Abdominal Pain - Case 7-5: 8-Year-Old Boy
I. History of Present Illness
The patient, an 8-year-old boy, was well until 4 hours before presentation. At
that time, he developed crampy periumbilical pain and bilious emesis. His
family denied fever, diarrhea, or ill contacts. The pain was described as
crampy and intermittent. He had six episodes of emesis before admission. His
last bowel movement was 1 day before admission. His mother gave him an enema
before presentation, with no relief of symptoms.
II. Past Medical History
The patient was a full-term infant without complications. His first episode of
abdominal pain and bilious vomiting occurred about 3 years ago. Over the past
few years, the pain and vomiting had been occurring about once every 4 months.
The patient would have 2 to 3 days of emesis that was usually bilious and
associated with abdominal pain. He had recently been treated with phenobarbital
and atropine, without good results. He also had a history of chronic
constipation that responded to mineral oil. Three months before presentation,
he was admitted with similar symptoms and had a normal abdominal CT. The pain
was never associated with eating, and he never missed school. There was no
family history of celiac disease, cystic fibrosis, or any GI disorder.
III. Physical Examination
T 36.5°C; RR, 24/min; HR, 110 bpm; BP, 135/85 mm Hg
Weight, 26 kg
Physical examination revealed an alert child who was lying in bed and crying in
pain. There were no oral lesions. The neck was supple with no lymphadenopathy.
The lungs were clear to auscultation, and the cardiac examination revealed no
murmurs, rubs, or gallops. On abdominal examination, there were diminished
bowel sounds. Although the abdomen was soft, there was intermittent guarding
and a question of a mass in the left upper quadrant, with no focal tenderness.
There was no hepatosplenomegaly. Rectal examination revealed no fissures or
skin tags; hard stool was palpable in the rectal vault on digital examination.
He was a Tanner I male. The neurologic examination was normal.
IV. Diagnostic Studies
A CBC showed 14,500 WBCs/mm3, with 80% segmented neutrophils, 3% band forms, 7% lymphocytes, and 2%
eosinophils. The hemoglobin was 12 g/dL, hematocrit 39.4%, and platelet count
314,000/mm
3. Serum bicarbonate was 18 mEq/L, but the electrolytes, blood urea nitrogen, and
creatinine were otherwise normal. Liver function tests, amylase, and lipase
were also normal. Urinalysis was negative except for the presence of ketones.
V. Course of Illness
The patient had an abdominal radiograph that showed a paucity of bowel gas,
stool in the rectum, and no free air. An upper GI series revealed the cause of
the patient
's cyclic vomiting (Fig. 7-5).
Discussion: Case 7-5
I. Differential Diagnosis
Although the differential diagnosis of abdominal pain and vomiting is important,
the key to the diagnosis in this patient was the cyclic nature of the vomiting.
Cyclic vomiting syndrome is an idiopathic disorder characterized by severe
episodic vomiting interspersed with periods of normal health. In a study of
patients with cyclic vomiting syndrome, 12% were found to have potentially
life-threatening disorders such as malrotation with volvulus, obstructive
uropathy, or brain tumor. The most common cause of cyclic vomiting, accounting
for as many as 50% of cases, is abdominal migraine. The family history is
usually significant for migraines. The second most common cause is chronic
sinusitis.
Apart from malrotation with intermittent volvulus, other GI causes of cyclic
vomiting include chronic idiopathic pseudo-obstruction, intestinal duplication,
pancreatitis or pancreatic pseudocyst, peptic ulcer disease, and superior
mesenteric artery syndrome. Urinary tract conditions include renal stones and
intermittent ureteropelvic junction obstruction. There are also several
endocrinologic and metabolic causes for cyclic vomiting, including Addison
's disease, porphyria, ornithine transcarbamylase deficiency, methyl malonic
acidemia, and hereditary fructose intolerance.
II. Diagnosis
On the upper GI barium study, the ligament of Treitz was located at the midline,
in an abnormal position compatible with a midgut malrotation (Fig. 7-5). The
intraluminal contrast tapered in the proximal jejunum, in an appearance
compatible with the presence of a midgut volvulus.
The diagnosis is malrotation. The patient underwent a Ladd procedure with appendectomy.
III. Incidence and Epidemiology
It is important to understand the underlying embryology that leads to
malrotation. At approximately 10 weeks
' gestation, the intestines undergo counterclockwise rotation around the
mesenteric artery and finally attach themselves to the posterior abdominal
wall. The midgut then rotates 270 degrees around the superior mesenteric
artery, with the duodenal-jejunal loop moving posterior to the artery while the
cecal-colic loop rotates anterior to it. The duodenum and ascending colon can
then attach to the posterior abdominal wall. This process of rotation and
attachment helps to support normal GI tract motility and balanced
gut-to-mesentery vascular supply.
With malrotation, the normal process is impeded and the cecum is in the right
upper quadrant, near the duodenum, while the duodenal-jejunal loop remains to
the right of midline. Because there is no mesenteric attachment, volvulus of
the midgut is likely to occur with malrotation. The incidence of volvulus in
association with malrotation is 44% in all age groups, but in neonates it is
more likely to require bowel resection because of more significant damage to
the bowel.
IV. Clinical Presentation
The clinical presentation of malrotation can vary widely. Malrotation is
commonly associated with other GI anomalies, namely esophageal atresia,
diaphragmatic hernia, jejunal atresia, duodenal atresia, omphalocele,
gastroschisis, intussusception, prune-belly syndrome, and Hirschsprung
's disease. It can also been in association with heterotaxy and congenital heart
disease.
Malrotation with midgut volvulus can occur at any age but is most commonly seen
in infancy. Acute volvulus manifests with bilious emesis, abdominal distention,
pain (constant, not crampy), and bright red blood per rectum (suggesting
ischemia). It is a surgical emergency, and untreated ischemic bowel can lead to
shock and sepsis with cardiovascular collapse.
A less commonly seen entity is malrotation with intermittent volvulus. It
usually manifests with recurrent abdominal pain and vomiting and signs of
failure to thrive.
V. Diagnostic Approach
Upper gastrointestinal series. Although both the barium enema and the upper GI series can be used, the upper GI
series is now preferred because of the possibility of cecal mobility on barium
enema and its inability to show volvulus. Findings that are suggestive of
malrotation in upper GI series include corkscrew-like deformity of the
duodenum, displacement of the duodenum and jejunum in the right upper quadrant,
and chronic obstruction of the duodenum.
VI. Treatment
In neonates, any suggestion of volvulus indicates the possibility of ischemic
gut and necessitates immediate surgical intervention. In older patients with
rotational abnormalities, definitive surgery is also performed. Timing depends
on the presentation. If possible, patients should be prepared for surgery with
nasogastric suction, fluid resuscitation, and prophylactic antibiotics to cover
the possibility of bowel resection. The Ladd procedure allows definitive
treatment with counterclockwise derotation of the midgut volvulus, lysis of
bands, appendectomy, and placement of the duodenum in the right side of the
abdomen and of the cecum in the left lower quadrant.
VII. References
1. Tunnessen WW. Cyclic vomiting. In: Tunnessen WW, ed. Signs and symptoms in pediatrics, 3rd ed. Philadelphia: Lippincott William & Wilkins, 1999:503–507.
2. Olson AD, Li BU. The diagnostic evaluation of children with cyclic vomiting:
a cost-effectiveness assessment.
J Pediatr 2002;141:724–728.
3. Groff D. Malrotation. In: Ashcraft KW, Holder TM, eds. Pediatric surgery, 2nd ed. Philadelphia: WB Saunders, 1993:320–330.
4. Liu PCF, Stringer DA. Radiography: contrast studies. In: Walker WA, Durie
PR, Hamilton JR, et al. eds.
Pediatric gastrointestinal disease, 3rd ed. Hamilton, Ontario: BC Decker, 2000:1555–1591.
5. Shuckett B. Cross-sectional imaging: ultrasonography, computed tomography,
magnetic resonance imaging. In: Walker WA, Durie PR, Hamilton JR, et al., eds.
Pediatric gastrointestinal disease, 3rd ed. Hamilton, Ontario: BC Decker, 2000:1591–1633.
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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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Lower abdominal pain
» Next page: Abdominal Pain - Case 7-6: 2-Year-Old Girl (Pediatric Complaints and Diagnostic Dilemmas)
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