• DPT 3 doses
• IPV 3 doses
• HiB 3 doses
• PCV 3 doses
• Family History non-contributory

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Review of systems

• Skin Eczema, no purpuric skin lesions
• Eyes Normal tearing
• Nose Rhinorrhea
• Respiratory No cough
• Gastrointestinal Vomiting, diarrhea
• Genitourinary Decreased urine output
• Neurological Irritable, less active

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Physical Exam

• Vitals
• Temperature 99.7 F
• Pulse 150/min
• Respiratory rate 34/min
• BP 101/50 mm Hg
• Weight 8.67 Kg (75th Percentile)
• Height 72.5 cm (90th Percentile)
• Head circumference 43 cm (50th Percentile)

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Physical Exam

• General Appearance
• No apparent distress
• Skin
• Skin turgor good
• Capillary refill
• Small eczematous patch on left knee
• Lymph nodes
• No lymphadenopathy
• Head
• Normocephalic atraumatic
• Anterior fontanelle open and flat

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Physical Exam

• Eyes
• Red reflex present bilaterally
• Extra ocular movements intact
• Ears
• Tympanic membrane bilaterally intact
• Nose
• Clear discharge
• Mouth
• Mucous membranes moist
• Pharynx
• No erythema
• No exudate

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Physical Exam

• Neck
• Supple
• Chest
• Air entry bilaterally equal
• No crackles/no wheeze
• Heart
• S1 S2 normal
• No murmurs
• Abdomen
• Soft/no masses
• Non tender/non distended
• Bowel sounds present

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Physical Exam

• Extremities/Pulses
• Full range of movement
• Neurologic
• Intact

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Assessment

• 8 month old girl with
• Gastroenteritis
• Dehydration

Plan

• NPO
• IV Fluids
• Strict I/O
• No medications

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Hospital Course

• Day 1
• Vomitting x 1
• No Diarrhea
• Day 2
• Diet advanced to clears
• Vomitting Small amounts initially yellow in
  color, later bilious
• Blood in the stool
• Vitals T97.9 F, P140/min, R34/min, BP114/44
  mm Hg
• No apparent distress
• Abdomen mild distension, soft, non-tender, no
  palpable masses, bowel sounds sluggish

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Differential Diagnoses

• Intussusception
• Meckels Diverticulum
• Villous adenoma

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Hospital Course

• Day 2 contd.
• Surgical consult
• Nasogastric tube inserted
• IV bolus
• Day 3
• Barium enema

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Hospital Course

• Surgery
• Reduction of intussusception with appendectomy
• Findings
• Area of ileoileal intussusception with large
  intraluminal hematoma, no necrosis

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Hospital Course

• Recovery
• PICU
• Vitals T98.6 F, Tmax101.2 F, P174/min,
  R34/min, BP108/51 mm Hg
• Hypoactive bowel sounds, surgical site clean,
  abdomen tender
• NG tube at low intermittent suction
• Ampicillin 450 mg IV Q 6 hrs (150 mg/kg/day)
• Gentamicin 18 mg IV Q 8 hrs (6 mg/kg/day)
• Clindamycin 90 mg IV Q 8 hrs (30 mg/kg/day)
• Chest X-ray faint air bronchogram visible
  through the heart

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Hospital Course
CBC
SMA 7
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Hospital Course

• Day 4
• Patient transferred to floor
• NG tube removed
• Antibiotics discontinued
• Day 5
• PO diet started
• CBC with differential
• SMA 7

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Hospital Course
CBC
SMA 7
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Hospital Course

• Day 5
• Tolerated PO intake
• Patient discharged
• Follow-up
• Pediatric surgery
• PMD

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Intussusception

• Background
• Telescoping or prolapse of one portion of bowel
  into an immediately distal adjoining part
• Epidemiology
• 1-4 per 1000 live births
• Age 3 mo 5 yrs
• Male-to-female 3-to-1
• Mortality/Morbitdity
• Mortality with treatment 1-3
• Recurrence 3-11

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Pathophysiology

• Types
• Ileocolic
• Colo-colic
• Ileo-ileal
• Compression of mesentery
• Venous engorgement
• Edema
• Ischemia of intestinal mucosa
• Gangrene and perforation

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Causes

• Idiopathic
• Predisposing factors
• Recent upper respiratory illness
• Recent diarrheal illness
• Intestinal polyps
• Intestinal lymphoma
• Meckels diverticulum
• Henoch-Schonlein purpura
• Cystic fibrosis
• Hemangioma

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Presentation

• History
• Sudden onset colicky abdominal pain
• Vomiting
• Bloody mucous stools
• Irritability
• Lethargy
• Altered mental status

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Physical Exam

• Abdomen distended, tender
• Abdominal mass
• Rectal exam
• Occult blood or frankly bloody stools

Laboratory Tests

• No laboratory test rules in or rules out the
  diagnoses of Intussusception reliably

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Diagnostic Imaging

• Plain abdominal films
• Ultrasound
• Target sign
• Pseudokidney sign
• Doppler flow
• Barium/air enema

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Management

• Main focus emergent reduction of obstructed
  bowel
• Non surgical reduction
• Barium enema
• Saline enema
• Air enema
• Advantages of air enema over barium enema
• Easy to administer
• Higher success rate
• Less radiation exposure
• Less dangerous if a perforation occurs

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Management

• Contraindications to enemas
• Absolute
• Clinical signs of peritonitis, perforation, or
  hypovolemic shock
• Relative
• Prolonged symptoms ( 24 hrs)
• Evidence of obstruction
• Ultrasound findings of intestinal ischemia or
  trapped fluid

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Management

• Surgical reduction