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

2. 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

3. Chief Complaint
Nausea and vomiting for 3 days

4. 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

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

6. 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

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

9. 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.

10. 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

11. Your impression?

12. 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

13. 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

14. Abdominal CT; C+/-

33. 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.

35. SMA Syndrome

36.  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.

37. 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

38. SMA Syndrome

39. 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

40. 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

41. 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

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

43. 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

44. Thanks for your attention