M M Conference

1
MM Conference

• 3/13/07

2
HPI

• TL 1 y/o Female with no prior PMHx
• presented on 3/5/07
• with a 3 day hx of loose stools
• and 1 day history of vomiting
• According to the father
• the baby began to experience loose watery stools
  up to 5 times a day starting on 3/2/03.
• As the stools became less frequent, the baby
  began to experience episodes of emesis

3
HPI

• She was take to her PMD
• who recommended the baby be kept
• well hydrated,
• given only liquids and
• also prescribed antidiarrheal medications
• The diarrhea did subside, but the episodes of
  emesis increased dramatically to approximately 12
  times a day
• The vomiting was described as yellow,
  non-bilious emesis with no signs of blood.
• The patient was unable to tolerate any liquid
  feeding

4
HPI

• There was no history of fever, URI symptoms or
  rash associated with this presentation
• The parents also noticed the baby becoming more
  lethargic
• This lack of progression in the patients status
  prompted the parents take the baby to the ED
• The patient was admitted to the Pediatric Service
  for IV hydration and further work up of a
  presumed Gastroenteritis

5
PMHx

• PMHx- unremarkable
• Birth Hx- Full term, vaginal delivery 8lbs 6 oz
• Nutritional- takes Enfamil with iron
• Immunizations- up to date
• Allergies- NKDA
• Medications- iron, antispasmodics, antidiarrheals
• Growth Development- Age appropriate

6
Physical Exam

• Vitals- Tmax-37.5 P-156 BP 115/82 O2-99 RA
• Gen-lethargic, but easily arousable
• HEENT-unremarkable, normal mucous membranes
• Skin- good turgor, no rashes, no bruising
• CVS- no murmurs
• Lungs- CTAB
• Abdomen- Soft, nondistended, nontender, bowel
  sounds were active

7
Labs

• WBC-8.9 Hgb-11.5 Hct-36.1 Plts-250
• Na-143 K-3.5 Cl-104 CO2-20 BUN 14 Crea 0.2
  Gluc-117
• Urine Cx- negative
• Fecal Leuk-no WBC seen
• Stool Cx- negative

8
Hospital Course

• During the afternoon on 3/6- General Surgery was
  called due the baby becoming
• More irritable, experiencing continued episodes
  of non-bilious vomiting
• the abdominal exam began to reveal some abdominal
  tenderness
• An abdominal x-ray was obtained
• Abnormal but nonspecific bowel gas pattern.
  Possible small bowel obstruction. Recommend
  small bowel series depending on clinical
  sircumstances.
• At this time- the General Surgery assessment was
  to observe and perform serial abdominal exams

9
Hospital Course

• A few hours later the baby began to experience
  bilious vomiting and also started to have
  generalized abdominal tenderness
• CT AP was performed
• Intussusception with moderate ascites. Site of
  obstruction was thought to be distal colon.

10
Hospital Course

• Pt. taken to Surgery for relief of obstruction
• BON-
• Pre Post operative Dx- Intussusception
• Procedure- Relief of intestinal obstruction
• EBL-minimal
• Complication-none
• Dispo-stable upon transfer from OR to PICU

11
Hospital Course

• POD 1- Patient begins to stool Oral feedings
  started
• POD 2- Patient tolerating feeding remains
  afebrile uncomplicated course
• POD 3- Patient discharged, to follow up in one
  week

12
Complication

• Complication-
• Delay in diagnosis
• Patient in operating room in total 30 hrs after
  initial admission 10 hrs after initial surgery
  consult
• What could have been done differently?
• Earlier CT AP vs Barium Enema