A case of abdominal pain and vomiting

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A case of abdominal pain and vomiting

• Dr charles panackel

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Demography

• 14 year old boy

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Presenting complaints

• Abdominal pain since early childhood
• Vomiting of 2 months duration

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History of presenting complaints

• Complaints started as recurrent attacks of
  abdominal pain since early child hood.
• Severe Colicky pain, lasting for 15- 20 mts.
• Periumblical in location.
• No radiation of pain.
• Pain aggravated by food intake.
• Relieved by injections and medications from local
  hospital.
• .

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• Patient used to have 2-3 episodes per year.
• Each episode used to last for 1-2 weeks and
  relieved with treatment from local hospital.
• Evaluated with x-rays and USG abdomen and no
  definite diagnosis made.

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History of presenting complaints

• Presently patient has abdominal pain for last 2
  months.
• Colicky pain lasting for 15-20mts. Periumblical
  in location. No radiation.
• Pain was aggravated by food intake
• There was no associated fever, jaundice.
• No dysuria, hematuria. No Steatorrhea

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History of presenting complaints

• Associated bilious vomiting and pain was relieved
  by vomiting
• 2-3 episodes per day.
• Occurs ½-1 hour after food intake.
• There was no delayed or stale food vomiting.
• Patient had associated ball rolling sensation.

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• There was no abdominal distension or borborygmi.
• There was no associated constipation.
• There was no hematemesis, melena or hematochizia.
• There was no associated postural symptoms or
  oliguria.

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• No autonomic symptoms like excessive sweating,
  postural syncope or palpitation
• No purpura, urticaria, vesicular / bullous
  eruptions,
• No arthritis/oral ulcers
• No history of pica.
• Was admitted and evaluated in local hospital
  treated symptomaticaly with no relief of pain or
  vomiting and referred here.

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Past history

• Second borne of a nonconsanguinous marriage.
  Normal developmental mile stones and scholastic
  performance.
• No history of steatorrhea, respiratory symptoms,
  jaundice.
• No history of tuberculosis
• No history of any anorectal, renal or cardiac
  anomalies.
• No history of surgery

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Family history

• No family history of Similar abdominal pain
• No history of pancreatitis, skin lesions,
  psychosis, tuberculosis
• Was on treatment from local hospital for
  abdominal pain.

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DD

• 14 year old boy with recurrent periumblical
  colicky abdominal pain from early childhood now
  presenting with sudden aggravation of pain and
  bilious vomiting of 2 months duration.

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Differential diagnosis

• Malrotation with mid gut volvulus
• Congenital band
• Meckels diverticulum with mid gut volvulus
• Annular pancreas
• Intussuception
• Recurrent pancreatitis
• Congenital biliary defects

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Examination

• No dehydration
• PR-78/ BP- 110/70 no postural fall
• RR -16/
• Moderately built and poorly nourished for the age
• Ht 142 cm Wt 32 kg BMI 15.8
• No pallor /No jaundice / edema / lymphadenopathy

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• No stigmata of malabsorption like phrynoderma,
  bitots spots, glossitis, cheilitis, bone
  tenderness
• No perioral or pigmentation, no skin lesions like
  purpura, vesicles, ulcers,
• No skeletal anomalies, ptosis, ophtalmoplegia
• No skin or joint laxity
• No anorectal or external genitalia abnormalities

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• Oral cavity- Normal. No perioral pigmentation
• Abdomen Not distended/ No visible peristalsis/
  dilated veins /swelling/ abdominal wall defects
• Liver was palpable 3cm below the right costal
  margin. Span 12cm. Soft, nontender, rounded
  margins and smooth surface
• Spleen was not palpable
• No mass palpable
• Normal bowel sounds
• P/R Normal
• Hernial orifices normal

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• Chest - Normal
• CVS S1 and S2 normal.No murmur
• CNS No ptosis, ophthalmoplegia, myopathy or
  neuropathy
• Fundus normal

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Differential diagnosis

• Malrotation with recurrent gut volvulus
• Congenital ladds band
• Meckels diverticulum with mid gut volvulus
• Annular pancreas
• Intussuception

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Investigations

• Hb 11.8 TC 6700 DC P68 L30 E2
• ESR 22
• RBS 82
• S.Na 142
• S.K 3.7
• S.Ca 8.2
• BU/Cr- 15/0.7
• Bb 0.7 SGOT /PT 32/23 ALP 72 TP 6.8 Alb 3.2

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• USG
• Dilated stomach with stasis no other abnormality
  noted
• OGD
• Esophagus was normal. Stomach, D1 and D2 were
  dilated with stasis. Scope was not introduced
  beyond D2.

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• CT Suggestive of intestinal malrotation with
  midgut vovulus

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Surgery

• Duodenum dilated upto D3
• Band from transverse colon to D3/D4 jn---released
  the band
• Volvulus 1/4th rotation No strangulation
  -Untwisted the bowel
• Small bowel put on the right side
• Large bowel put on the left side
• Inversion appendicectomy done

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Final diagnosis

• Intestinal Malrotation
• Partial intestinal obstruction at D3 level with
  Ladds bands and Midgut Volvulus

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Malrotation of midgut

• Occurs in 1/1600 live births
• Normally midgut goes out of the abdominal cavity
  during 4 th week of gestation
• Comes back inside by the 10 th week
• Midgut rotates around the axis of SMA for an
  angle of 270degrees

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• Initial 90 degree rotation takes place outside
  the abdominal cavity
• Second stage inside the abdomen rotates through
  180 degrees
• Third stage is the descend of cecum

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Anomalies

• Non rotation (most common)
• Malrotation
• Reverse rotation

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Symptoms

• Most patients have symptoms within the first
  month
• Recurrent vomiting
• Abdominal pain
• Malabsorption
• Chylous ascites
• Asymptomatic

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Associations

• 30 to 60
• Omphalocoele
• Gastroschisis
• Diaphragmatic hernia
• Duodenal or jejunal atresia
• Hirshsprungs disease
• Esophageal atresia
• Biliary atresia
• Annular pancreas
• Meckels diverticulam
• Mesenteric cysts
• Congenital cardiac defects

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Imaging modality Findings suggestive of malrotation
Plain radiograph Nasogastric or orogastric tube that extends into an abnormally positioned duodenum
Plain radiograph The "double-bubble"sign of duodenal obstruction
Upper GI contrast study A clearly misplaced duodenum (ie, ligament of Treitz on the right side of the abdomen) that has a "corkscrew" appearance
Upper GI contrast study Duodenal obstruction, which may appear similar to that seen with duodenal atresia or may have more of a "beak" appearance if a volvulus is present
Barium enema Complete obstruction of the transverse colon, particularly if the head of the barium column has a beaked appearance
Ultrasonography Abnormal position of the superior mesenteric vein (either anterior or to the left of the superior mesenteric artery)
Ultrasonography Dilated duodenum (indicating duodenal obstruction)
Ultrasonography The "whirlpool" sign of volvulus (caused as the vessels twist around the base of the mesenteric pedicle)
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Treatment

• Surgery

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Thank you