acute vomiting in a 1 month old baby boy – the colour of ... · acute vomiting in a 1 month old...
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Acute vomiting in a 1 month old baby boy –the colour of the vomitus
matters !
Medical Update Group – UOM 11 Sept 2019
Radio-clinical case in pediatric surgery
Dr Kevin Teerovengadum - Consultant Pediatric surgeon, Wellkin Hospital
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Referral
• Recent case
• Phone call from an experienced pediatrician for referral of a 26 days old baby boy with acute vomiting
• Vomiting curd milk / severe dehydration / BW 3.1kg and actual weight 2.9kg (failure to thrive) / on examination – distended upper part of stomach with visible peristaltic movements of stomach
• Probable diagnosis : hypertrophic pyloric stenosis
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Admission
• Severe dehydration -> IV fluids started – bolus 10ml/kg NS over 30min
• Blood investigations sent and urgent abdominal ultrasound requested
• US done within 1h of admission : report relayed to me by phone by RMO in pediatric ward – very large distended stomach , rest of intestines look flat, compatible with HPS
• OT booked for surgery the next morning
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Examination and history taking
• Baby very weak / unusual for HPS particulary after bolus N/S
• Upper part of abdomen distended/ no olive palpated
• Episode of acute vomiting at Day 9 of life – admitted for less than 24h in public hospital – no report / ? AGE
• Blood results : Cl 101 mmol/L (98-108), Hb 9 g/dL
• Gut feeling of something unusual when I saw a green colour patch on the baby’s bib…
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“Se méfier de la solution de facilité…”
• Already 8pm
• OT was booked for next morning
• But …
• “ tout vomissement bilieux chez un nouveau-ne doit etre considerecomme un volulus intestinal jusqu’a preuve du contraire…”
• Urgent contrast study – upper GI series.
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What we normally see
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Upper GI contrast study
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What we expect to see
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Surgery
• Called anesthetist for immediate surgery (11pm)
• Risk of intestinal gangrene – surgery cannot wait for next morning
• Diagnosis of malrotation of gut confirmed
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A
After reduction of midgut volvulus, an abnormal band (Ladd’s band) is seen crossing the root of the mesentery
After section of Ladd’s band
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Outcome
• Good
• Baby could be extubated immediately after surgery and could be fed after 24h
• Stayed 5 days for full recovery
• 10 days postop: weight=3.3kg
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Conclusion and take home msgs
• In pediatrics, always pay attention to details (normal Cl ob blood, abnormally weak baby, episode of vomiting at Day 9 of life…)
• See radiological images yourself instead of just reading reports
• For a surgeon, always be ever ready to challenge the “referral diagnosis” / always start with a clean sheet / tjs se méfier…