A case of abdominal pain and vomiting Dr charles panackel

Demography  14 year old boy

Presenting complaints  Abdominal pain since early childhood  Vomiting of 2 months duration

History of presenting complaints  Complaints started as recurrent attacks of abdominal pain since early child hood.  Severe Colicky pain, lasting for mts.  Periumblical in location.  No radiation of pain.  Pain aggravated by food intake.  Relieved by injections and medications from local hospital. .

 Patient used to have 2-3 episodes per year.  Each episode used to last for 1-2 weeks and relieved with treatment from local hospital.  Evaluated with x-rays and USG abdomen and no definite diagnosis made.

History of presenting complaints  Presently patient has abdominal pain for last 2 months.  Colicky pain lasting for 15-20mts. Periumblical in location. No radiation.  Pain was aggravated by food intake  There was no associated fever, jaundice.  No dysuria, hematuria. No Steatorrhea

History of presenting complaints  Associated bilious vomiting and pain was relieved by vomiting  2-3 episodes per day.  Occurs ½-1 hour after food intake.  There was no delayed or stale food vomiting.  Patient had associated ball rolling sensation.

 There was no abdominal distension or borborygmi.  There was no associated constipation.  There was no hematemesis, melena or hematochizia.  There was no associated postural symptoms or oliguria.

 No autonomic symptoms like excessive sweating, postural syncope or palpitation  No purpura, urticaria, vesicular / bullous eruptions,  No arthritis/oral ulcers  No history of pica.  Was admitted and evaluated in local hospital treated symptomaticaly with no relief of pain or vomiting and referred here.

Past history  Second borne of a nonconsanguinous marriage. Normal developmental mile stones and scholastic performance.  No history of steatorrhea, respiratory symptoms, jaundice.  No history of tuberculosis  No history of any anorectal, renal or cardiac anomalies.  No history of surgery

Family history  No family history of Similar abdominal pain  No history of pancreatitis, skin lesions, psychosis, tuberculosis  Was on treatment from local hospital for abdominal pain.

DD  14 year old boy with recurrent periumblical colicky abdominal pain from early childhood now presenting with sudden aggravation of pain and bilious vomiting of 2 months duration.

Differential diagnosis  Malrotation with mid gut volvulus  Congenital band  Meckels diverticulum with mid gut volvulus  Annular pancreas  Intussuception  Recurrent pancreatitis  Congenital biliary defects

Examination  No dehydration  PR-78/’ BP- 110/70 no postural fall  RR -16/’  Moderately built and poorly nourished for the age  Ht 142 cm Wt 32 kg BMI 15.8  No pallor /No jaundice / edema / lymphadenopathy

 No stigmata of malabsorption like phrynoderma, bitots spots, glossitis, cheilitis, bone tenderness  No perioral or pigmentation, no skin lesions like purpura, vesicles, ulcers,  No skeletal anomalies, ptosis, ophtalmoplegia  No skin or joint laxity  No anorectal or external genitalia abnormalities

 Oral cavity- Normal. No perioral pigmentation  Abdomen – Not distended/ No visible peristalsis/ dilated veins /swelling/ abdominal wall defects  Liver was palpable 3cm below the right costal margin. Span 12cm. Soft, nontender, rounded margins and smooth surface  Spleen was not palpable  No mass palpable  Normal bowel sounds  P/R – Normal  Hernial orifices normal

 Chest - Normal  CVS; S1 and S2 normal.No murmur  CNS –No ptosis, ophthalmoplegia, myopathy or neuropathy  Fundus; normal

Differential diagnosis  Malrotation with recurrent gut volvulus  Congenital ladds band  Meckels diverticulum with mid gut volvulus  Annular pancreas  Intussuception

Investigations  Hb 11.8 TC 6700 DC P68 L30 E2  ESR 22  RBS 82  S.Na 142  S.K 3.7  S.Ca 8.2  BU/Cr- 15/0.7  Bb 0.7 SGOT /PT 32/23 ALP 72 TP 6.8 Alb 3.2

 USG  Dilated stomach with stasis no other abnormality noted  OGD  Esophagus was normal. Stomach, D1 and D2 were dilated with stasis. Scope was not introduced beyond D2.

 CT – Suggestive of intestinal malrotation with midgut vovulus

Surgery  Duodenum dilated upto D3  Band from transverse colon to D3/D4 jn---released the band  Volvulus 1/4 th rotation – No strangulation -Untwisted the bowel  Small bowel put on the right side  Large bowel put on the left side  Inversion appendicectomy done

Final diagnosis  Intestinal Malrotation  Partial intestinal obstruction at D3 level with Ladds bands and Midgut Volvulus 

Malrotation of midgut  Occurs in 1/1600 live births  Normally midgut goes out of the abdominal cavity during 4 th week of gestation  Comes back inside by the 10 th week  Midgut rotates around the axis of SMA for an angle of 270degrees

 Initial 90 degree rotation takes place outside the abdominal cavity  Second stage inside the abdomen – rotates through 180 degrees  Third stage is the descend of cecum

Anomalies  Non rotation (most common)  Malrotation  Reverse rotation

Symptoms  Most patients have symptoms within the first month  Recurrent vomiting  Abdominal pain  Malabsorption  Chylous ascites  Asymptomatic

Associations  30 to 60%  Omphalocoele  Gastroschisis  Diaphragmatic hernia  Duodenal or jejunal atresia  Hirshsprung’s disease  Esophageal atresia  Biliary atresia  Annular pancreas  Meckel’s diverticulam  Mesenteric cysts  Congenital cardiac defects

Imaging modalityFindings suggestive of malrotation Plain radiograph Nasogastric or orogastric tube that extends into an abnormally positioned duodenum The "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" appearance Duodenal 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 enema Complete 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  Surgery

Thank you