A case of abdominal pain A case of abdominal pain and vomitingand vomiting

Dr charles panackelDr charles panackel

DemographyDemography

14 year old boy14 year old boy

Presenting complaintsPresenting complaints

Abdominal pain since early childhoodAbdominal pain since early childhood Vomiting of 2 months durationVomiting of 2 months duration

History of presenting complaintsHistory of presenting complaints Complaints started as recurrent attacks of Complaints started as recurrent attacks of

abdominal pain since early child hood. abdominal pain since early child hood. Severe Colicky pain, lasting for 15- 20 mts. Severe Colicky pain, lasting for 15- 20 mts. Periumblical in location. Periumblical in location. No radiation of pain. No radiation of pain. Pain aggravated by food intake. Pain aggravated by food intake. Relieved by injections and medications from local Relieved by injections and medications from local

hospital.hospital.

..

Patient used to have 2-3 episodes Patient used to have 2-3 episodes per year. per year.

Each episode used to last for 1-2 Each episode used to last for 1-2 weeks and relieved with treatment weeks and relieved with treatment from local hospital.from local hospital.

Evaluated with x-rays and USG Evaluated with x-rays and USG abdomen and no definite diagnosis abdomen and no definite diagnosis made.made.

History of presenting complaintsHistory of presenting complaints Presently patient has abdominal pain for Presently patient has abdominal pain for

last 2 months. last 2 months. Colicky pain lasting for 15-20mts. Colicky pain lasting for 15-20mts.

Periumblical in location. No radiation. Periumblical in location. No radiation. Pain was aggravated by food intakePain was aggravated by food intake There was no associated fever, jaundice. There was no associated fever, jaundice. No dysuria, hematuria. No SteatorrheaNo dysuria, hematuria. No Steatorrhea

History of presenting complaintsHistory of presenting complaints

Associated bilious vomiting and pain Associated bilious vomiting and pain was relieved by vomitingwas relieved by vomiting

2-3 episodes per day.2-3 episodes per day. Occurs ½-1 hour after food intake.Occurs ½-1 hour after food intake. There was no delayed or stale food There was no delayed or stale food

vomiting. vomiting. Patient had associated ball rolling Patient had associated ball rolling

sensation.sensation.

There was no abdominal distension or There was no abdominal distension or borborygmi. borborygmi.

There was no associated constipation. There was no associated constipation. There was no hematemesis, melena or There was no hematemesis, melena or

hematochizia.hematochizia. There was no associated postural There was no associated postural

symptoms or oliguria. symptoms or oliguria.

No autonomic symptoms like excessive No autonomic symptoms like excessive sweating, postural syncope or palpitationsweating, postural syncope or palpitation

No purpura, urticaria, vesicular / bullous No purpura, urticaria, vesicular / bullous eruptions, eruptions,

No arthritis/oral ulcersNo arthritis/oral ulcers No history of pica. No history of pica. Was admitted and evaluated in local Was admitted and evaluated in local

hospital treated symptomaticaly with no hospital treated symptomaticaly with no relief of pain or vomiting and referred here.relief of pain or vomiting and referred here.

Past historyPast history Second borne of a nonconsanguinous Second borne of a nonconsanguinous

marriage. Normal developmental mile marriage. Normal developmental mile stones and scholastic performance. stones and scholastic performance.

No history of steatorrhea, respiratory No history of steatorrhea, respiratory symptoms, jaundice.symptoms, jaundice.

No history of tuberculosisNo history of tuberculosis No history of any anorectal, renal or No history of any anorectal, renal or

cardiac anomalies.cardiac anomalies. No history of surgeryNo history of surgery

Family historyFamily history

No family history of Similar abdominal No family history of Similar abdominal painpain

No history of pancreatitis, skin lesions, No history of pancreatitis, skin lesions, psychosis, tuberculosispsychosis, tuberculosis

Was on treatment from local hospital Was on treatment from local hospital for abdominal pain.for abdominal pain.

DDDD 14 year old boy with recurrent 14 year old boy with recurrent

periumblical colicky abdominal pain periumblical colicky abdominal pain from early childhood now presenting from early childhood now presenting with sudden aggravation of pain and with sudden aggravation of pain and bilious vomiting of 2 months bilious vomiting of 2 months duration.duration.

Differential diagnosisDifferential diagnosis

Malrotation with mid gut volvulusMalrotation with mid gut volvulus Congenital bandCongenital band Meckels diverticulum with mid gut Meckels diverticulum with mid gut

volvulusvolvulus Annular pancreas Annular pancreas IntussuceptionIntussuception Recurrent pancreatitisRecurrent pancreatitis Congenital biliary defectsCongenital biliary defects

Examination Examination No dehydrationNo dehydration PR-78/’ BP- 110/70 no postural fallPR-78/’ BP- 110/70 no postural fall RR -16/’ RR -16/’ Moderately built and poorly nourished Moderately built and poorly nourished

for the agefor the age Ht 142 cm Wt 32 kg BMI 15.8Ht 142 cm Wt 32 kg BMI 15.8 No pallor /No jaundice / edema / No pallor /No jaundice / edema /

lymphadenopathylymphadenopathy

No stigmata of malabsorption like No stigmata of malabsorption like phrynoderma, bitots spots, glossitis, phrynoderma, bitots spots, glossitis, cheilitis, bone tendernesscheilitis, bone tenderness

No perioral or pigmentation, no skin lesions No perioral or pigmentation, no skin lesions like purpura, vesicles, ulcers,like purpura, vesicles, ulcers,

No skeletal anomalies, ptosis, No skeletal anomalies, ptosis, ophtalmoplegiaophtalmoplegia

No skin or joint laxityNo skin or joint laxity No anorectal or external genitalia No anorectal or external genitalia

abnormalities abnormalities

Oral cavity- Normal. No perioral pigmentationOral cavity- Normal. No perioral pigmentation Abdomen – Not distended/ No visible peristalsis/ Abdomen – Not distended/ No visible peristalsis/

dilated veins /swelling/ abdominal wall defectsdilated veins /swelling/ abdominal wall defects Liver was palpable 3cm below the right costal Liver was palpable 3cm below the right costal

margin. Span 12cm. Soft, nontender, rounded margin. Span 12cm. Soft, nontender, rounded margins and smooth surfacemargins and smooth surface

Spleen was not palpableSpleen was not palpable No mass palpableNo mass palpable Normal bowel soundsNormal bowel sounds P/R – NormalP/R – Normal Hernial orifices normalHernial orifices normal

Chest - NormalChest - Normal CVS; S1 and S2 normal.No murmurCVS; S1 and S2 normal.No murmur CNS –No ptosis, ophthalmoplegia, CNS –No ptosis, ophthalmoplegia,

myopathy or neuropathymyopathy or neuropathy Fundus; normalFundus; normal

Differential diagnosisDifferential diagnosis

Malrotation with recurrent gut Malrotation with recurrent gut volvulusvolvulus

Congenital ladds bandCongenital ladds band Meckels diverticulum with mid gut Meckels diverticulum with mid gut

volvulusvolvulus Annular pancreasAnnular pancreas IntussuceptionIntussuception

InvestigationsInvestigations

Hb 11.8 TC 6700 DC P68 L30 E2Hb 11.8 TC 6700 DC P68 L30 E2 ESR 22ESR 22 RBS 82RBS 82 S.Na 142S.Na 142 S.K 3.7S.K 3.7 S.Ca 8.2S.Ca 8.2 BU/Cr- 15/0.7BU/Cr- 15/0.7 Bb 0.7 SGOT /PT 32/23 ALP 72 TP 6.8 Bb 0.7 SGOT /PT 32/23 ALP 72 TP 6.8

Alb 3.2Alb 3.2

USGUSG Dilated stomach with stasis no other Dilated stomach with stasis no other

abnormality notedabnormality noted

OGDOGD Esophagus was normal. Stomach, D1 Esophagus was normal. Stomach, D1

and D2 were dilated with stasis. and D2 were dilated with stasis. Scope was not introduced beyond D2. Scope was not introduced beyond D2.

CT – Suggestive of intestinal CT – Suggestive of intestinal malrotation with midgut vovulusmalrotation with midgut vovulus

Surgery Surgery

Duodenum dilated upto D3Duodenum dilated upto D3 Band from transverse colon to D3/D4 Band from transverse colon to D3/D4

jn---released the bandjn---released the band Volvulus 1/4Volvulus 1/4thth rotation – No rotation – No

strangulation -Untwisted the bowelstrangulation -Untwisted the bowel Small bowel put on the right sideSmall bowel put on the right side Large bowel put on the left sideLarge bowel put on the left side Inversion appendicectomy doneInversion appendicectomy done

Final diagnosisFinal diagnosis

Intestinal Malrotation Intestinal Malrotation Partial intestinal obstruction at D3 Partial intestinal obstruction at D3

level with Ladds bands and Midgut level with Ladds bands and Midgut VolvulusVolvulus

Malrotation of midgutMalrotation of midgut

Occurs in 1/1600 live birthsOccurs in 1/1600 live births Normally midgut goes out of the Normally midgut goes out of the

abdominal cavity during 4 th week of abdominal cavity during 4 th week of gestationgestation

Comes back inside by the 10 th weekComes back inside by the 10 th week Midgut rotates around the axis of Midgut rotates around the axis of

SMA for an angle of 270degreesSMA for an angle of 270degrees

Initial 90 degree rotation takes place Initial 90 degree rotation takes place outside the abdominal cavityoutside the abdominal cavity

Second stage inside the abdomen –Second stage inside the abdomen –rotates through 180 degreesrotates through 180 degrees

Third stage is the descend of cecumThird stage is the descend of cecum

Anomalies Anomalies

Non rotation (most common)Non rotation (most common) Malrotation Malrotation Reverse rotationReverse rotation

Symptoms Symptoms

Most patients have symptoms within Most patients have symptoms within the first monththe first month

Recurrent vomitingRecurrent vomiting Abdominal painAbdominal pain Malabsorption Malabsorption Chylous ascitesChylous ascites Asymptomatic Asymptomatic

Associations Associations 30 to 60%30 to 60%

Omphalocoele Omphalocoele Gastroschisis Gastroschisis Diaphragmatic herniaDiaphragmatic hernia Duodenal or jejunal atresiaDuodenal or jejunal atresia Hirshsprung’s diseaseHirshsprung’s disease Esophageal atresiaEsophageal atresia Biliary atresiaBiliary atresia Annular pancreasAnnular pancreas Meckel’s diverticulamMeckel’s diverticulam Mesenteric cystsMesenteric cysts Congenital cardiac defectsCongenital cardiac defects

Imaging modality Findings suggestive of malrotation

Plain radiograph

Nasogastric or orogastric tube that extends into an abnormally positioned duodenumThe "double-bubble"sign of duodenal obstruction

Upper GI contrast study

A clearly misplaced duodenum (ie, ligament of Treitz on the right side of the abdomen) that has a "corkscrew" appearanceDuodenal obstruction, which may appear similar to that seen with duodenal atresia or may have more of a "beak" appearance if a volvulus is present

Barium enemaComplete obstruction of the transverse colon, particularly if the head of the barium column has a beaked appearance

Ultrasonography

Abnormal position of the superior mesenteric vein (either anterior or to the left of the superior mesenteric artery)Dilated duodenum (indicating duodenal obstruction)The "whirlpool" sign of volvulus (caused as the vessels twist around the base of the mesenteric pedicle)

Treatment Treatment

SurgerySurgery

Thank youThank you