Diarrhea - Case 17-1: 2-Month-Old Boy
Diarrhea - Case 17-1: 2-Month-Old Boy: Excerpt from Pediatric Complaints and Diagnostic Dilemmas
I. History of Present Illness
A 2-month-old male child presented with vomiting and diarrhea. He had been
discharged from the hospital 3 days earlier, with a diagnosis of
gastroesophageal reflux based on a pH probe and an upper gastrointestinal
radiographic series. He was discharged to home on ranitidine and metoclopramide
and had been doing well until the evening before presentation, when he
developed vomiting and diarrhea. He had 12 episodes of nonbloody, nonbilious
vomiting and 8 episodes of loose stools. There was no fever or associated upper
respiratory tract symptoms. He had normal urine output. His mother reported
that he was more fussy than usual, and she noted a lump in his groin on the day
of presentation to the hospital.
II. Past Medical History
The patient was a full-term baby with an uncomplicated pregnancy, labor, and
delivery history. He had been hospitalized only once, diagnosed with
gastroesophageal reflux, and prescribed ranitidine and metoclopramide.
III. Physical Examination
T, 36.9C; RR, 32/min; HR, 136 bpm; BP, 100/54 mm Hg
Weight, 5th percentile
On examination, the infant was alert and in no acute distress. His head, neck,
cardiac, and respiratory examinations were unremarkable. He was well hydrated
with a nontender and nondistended, soft abdomen. There was no
hepatosplenomegaly. There were no abdominal masses. He had normal male
genitalia, with bilaterally descended testicles. A tender, firm, and
erythematous mass measuring 5
× 3 cm was palpable in the right inguinal region.
IV. Diagnostic Studies
The complete blood count revealed 10,100 white blood cells (WBCs)/mm3, with 11% segmented neutrophils and 76% lymphocytes). The hemoglobin was 10.8
g/dL with a mean corpuscular volume of 87 fL, and the platelet count was
387,000 mm
3. Serum electrolytes, blood urea nitrogen (BUN), and creatinine values were
normal.
V. Course of Illness
An abdominal radiograph obtained on his previous admission suggested a cause of
the current complaint (Fig. 17-1). A surgical consultation was requested.
Discussion: Case 17-1
I. Differential Diagnosis
In this case, diarrhea was associated with vomiting and a critical physical
finding, that of an inguinal mass. This essential finding directed the
differential diagnosis toward causes of inguinal or scrotal swelling. An
important distinction to make is between a painful and a painless mass. A
hydrocele is a common entity that causes painless inguinal or scrotal swelling.
It is primarily differentiated from an inguinal hernia by the ability to
palpate above the mass, revealing discontinuity between the mass and the
inguinal canal. The mass, as a result, does not change in size with straining
or crying. In addition, a hydrocele is not reducible and usually
transilluminates, although the ability to transilluminate the mass does not
exclude the possibility of an incarcerated hernia.
Another cause of a painful scrotal mass is testicular torsion. There often is no
history of a prior scrotal mass, and in fact there may be a history of
undescended testis. This mass is very tender and does not extend into the
inguinal canal.
Torsion of the appendix testis results in a painful scrotal mass that may appear
as a tender blue nodule on the upper pole of the testis, which itself is not
tender. Inguinal lymphadenopathy may be tender or painless, but the key to
diagnosis is the lateral and inferior location of these nodes in relation to
the inguinal canal. Signs of infection in the area of lymphatic drainage are
also important in making this diagnosis. An inguinal hernia is usually
characterized by a painless swelling in the inguinal area that often increases
in size with crying or straining. Incarceration of the hernia results in
extreme pain and signs of bowel obstruction. If strangulation occurs, bloody
diarrhea may result.
II. Diagnosis
A thorough history and physical examination are the keys to this diagnosis. In
this case, the painful nature and inguinal location of this mass are the
essential findings. An abdominal radiograph from the previous admission
revealed a right inguinal hernia (Fig. 17-1) that had now become incarcerated.
The diagnosis is incarcerated inguinal hernia. The hernia was reduced in the emergency department by pediatric surgical staff.
No hernia was noted on the left side on physical examination. The patient was
admitted for administration of intravenous fluids and observation, to allow the
bowel edema from the incarceration to resolve. The patient manifested no signs
or symptoms of bowel necrosis during 2 days in the hospital, after which he was
taken to the operating room. Intraoperatively, bilateral inguinal hernias were
found and repaired without any complications.
III. Incidence and Epidemiology
The incidence of inguinal hernia is estimated to be between 1% and 5%, or
approximately 10 to 20 cases per 1,000 live births. The incidence in premature
infants is significantly higher, approaching 30%. The ratio of boys to girls is
6:1. In boys, the right side is more frequently involved than the left,
presumably due to the embryologic origin of inguinal hernias through a patent
processus vaginalis and the fact that the right testis descends later during
gestation than the left. In both boys and girls, 60% of inguinal hernias occur
on the right, 30% on the left, and 10% bilaterally. Inguinal hernias are
usually diagnosed during the first year of life, most frequently during the
first month. There is often a family history of inguinal hernia. Undescended
testes may be associated with inguinal hernias. Other conditions associated
with inguinal hernias include Ehlers-Danlos syndrome, cystic fibrosis,
congenital cytomegalovirus infection, and testicular feminization. There is no
apparent ethnic or racial predisposition to inguinal hernia. Incarcerated
inguinal hernias occur most frequently before 6 months of age, are less common
after 2 years of age, and are rare after 5 years of age.
IV. Clinical Presentation
An inguinal hernia usually manifests as an asymptomatic swelling in the scrotal
or labial area that increases in size with any increase in intraabdominal
pressure, as occurs with crying or straining. Reducible hernias disappear
spontaneously or with minimal pressure. An incarcerated hernia develops when a
loop of bowel becomes trapped, and it is accompanied by severe pain and signs
of bowel obstruction, such as bilious emesis. Strangulation of the herniated
loop of bowel occurs when the blood supply to the bowel is compromised and may
develop within 2 hours after incarceration. Urgent medical attention is
required in cases of incarceration, and emergency surgical intervention may be
necessary in cases of strangulation.
V. Diagnostic Approach
The key to diagnosis of inguinal hernia lies in maintaining an index of
suspicion in the appropriate historical context, which is then confirmed by
physical examination. In distinguishing an incarcerated hernia, awareness of
the other important entities in the differential diagnosis is important. The
diagnosis itself is founded primarily on the history and physical examination
as well as a thorough knowledge of the disease process.
Abdominal radiography. An abdominal radiograph may show signs of bowel obstruction and may serve as an
adjunctive and supportive piece of evidence in making the diagnosis.
VI. Treatment
In cases of incarcerated hernia, time is of the essence. Compromised blood flow
to the affected loop of bowel can result in strangulation and bowel necrosis
within 2 hours, so medical intervention is necessary. Reduction of the
incarcerated hernia by experienced pediatric surgical staff is optimal. A
gentle attempt at reduction using pressure on the scrotum with simultaneous
counterpressure above the external inguinal ring is indicated but should never
be forcefully done. Intravenous hydration and nasogastric tube decompression,
in anticipation of definitive surgical management, are also indicated.
Emergency surgery is sometimes required if the incarcerated hernia is not
reducible. If the incarcerated loop of bowel is reduced, surgery may be
postponed 12 to 36 hours so that the bowel edema can resolve.
Elective repair of an asymptomatic inguinal hernia should be performed as soon
as possible after diagnosis, to avoid complications such as incarceration. All
inguinal hernias require surgical intervention, because they do not resolve
spontaneously. In boys, undescended testes may be associated with inguinal
hernia, requiring orchiopexy. There is still some debate as to the importance
of surgical exploration of the contralateral side in search of an occult
inguinal hernia not detected by physical examination, as was the case in this
patient. This decision is left to the individual surgeon, but contralateral
exploration is commonly performed.
VII. References
1. Kapur P, Caty M, Glick P. Pediatric hernias and hydroceles. Pediatr Clin North Am 1998;45:773–789.
2. Irish M, Pearl R, Caty M, et al. The approach to common abdominal diagnoses
in infants and children.
Pediatr Clin North Am 1998;45:729–772.
3. Pillai S, Besner G. Pediatric testicular problems. Pediatr Clin North Am 1998;45:813–830.
4. Kelly C, Kelly R. Lymphadenopathy in children. Pediatr Clin North Am 1998;45:875–888.
5. Davenport D. ABC of general paediatric surgery: inguinal hernia, hydrocele
and the undescended testis.
BMJ 1996;312:564–567.
6. Katz D. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann 2001;30:729–735.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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