- This is a 3-month old female who is brought to the emergency room. this evening for vomiting. She began vomiting lastnight. She vomited twice last night and 8 times today.Initially, the vomitus was yellow in color but the last 3episodes have been green. There is no history of diarrhea. She has a history of feeling warm, but hertemperature was not measured at home. She lastpassed a stool yesterday. She is urinating less, only twice since this morning. Her past history is significant for poor weight gain and an illness one month ago characterized by vomiting four times which resolved onits own. She normally feeds a partially hydrolyzed formula because of “colic“.
Exam: Vital Sign T37.5 (rectal), P168, R38, BP not obtained because of crying. Wt 4.94 kg (25thpercentile). She is alert, crying, difficult to console. She arches her back at times and appears to be inpain. Her color is slightly pale. nterior fontanelle softand flat. No tears when crying. Her eyes appear to besomewhat sunken. Oral mucosa sticky. Neck supple(difficult to be certain). Heart regular, tachycardic.Lungs clear. Not coughing. Abdomen firm, difficult to
examine. Bowel sounds are diminished but present.No detectable masses, but because of the firmness,this is inconclusive. No hernias. Rectal exam no stool.Residue is guaiac negative. Color slightly pale and mottled. Capillary refill time in the lower extremities is3-4 seconds. Turgor good.
- Laboratory studies are drawn and an IV is begun.She is given a lactated Ringers solution fluid bolus andis continued on an IV infusion. After the fluid bolus, she is no longer crying. She is not fussy and her abdominalexam is now soft with active bowel sounds. No masses are palpable. Her color looks better. She is sent to theimaging department for an abdominal series.
- Lab results:
Na 138, K 4.3, Cl 101, Bicarb 21
Glucose 95, BUN 11, Creat 0.5
CBC WBC 12.0, 3% bands, 47% segs, 40% lymphs,
7% monos, Hgb 11.9, Hct 35.7, platelets 596,000
.
Questions
Would you order a barium enema, an UGI series, or an ultrasound at this point?
What would each of these studies be most effective in ruling out?
Since your decision should be based on what you think the most likely diagnosis is, what is the most likely diagnosis at this point?
- bilious vomiting x ray barium
- Bilious vomiting discussion
Dr. Jayaprakash
Superintendent, ICH.
Institute of Child Health.
Gov. Medical College Kottayam.
Kerala, India.