Interesting Pediatric Case

[ohiovolffemtp]

This is a patient who came into my CAH this past week.  ED staff: 1 RN, 1 medic, me.  1 rad tech who can do plain films and CT, no U/S or MRI, 1 lab tech.  No ability to admit peds.

9 month 3 week male brought in by his parents with a 2 day history of nausea and vomiting.  It had started relatively suddenly.  Parents said the child would still take a bottle with clear liquids or milk but within 5-10 minutes of eating he'd vomit.  They said he was much more tired and fussy than normal.  They also said it had been over 14 hours since his last wet diaper.  

Patient was born after a full term uncomplicated pregnancy and is otherwise healthy.  He's up to date on all immunizations.  He's been seen by pediatrics, no chronic medical problems, no meds, no allergies.  No surgical history.  No sick contacts.

Vitals: P:170, temp 98.8 axillary, 97% sat on room air.  No BP obtained.  Glucose 106.

Physical exam: eyes OK, but no tears when crying.  Oropharynx very dry.  Rest of ENT exam normal.  Lungs CTA all fields, no retractions or accessory muscle use.  Heart tachycardic, no murmurs, rubs, or gallops.  Abdomen had diffuse generalized tenderness, no masses or pulsatile masses, no localized tenderness.  Reduced bowel sounds.  

Medic got a line, unable to draw for labs. Fluids given: 20 cc/kg NS bolus followed by 5 cc/kg/hour.  Plain films showed "nonspecific gaseous distention of bowel".  Patient a little better, but still very uncomfortable.  COVID and influenza swabs negative.

Patient transferred to a larger facility that can admit peds.

What was the presumptive diagnosis?  (I couldn't rule it in or out.  First time I've ever seen it.)

 

 

 

[LT_Oneal_PAC]

Any history of constipation? Recent viral illness?

I can't think of something based on that history and exam that I would be "oh this is it until proven otherwise."

By the age and symptoms, my best guess would be intussusception, but you didn't mention a sausage like mass and isn't uncommon enough to think you have never seen it. Suppose the latter is possible as you see way more geriatrics than infants in the rural area if yours is anything like mine. Most also have gross blood in stool, but not always. 

Very unlikely but possible could be a later or atypical presentation of hirschsprung, volvulus, meningitis, appendicitis, rumination syndrome, gastroparesis. 

 

[kidpresentable]

Good DDx so far. Kinda sounds like pyloric stenosis, even without the olive-shaped abdominal mass

[LT_Oneal_PAC]

4 hours ago, kidpresentable said:

Good DDx so far. Kinda sounds like pyloric stenosis, even without the olive-shaped abdominal mass

It does, but I don’t ever think I’ve seen that in a kid so old.

[EMEDPA]

34 minutes ago, LT_Oneal_PAC said:

It does, but I don’t ever think I’ve seen that in a kid so old.

agree- That is generally a dx in the first 2 months of life. 

[ohiovolffemtp]

It was an intussusception - but no physical findings on exam - no sausage like mass.  I was pretty sure, given the child's age, normal growth, and lack of suggestion of an infectious process.  

Receiving hospital confirmed an 9 cm intussusception with serial U/S.  He had an air enema which only partially resolved the problem.  He later had a bowel resection and appendectomy - I believe at a tertiary center.  Can't tell for sure because he went out of our system and the state wide system only has a few notes, labs, and imaging results.

Actually, it's the 1st one I've ever had personally, in about 9 years of EM.

[EMEDPA]

Great job! A lot of folks might have sent that kid home. 

[MediMike]

Hah! Yes!

I got this one. 

But where are the currant jelly stools?! You can't have intussusussusssception without currant jelly stools and a sausage mass. Think I saw it in a book somewhere.

[ohiovolffemtp]

19 hours ago, MediMike said:

But where are the currant jelly stools?! You can't have intussusussusssception without currant jelly stools and a sausage mass. Think I saw it in a book somewhere.

But what can you say if the kid hasn't pee'd or poop'd in 14+ hours and his belly is diffusely tender without localization or masses? (or if the patient didn't read the textbook - which is exactly your point)

Biggest thing was the kid looked sick: clearly dehydrated, tired, not keeping down orals.  Too sick to go home, we can't keep a kid that young, so transfer.  Didn't look like an infectious process (transferred one of them 2 days later), so it felt like a mechanical issue.  Couldn't think of why he would have had a volvulus and age seemed too old for pyloric stenosis, so intussusception seemed the most likely.  My note said "can't rule in or out intussusception".  

PA school never taught my class the % of time particular conditions have the text book phrase symptoms.  We even checked for Homan's sign like it meant something.

Honestly, my highest yield sign is positive yelp sign.  If the patient yelps when I push, some structure there: organ, nerve, muscle, etc. is sick and needs further eval and tx.

[mtnmed]

The most recent intuss I saw was a kid brought in by parents just looking sorta sick.  Not really any specific belly pain.  Just vomiting, pale, ill-appearing, limpbizkit.  Often times these kids just make you sorta queezy which is enough to explore further or transfer to a place that can.  Pretty much every time I follow my gut with a pediatric patient who is sort of "borderline" it is generally right.