Pediatric Case Conference Speaker: R4 邱明達 Supervisor: MA 吳孟書 2007/12/26

General Data 13 y/o, Female ER visit on: 2007/11/25 07:38 AM 檢傷主訴: 噁心嘔吐 Vital signs: BT: 35.3C, HR:86/min RR: 17/min, BP:110/87 mmHg GCS: E4V5M6

Chief Complaint Nausea and vomiting for 3 days

Present illness Post-prandial epigastric abdominal distress since 3 days ago. Progressive abdominal pain(diffuse?) Poor appetite (even to liquid diet) with no stool passage for 3 days No fever, no URI symptoms 壢新ER with IM drug and IVF but in vain our ER

Past and Personal History Denied systemic disease by history Allergy: no known drug allergy Vaccination: as schedule

Physical Exam Appearance: fair looking HEENT: no pale conjunctiva, no injected throat Chest: bilateral clear breath sound CV: RHB Abdomen: diffuse distended, no focal tenderness hypoactive bowel sound Skin: no rashes Extremity: freely, no pitting edema

ER initial order (07:57, 19min) CBC/DC, CRP BUN, Na, K AST/ALT Amylase/Lipase IVF: D5S1/4 run 100ml/hr Abdomen(Supine)

X-ray report elevated left diaphragm. No visible radiopaque stone along the course of ureteral tracts. Clear bilateral psoas. Neither abnormal free air nor air-fluid level seen. Nonspecific bowel gas pattern with stool in colon.

Hemogram and Biochemistry WBC: 15.7/uL Segment: 86.6 % Lymphocyte: 7.7 % Monocyte: 5.6 % HgB: 15.1 g/dl Hct: 44.3 % MCV: 89.7fL Platelet: 317 k/uL RBC: 4.94 million/uL CRP: 0.93 mg/L BUN: 19 mg/dL ALT: 13 U/L AST: 27 U/L Na: 138 meq/L K: 3.2 meq/L Amylase: 71 U/L Lipase: 31 U/L

Your impression?

Differential diagnosis Bowel obstruction: - Stomach: Pyloric stricture (ulcer).. - Intestine: Extrinsic: volvulus, SMA syndrome.. Intrinsic : stone, neoplasm, bezoar.. Gastritis, GERD, Pancreatitis… Inflammatory bowel disease Appendicitis Pregnancy

Impression: Abdominal pain, etiology? Suggestion: Abdominal CT Consult GYN (08:29, 51min) ICON: (-), Dysmenorrhea: (+) Trans-abdominal Echo: Diffusely bizzare fluid collection with floating material Impression: Abdominal pain, etiology? Suggestion: Abdominal CT

Abdominal CT; C+/-

Abdominal CT Report Marked distension of the stomach, duodenal bulb , 2nd portion and proximal 3rd portion of duodenum. D/D: Duodenal web (unlikely in this age), Malrotation with volvulus (not likely, since normal relationship of SMA and SMV is noted) Impression: SMA syndrome is considered first. Suggest correlate with UGI study after NG decompression.

SMA Syndrome

 Consult Surgeon Impression: 1. Favor SMA syndrome 2. Dehydration Plan: 1. No surgical indication at present time 2. Adequate hydration 3. NPO and NG decompression 4. Admitted to Pediatric ward, consult us for follow up if necessary.

Brief Hospital course 11/26: Abdominal Echo: Small SMA-Aorta angle, gastric and duodenal dilatation, cause ? 11/27: PES: Duodenal obstruction, C/W SMA syndrome, gastroparesis 11/28: UGI series: C/W SMA syndrome. 11/30: Surgery : Collapsed bowel after Triezt’s ligament due to SMA compression  Bypass surgery with Duodenojejunostomy 12/08: MBD

SMA Syndrome

Diagnostic criteria Duodenal obstruction with an abrupt cutoff in the 3rd portion and active peristalsis A narrow angle between the aorta and the SMA with high fixation of the duodenum by the ligament of Treitz

Predisposing factors most common is significant weight loss leading to loss of the mesenteric fat pad. --malignancy or malabsorption syndromes --anorexia nervosa --trauma or burns --spinal cord injury and paraplegia. ~ from Br J Surg 1981, Spinal Cord 2002 Feb surgical correction of scoliosis (in younger patients) ~from Spine 2002 Dec 15 congenitally short ligament of Treitz Identical twins ~from Intern Med 2001 Aug pregnancy ~from Eur J Obstet Gynecol Reprod Biol 1986 Apr

Clinical manifestation may present acutely (such as following surgery for scoliosis) or more insidiously with gradual or progressive symptoms mild obstruction --postprandial epigastric pain --early satiety more advanced obstruction --severe nausea and bilious emesis. Symptoms may be relieved when patients are in the left lateral decubitus, prone, or knee-chest position

Diagnostic Modalities abdominal radiograph Upper gastrointestinal series superior mesenteric arteriography CT angiogram Endoscopic ultrasound

Treatment Three major goals Correction of dehydration and electrolyte imbalances Decompression of the obstruction via a NG tube Institution of nutrition.  OP will be indicated if medical treatment failure

Thanks for your attention