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Vomiting Infant

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 2-month-old male is brought to the ED for 4 days of vomiting.   He vomited a few times two days ago, then was better for two days, then it started again about 16 hours ago with the most recent episode bilious.  No fever or change in BM’s.

Vital Signs & Physical Exam:

Vital signs are normal.  Physical exam is otherwise normal

Initial Differential Diagnosis: 

  • Early gastroenteritis
  • Pyloric stenosis
  • Duodenal atresia
  • Intussusception
  • Malrotation

Relevant Test Results:

  • Labs: CBC, BMP and UA were normal
  • Imaging: See below of upper GI with iohexol (Omnipaque)

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows opacification of the stomach, duodenum, and jejunum with the ligament of Treitz and proximal jejunum located on the right consistent with malrotation. There is tapering of the proximal jejunum which spirals to the right lower quadrant in a corkscrew configuration. There is no evidence of small bowel obstruction.
  2. What should you do next?  Consult surgery, IV fluids and antiemetics
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient? See below

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: The patient was taken to the OR and surgery confirmed malrotation.

CASE LESSONS:

  1. Always consider other etiologies of vomiting in an infant than gastroenteritis and pyloric stenosis.
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