A YOUNG INFANT WITH PERSISTANT VOMITING AND

FAILURE TO THRIVE

Dr.Saima BashirPost Graduate ResidentDepartment Of PaediatricsKing Edward Medical University/Mayo Hospital, Lahore.

BIODATA

Asad S/O Mr. Shaukat

• 50 days old • R/O: Shahidra • D.O.A.: August 14,

2010• M.O.A.: via

emergency in MHL

PRESENTING COMPLAINTS

Vomiting • 2nd day of life• Aggravated during last 7 days

Loose motion• 3 days

Fever • 1 day

History of presenting illness

Failure to thrive

• High grade• Relieved with

medication

Fever

• Multiple episodes

• Grade -IV• No mucus and

blood

Loose Motion

• Projectile • Non bilious• Multiple episodes• Associated with

feed

Vomiting

SYSTEMIC REVIEW

No history of constipation, abdominal distension

No urinary complaint

TREATMENT HISTORY

Treatment taken from local G.P and treated with oral medicines

Record not available

MISCELANEOUS DETAILS

Birth History• No H/O polyhydramnios• He was born to consanguineous parents

by SVD• Normal birth weight

Nutritional History• Exclusive Breast-feeding

MISCELANEOUS DETAILS

Developmental History• Social smile

Family History• Insignificant

Socio-economic History• Poor

EXAMINATION

A Malnourished Baby

Pulse: 100/min

Temp: 98 ⁰F

Respiratory rate:32/min

Some dehydration Genitalia: Normal

No pallor, jaundice

Weight: 2.5 kg

Length: 50 cm

GIT EXAMINATION

Soft, non tender abdomen

No localized swelling or mass

No visible peristalsis

No visceromegaly

Bowel sounds normal

OTHERS

CVS:

Resp. exam:

CNS:

All Normal

SUMMING UP EVIDENCES

History•Persistent non bilious Vomiting

in the absence of other systemic manifestation

•Failure to thrive

Examination•Growth parameters below 5th

centile

DIFFERENTIAL DIAGNOSIS

Pyloric stenosis

Malrotation of gut

GERD

RTA

Adrenal insufficiency

IEM

INVESTIGATIONS

Complete Blood Count• Hb.: 12.7 g/dL• TLC: 6,700• DLC:• Neutrophils: 45%• Lymphocytes: 55%

• Hct: 49• Platlet: 250,000/mm

ESR: 20mm during first hour

INVESTIGATIONS

ABGs:pH: 7.4PCO2: 40 mmHgPO2: 95 mmHgHCO3: 22B.E: -1

S/E: Na: 125K: 3.0 Cl: 95 HCO3: 22

Urine C/E & C/S:

BSR:

RFTs:

LFTs:All Normal

ABDOMINAL USG ANDCOLOR DOPPLER

Normal pylorus

Color Doppler has shown superior mesenteric vein lying superior and lateral (right) to superior mesenteric artery indicating MALROTATION of gut

BARIUM MEAL AND FOLLOW THROUGH

Suggestive of Gastric Volvulus (organoaxial)

MANAGEMENT

Correction of dehydration and electrolyte imbalance

Antibiotic cover

Pediatric surgeon consultation

GASTRIC

VOLVULUS

DEFINITION

Gastric volvulus” refers to the revolution of all or a portion of the stomach at least 180˚ about an axis that causes an obstruction of the foregut.

Obstruction - acute, recurrent, intermittent, or chronic.

FREQUENCY

Males and females are equally affected

Ten to 20% of cases occur in children,

usually before age 1 year.

Cases have been reported in children up to age 15 years.

In children is often secondary to congenital diaphragmatic defects.

Anatomy

The stomach is normally fixed to the abdominal cavity by 4 ligaments:

1. Gastrocolic

2. Gastrohepatic

3. Gastrophrenic

4. Gastrosplenic

CLASSIFICATION

Most commonly used classification

system

Organoaxial

Mesentero-axial

Combined

Organoaxial Volvulus

Mesentero-axial Volvulus

Combined Volvulus

TYPES

Idiopathic or primary gastric volvulus (Type 1)

Failure of these normal attachments may be the result of absence, elongation or disruption of the gastric ligaments, which results in idiopathic or primary gastric volvulus.

Secondary gastric volvulus (Type 2)

Congenital or acquired

1. Disorders of gastric anatomy or gastric

Function

2. Abnormalities of adjacent organs

CLINICAL FEATURES

The clinical presentation of gastric volvulus is nonspecific and suggests high intestinal obstruction.

Gastric volvulus presents as a triad of – A sudden onset of severe epigastric pain,– Intractable retching with emesis– Inability to pass a tube into the stomach.

In infancy is usually associated with nonbilious vomiting.

May present as1. Acute volvulus

2. Chronic volvulus

CLINICAL FEATURES

DIAGNOSIS

Presence of a dilated stomach in plain abdominal radiograph.

Erect abdominal films demonstrate – In mesenteroaxial volvulus, a double fluid

level with a characteristic “beak” near the lower esophageal junction.

– In organoaxial volvulus, a single air-fluid level is seen without the characteristic beak.

TREATMENT

Acute volvulus– Surgical correction after stabilization

Chronic volvulus– Endoscopic correction

OUTCOME AND PROGNOSIS

Acute volvulus– Surgical correction after stabilization

Chronic volvulus– Endoscopic correction

LITERATURE REVIEW

There have been 581 cases of gastric volvulus in children published in English between 1929 and 2007. Of these, 252 were acute and 329 were chronic cases.Of all children with acute volvulus, 54 (21%) presented in the first month of life.

Literature Review

The majority of the patients presented with organoaxial volvulus (136 of 252 [54%]), while 103 (41%) cases of mesenteroaxial volvulusCribbs KR et al. Gastric Volvulus in Infants and Children. Pediatrics 2008;122:e752–e762.

Literature Review

Gastric volvulus is not the rare condition it was once thought to be; as Youssef et al stated more than 20 years ago, “perhaps this entity is more common than generally thought.”

It does require a heightened sense of awareness by pediatric providers to avoid delays in appropriate therapy and minimize the risk of gastric ischemia and perforation, which can lead to death.

CONCLUSION

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