1. Newborn with vomiting 報告者 : 徐天佑 指導者 : 吳孟書

2. 7 day old male BW: 2778gm (3 rd -10 th percentile) Chief complaint  Projectile vomiting since last night

3. G3P3, c/s, GA 38+ weeks BBW: 3195gm, BL: 48cm Head girth: 34cm, chest girth: 33cm Apgar score: 9  10

4. Vomiting and spit up “Vomiting” is a highly complex act, involving coordinated closure of gastric pylorus and glottis; relaxation of stomach, cardioesophageal junction, and esophagus; and vigorous diaphragmatic and abdominal wall muscular contraction. “Spit up” refers to the nonforceful reflux of milk into the mouth, which often accompanies eructation. Such nonforceful regurgitation of gastric or esophageal contents is most often physiologic and of little consequence.

5. Vomiting and Regurgitation: Principal Causes by Usual Age of Onset and Etiology Newborn (Birth to 2 weeks) Normal variations Gastroesophageal reflux (± hiatal hernia) Esophageal stenosis, atresia Infantile achalasia Obstructive intestinal anomalies  Intestinal stenosis, atresia  Malrotation of bowel (± midgut volvulus)  Meconium ileus (cystic fibrosis) Meconium plug  Hirschsprung's disease  Imperforate anus  Enteric duplications Other gastrointestinal causes  Necrotizing enterocolitis  Cow's milk allergy  Lactobezoar  Gastrointestinal perforation with secondary peritonitis Neurologic  Subdural hematoma  Hydrocephalus  Cerebral edema  Kernicterus Renal  Obstructive uropathy  Renal insufficiency Infectious  Meningitis  Sepsis Metabolic  Inborn errors of urea cycle; amino acid, organic acid, and carbohydrate metabolism (phenylketonuria, galactosemia) Congenital adrenal hyperplasia Textbook of Pediatric Emergency Medicine Ch 78 vomiting

6. How to approach child's age evidence of obstruction signs or symptoms of extra-abdominal organ system disease appearance of the vomitus overall degree of illness (including the presence and severity of dehydration or electrolyte imbalance) associated GI symptoms.

7. Life-threatening Causes of Vomiting Newborn (Birth to 2 wk) Anatomic anomalies  esophageal stenosis/atresia  intestinal obstructions, especially malrotation and volvulus  Hirschsprung's disease Other gastrointestinal (GI) causes Necrotizing enterocolitis Peritonitis Neurologic— kernicterus, mass lesions, hydrocephalus Renal — obstructive anomalies, uremia Infectious—sepsis, meningitis Metabolism — inborn errors, especially congenital adrenal hyperplasia Textbook of Pediatric Emergency Medicine, Ch 78 vomiting

8. flow chart of vomiting

9. Physical examination T: 36.5 P: 128 R: 48 BP:73/41 Acute ill looking Mild icteric, no rash, no pigmentation HEENT:  Anterior fontanel: soft/flat  Eye: no discharge  Ear: no discharge  Mouth: no ulceration  Neck: supple, no LAP Chest: symmetric expansion  BS clear  RHB, no murmur Abdomen:  Soft / mild distension  BoS: silent  Peritoneal sign: neg  Mass: palpable but ambigous  Liver: impalable  Spleen: palpable Extremity:  Freely, no edema

10. Initial impression New born with vomiting, cause? dehydration

11. Lab data WBC: 16400  Seg: 59  Lym: 34  Mon: 4  Eos: 1  Bas: 1 RBC: 4.72  Hb/Hct: 16.7 / 47.5 Platelet: 305k Ca: 9.4 CRP: 1.32 Na: 141 K: 5.2 Cl: 110 BUN: 11 Cr: 0.4 Bil (D): 0.7 Bil (T): 15.5 AST: 23 ALT: 7 Sugar: 91

13. CXR ＜報告內容＞ 收件號： 06042033145 Supine chest including abdomen shows: Normal heart size and configuration. Nasogastric tube in place. gasless lower abdomen

14. Abdominal echo The stomach and proximal intestinal is filled with gas and contents. The SMV is located anterior to SMA in the upper abdomen. 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. Imp.: The SMV is located anterior to SMA in the upper abdomen. Proximal bowel obstruction is likely, malrotation can't be excluded.

15. UGI series

21. UGI series report S/P NG tube insertion. Localized ileus of bowel loops at the LUQ of the abdomen. About 10ml of barium was injected via the NG tube. Abnormal position D-J junction at the midline position and causing significant obstruction, consistent midgut malrotation with Ladd's band compression. Questionable cork-screw appearance of the proximal jejunum, so volvulus is suspected. IMP: Midgut malrotation with Ladd`s band compression.

22. Operation note Operative indication: suddent onest bilious vomiting Operative method: Ladd's procedure Operative findings: 360 degree midgut volvulus without bowel gangrene and the appendix and cecum located at upper abdomen, Ladd's bands from cecum to right abdominal fold induced duodenum extrinsic compression Operative procedures: Under successful endotracheal anesthesia, the patient was placed in supine position with the skin well draped and sterilized as proper manner, foley and OG inserted for decompression. Upper transverse incision was made at right abdomen above the umbilicus 1.5 cm level and deepened into the abdominal cavity layer by layer, after the peritonium was opened, carefully retarcetd the bowel out the abdominal incsion and inspection. 360 degree midgut volvulus was found, reduction the volvulus was carried out first in a counterclockwise rotation. Ladd's bands from the cecum to the rigt abdominal fold which induced duodenal extrinsic compression. Enterolysis the Ladd's bands from the pylorus to the duodenojejunal junction until the duodenum was straight. Then the small bowel lied on the right abdomen and pull the cecum and colon to left abdomen after appendectomy was performed. After irrigation and hemostasis, the wound was closed layer by layer.The blood loss was minimal and the patient tolerated the operation well. The patient was then sent to NICU for further management.

23. What is malrotation Rotational anomalies occur as a result of an arrest of normal rotation of the embryonic gut Epidemiology:  1/200~1/500  1/6000 with symptoms  2/3 require surgery younger than 1m/o

24. Pathogenesis of malrotation

25. The duodenojejunal limb remains in a position of nonrotation The cecocolic limb has partial rotation (usually approximately 90º instead of 180º) The end result is that the cecum ends up in the mid-upper abdomen and the abnormally positioned cecum is fixated to the right lateral abdominal wall by bands of peritoneum. These bands of peritoneum, called Ladd bands, cross the duodenum and can cause extrinsic compression and obstruction of the duodenum

26. Bowel fixation

27. malrotation

28. Clinical presentation Volvulus  > 50% of children with malrotation present before one month of age with life threatening complication of volvulus Duodenal obstruction  Caused by Ladd bands or duodenal atresia Other presentation  Intermittent abdominal pain or vomiting  Failure to thrive  Solid food intolerance

29. Diagnosis (plain radiographs) Rarely helpful Gasless abdomen NG or OG extends to abnormally positioned duodenum Double-bubble sign

30. Diagnosis (UGI series) The best examination to visualize the duodenum  Misplaced duodenum (ligment of Treitz on the right side of the abdomen) that has a corkscrew appearance if a volvulus is present False negative: 6~14% False positive: 7~15%

32. Diagnosis (barium enema) High false positive rate Used only as an adjust to UGI series “Beaked appearance” means complete obstruction of T-colon

33. Diagnosis (ultrasonography) Can be used for screening A normal ultrasonogram does not exclude malrotation Findings that are suggestive of malrotation  Abnormal position of SMV (either anterior or to the left of the SMA)  Duodenal dilation  “Whirlpool” sign of volvulus

34. Treatment Symptomatic  Can only be treated surgically  Pre-op resuscitation  NG decompression  Broad-spectrum antibiotics Asymptomatic  Incidentally finding  Most surgeon recommend surgery when malrotation is diagnosed  Laparoscopy

35. Complication Short gut syndrome  Occurred in necrotic bowel in malrotation and volvulus Small bowel obstruction  Due to adhesion (15%)

36. Outcome Mortality  3%~9%, associated to volvulus, intestinal necrosis, prematurity, and associated anomalies  0% in healthy child without intestinal ischemia Recurrent volvulus  1.8%~8%

37. Thank you for your attention