Best Pediatric Board Review Course 2019

A 7-year-old girl is brought to you with a chief complaint of abdominal pain. The pain began 1 hour after eating soup at a food truck, is worse in the periumbilical region, and is described as painful and somewhat intermittent. She has had 1 episode of greenish vomiting. She has not had a bowel movement since early in the morning before the onset of these symptoms, and that moment was reportedly soft but nonbloody.

Vital signs are: temperature 37.0 °C, pulse 166 beats/minute, respiratory rate 48 breaths/minute, blood pressure 88/57 mm Hg, and oxygen saturation 97% in room air. Her examination shows a distended abdomen, diffuse tenderness (more so periumbilical, without rebound), and no stool or tenderness on rectal examination, with a smear showing specks of heme-positive material.

Laboratory values are as follows:
Complete blood count: white blood cells of 21,500/µL, 65 segments, and 20 bands
Hemoglobin: 12.4 g/dL
Hematocrit: 36.4%
Sodium: 142 mEq/L
Potassium: 3.1 mEq/L
Bicarbonates: 17

Shortly after arrival, she vomits 800 cc of bilious fluid. Abdominal series is ordered (Figures 1 and 2).

Figure 1.

Figure 1.

What is your leading diagnosis based on the history and examination of the patient?

 intussusception
 midgut malrotation
 food poisoning
 appendicitis

Correct Answer:

midgut malrotation

Educational Objective:

Identify the clinical and radiologic presentation of midgut malrotation.

Key Point:

A child with midgut malrotation may present with colicky abdominal pain and bilious vomiting. The abdominal series shows distended loops of bowel and an absence of gas in certain areas.

Explanation:

The distended loops and absence of gas in other areas of the abdomen, in conjunction with the clinical findings of abdominal distention and bilious vomiting, should raise the suspicion of bowel obstruction. The aim of this case is to consider the following in the differential diagnosis of bowel obstruction using the mnemonic "AAIIMM":

Adhesions
Appendicitis
Intussusception
Inguinal hernia
Malrotation
Miscellaneous (eg, Meckel diverticulum, tumor, duplication)

This patient is outside the normal age range for intussusception, although the pain in both cases may be colicky, or intermittent. Food poisoning causes more vomiting and often diarrhea, but the vomitus is not bilious green because there is normally no obstruction. Symptoms of appendicitis include increasing, not intermittent, abdominal pain.

References:

Chung D. Pediatric surgery (chapter 66). In: Townsend CM Jr, Beauchamp RD. Sabiston Textbook of Surgery. 20th ed., 2017:1857-1899.

DiBrito S, Duncan M. Management of small bowel obstruction. In: Cameron JL, Cameron AM. Current Surgical Therapy. 12 th ed., 2017:109-113.

Kliegman R, et al. Ileus, adhesions, intussusception, and closed-loop obstructions (chapter 333). In: Kliegman R, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:1812-1814.

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