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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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