1. Pediatric Case Conference
報告人：李怡農
指導者：吳孟書

2. Pediatric Case Conference
袁XX之女
8d/o 女
就診日期： 2009/7/13
Vital sign：
TPR： 37.7/125/24
E4V5M6
病患來診為噁心和/或嘔吐,間歇性的噁心和嘔吐已緩解

3. Present Illness 8 d/o bilious vomiting since last night
feeding amount: RF 30ml/meal Q4h
No cough, some rhinorrhea
No diarrhea, no nausea
Activity: decreased
Appetite: decreased
referred from 怡仁hospital due to suspect GI obstruction

4. Past History
過去史:
Born via CS due to rupture of the membrane at GA 34 weeks with BBW 1915 gm in our hospital and Apgar score was 9 (at 1 min) -> 10(at 5 min).
Family history :
Maternal chronic ITP history was mentioned with steroid control.
The condition of thrombocytopenia was more severe during the pregnancy course and the steroid was increased in the dosage and the mother ever under 6 dose of the Plt transfusion.

5. Physical Examination Conscious:clear,E4V5M6
Conjunctiva: not injected, not pale
Throat: no injected, not enlarged, exudate(-),
Eardrum: not injected
Chest: symmetric expansion, no retraction
coarse BS, crackle(-), wheezing(-),
Heart: regular heart beat, no murmur
腹部：soft & flat, normoactive BS
tenderness(-), no rebounding pain
四肢：Extremity: freely,
Muscle power: OK
神經學：Normal
Capillary refill time:<3 sec

6. What do you need to know more. What is your impression now
What do you need to know more? What is your impression now? What do you want to do next?

7. Approach to the child with nausea and vomiting UpToDate 2009
A standardized approach to children with nausea and vomiting cannot be recommended because these symptoms may be caused by many pathologic states involving several systems.
The most important consideration during the initial encounter is recognition of serious conditions for which immediate intervention is required.

8. Approach to the child with nausea and vomiting UpToDate 2009
DIAGNOSIS BY AGE GROUP — The differential diagnosis of vomiting is age dependent.
NEONATES AND YOUNG INFANTS
Forceful and repeated vomiting in newborns is not normal and should be taken seriously, particularly if there are other signs of illness.
The most frequent diagnostic considerations in newborns and young infants are gastroesophageal reflux, pyloric stenosis, and intestinal obstruction.
Other conditions that may present with vomiting are sepsis, excessive feeding volume, or increased intracranial pressure. Although much less common, inborn errors of metabolism also can present with vomiting.

9. Approach to the child with nausea and vomiting UpToDate 2009
OLDER INFANTS AND CHILDREN
Multiple disorders may present with vomiting in older infants and children.
By far, the most common is gastroenteritis.
However, GERD, gastroparesis, mechanical obstruction, anaphylaxis, Munchausen syndrome by proxy (factitious disorder by proxy), intracranial masses, peptic ulcer disease, and cyclic vomiting also may be diagnostic considerations.
Adrenal crisis and anaphylaxis should be considered in children with disproportionate hypotension and/or predisposing factors.

10. Tintinalli Chap 127 Pediatric Abdominal Emergencies
Bilious vomiting is always a serious manifestation in an infant or child. Vomiting may be a sign of obstructive or nonobstructive GI diseases, or of infections or metabolic disorders.
Vomiting (bilious or not) is a classic symptom of mechanical intestinal obstruction in children.
In the early phases of illness, before a child has developed electrolyte abnormalities or before a child has gangrenous bowel the child's general condition may appear to be good.

11. How do we approach this patient?
Is the patient stable? - PAT triangle
Is the vomit normal?
Onset time
Relation with feeding
Vomit contents
Associated symptoms
Is there any emergency condition we should rule out?
Pyloric stenosis, Adrenal insufficiency, Intestinal obstruction, Inborn errors of metabolism

12. Initial Order CBC/DC CRP, B/C BUN/Cr AST/ALT Na/K/Cl/Ca
CXR including abdomen
Admission to NBICU
IVF with D5-1/4S

13. Lab Data Sugar 60 60-100 (child) BUN 15 3-25 (<1Y) Cr 0.51
(infant-18Y) Na
138
(<18Y) K
5.3
(<1Month) Ca
11.1
(0-10d) Cl
104
(1-18Y)
AST 22
(0-10day)
ALT 16
13-45 (<1Y)
CRP
< 0.5
< 5

14. Lab Data RBC 5.44 3.99~4.98(>1d-8d) Hb 18.7 14.0~17.4(>1d-8d)
HCT
52.1
41.0~51.4(>1d-8d)
MCV
95.8
97.4~106.7(>1d-8d)
PLT
590
WBC
10.0
5.2~13.4(>1d-8d)
Seg
54.0
32.6~70.7(>1d-8d)
Band
1.0
0-3
Lymphocyte
34.0
16.8~48.1(>1d-8d)
Monocyte
5.0
5.2~19.6(>1d-8d)
Eosinophil
6.0
1.0~ 6.1(>1d-8d)

15. KUB What’s your Interpretation of the KUB?
What is your impression now?
What do you want to do next?

16. Abd echo (pedatric)
Liver: Homogeneous echogenicity, no enlargement, no space taking lesion.
Spleen: Negative.
Gall bladder: Negative
Biliary tree: Negative.
Right Kidney and perirenal area: Negative.
Left Kidney and perirenal area: Negative.
Aorta and IVC of upper abdomen: Negative.
Imp.:Negative for malrotation or IHPS
判讀主治醫師：江文山　
2009/07/ :45:17

17. Still vomiting
怎麼辦？

18. Upper GI series 1. Infusion of 5mL of barium via OG tube.
2. Malrotation of duodenum with abrupt stenosis at the 3rd portion, suggesting band compression.
3. Vigorous peristasis of the stomach and proximal duodenum.
4. No definite volvulus.
Impression: Malrotation with Ladd band compression at junction of 2nd and 3rd portion duodenum causing outlet obstruction.
主治醫師：王超然 MA2530 放診專字0339號
報告日期：2009/07/

20. Operative Findings
The malrotated intestine loops were wrapped around the incompletely anchored mesentery. The descending duodenum was dilated because of extrinsic pressure from Ladd's band across it.
The malrotated intestinal loops were reduced by taking the entire intestinal mass in the hand and rotating it counter-clockwise.
After reduction, the cecum lied in the right upper quadrant.

21. Operative Findings
The peritoneal folds from the cecum and the ascending colon to the lateral peritoneum (Ladd''s band) was incised closed to the lateral serosal border of the duodenum.
Finally, the duodenum descended along the right gutter. The small intestines lied on the right side of the abdomen, while the cecum and the ascending colon were in the left side of the abdomen.
The appendix was excised smoothly.
The intestinal loops were delivered into the peritoneal cavity again in the reduction manner.

22. Intestinal Malrotation

23. Intestinal Malrotation
Symptomatic malrotation is estimated to occur in 1/6000 live births.
Approximately two-thirds of children who require surgery for malrotation are younger than one month of age; 18 to 25 percent are between one month and one year of age; and 10 to 18 percent are older than one year.

24. Intestinal Malrotation
Between 30 and 62 percent of children who have intestinal malrotation have an associated anomaly.
Rotational defects are present in all children with diaphragmatic hernia, gastroschisis, and omphalocele. As many as 17 percent of children with duodenal atresia and 33 percent of children with jejunoileal atresia may have an associated malrotation.

25. Normal rotation of the midgut

26. Normal rotation of the midgut

27. Intestinal Malrotation

28. Intestinal Malrotation
Most individuals with intestinal malrotation develop signs of acute small bowel obstruction in early infancy.
Intestinal malrotation should be considered in any infant with bilious vomiting and any child with bilious emesis and abdominal pain.
Over 50 percent of children with malrotation present before one month of age with the life-threatening complication of volvulus.
Vomiting, which may or may not be bilious, occurs in >90 percent of newborns with volvulus and is by far the most common presenting symptom of malrotation in infancy.

29. Midgut volvulus

30. Intestinal Malrotation
Radiologic evaluation typically begins with plain radiographs, which are rarely diagnostic.
Plain radiographs are followed by an upper GI contrast series, which is the best examination to visualize the duodenum.
Barium enema and ultrasonography can be useful adjuncts when abnormal findings are present, but normal findings do not exclude malrotation.
Third space fluid losses and sepsis, caused by necrotic bowel, can cause rapidly progressive cardiovascular compromise.
Prompt fluid resuscitation and surgical intervention are essential.

31. Textbook of Pediatric Emergent Medicine 5th Edition 2006

32. Thanks for Your Attention