Suzanne Bailey Friday 8/5/2011

0630:

child arrives from OSH c hematochezia and hypovolemic shock Healthy 7 mo 5 d of URI, tactile fevers Fussy x24 hours 1 episode of NBNB emesis in evening 0100: small amt of blood in diaper 0400: fussy, large amt of blood in diaper Taken to Local Outside Hospital

 Cyanotic HR

and lethargic

200 Hct: 22? 28? pH 7.17, bicarb 13, glu 400 NS 40ml/kg Started 10ml/kg of PRBCs

 Persistent Poor

tachycardia

color Awake Completed 10ml/kg of PRBCs Otherwise uneventful transport

 PMH:

full term, NSVD. No complications. No hosp. No surgeries. Diet: Similac formula, bottled baby water. Store bought baby food. Occasional rice and homemade pasta and soups. MEDS: None ALL: NKDA IMM: UTD

 FHX:

paternal cousin c leukemia, dxd 12yo. Grandfather c leukemia.

No IBD, autoimmune conditions, infectious bowel

issues.
Social:

Lives c mom and extended fam. Dad is incarcerated. Spanish speaking.

 Exposures:

No travel outside Utah. No petting zoos, livestock or other animals. No undercooked beef/chicken.

No unpasteurized dairy.
1 day PTP: rice that had been cooked 72 hr prior,

refrigerated and then reheated in microwave

 Vitals: ED: afebrile, HR 190s T 36.8, HR 166, RR 20, BP 78/58, Sats 97% RA Height and weight: appropriate for age GEN: pale, tired, eerily calm

HEENT:

AFOSF. NC/AT. PERRL. Conjugate gaze. TMs nml. OP clear c no lesions. Has a few erupting teeth. CV: tachy. No murmur. Peripheral pulses 1+, femoral pulses 2+. CR 3 secs PULM: CTAB. No increased WOB.

ABD: NBS. Soft. Mildly distended but apparently NTTP. Liver edge 1 cm below costal margin. No palpable spleen. GU: uncircd, testes down bilaterally. Normal rectal tone with blood on glove. EXT: mildly cool compared to core, moving all 4 SKIN: 1.5x2cm irregular, hyperpigmented macule on chest.

No rashes, birthmarks, bruises, petechiae, purpura

Neuro: occasionally fussy but otherwise seems sedated. tracks visually. Grossly nml strength and tone.

Infection
Shigella, Salmonella, Campylobacter, E. coli, Yersinia, C. diff, N. Gonorrhea, C.

trachomatis, HSV, beta hemolytic strep

OP trauma Esophagitis Gastritis: think about NSAIDS Meckel diverticulum

With or without volvulus or intussussception

Intussussception Malrotation/Volvulus Inflammatory bowel disease Vascular malformation Vasculitis

HSP

Infants: NEC, Hirschsprungs, swallowed maternal blood Older kids/adults: Anal fissures, hemorrhoids Milk or soy induced colitis Lymphonodular hyperplasia GI duplication Abuse

Ramsook, C and E Endom. Diagnostic approach to lower gastrointestinal bleeding in children. Up-to-date. September 30, 2010.

 0721:

pH 7.25, CO2 32, bicarb14 WBC 24.7 (16B, 54N, 24L), Hct 37.4, Plt 195 INR 1.7, PTT 19.7, PT 38 CMP: K 5.1, Cl 112, CO2 16, Glu 318, Ca 7.8, Prot 4.2, T bili <0.1, AST 52 UA: unremarkable, 2 WBC, neg bacteria LDH 1717 (425-975)

 E.

coli negative C. diff negative Yersinia culture negative Stool culture: nml enteric flora Blood, urine cultures NG

 KUB

0720: NS bowel gas pattern, no pneumatosis, no free air Abd XR 0806: no free air U/S 0814: no intussusception, diffuse wall thickening small bowel U/S 1240: diffuse thickening sm bowel and colon

 ED: ICU

grossly bloody diaper

Ultrasound versus CT Pressors

Broad spectrum antibiotics

Serial abdominal exams and KUBS
GI:

Meckel scan negative One additional bloody diaper Repeat imaging:

KUB 1838: relatively gasless abd, no pneumatosis Abd XR 2302: no pneumatosis or pneumoperitoneum

 Surgery

consulted 0400: felt that abd exam was worsening CT abd: malrotation with volvulus, L sided colon OR: Diffusely necrotic bowel. Closed. Returned to ICU intubated. Support withdrawn and pt died at 2100.

 Hemodynamically stable? HR, BP, pallor, CR Is blood present? Guaiac leukodye causes oxidative rxn when

blood is present; can have

false + (oxidative rxn) False (vit C even small amt, out of date cards or specimen)

Looks like blood: iron, licorice, blueberries,

spinach, beets, pepto, lead, charcoal, dirt, swallowed non-human blood

Figure 1. Red stool, guaiacpositive. Intussusception

Figure 2. Red stool, guaiacnegative. Cake frosting ingestion.

Figure 3. Red stool, guaiacnegative. Cefdinir-Iron Interaction

Figure 4. Red stool, guaiacnegative. Kool-Aid Ingestion

Lowers, J, et al. Visual diagnosis: four infants who have red, bloody stools. Peds in Review. 2009;30;146-149

 Identify the source History: pain?, rash?, medications (including

NSAIDS), foods, time course, trauma, h/o surgery, FHx of polyps, B symptoms Exam: nares, mouth, enlarged liver, s/s liver dysfct s/s trauma, hemangiomas, pigmented lesions? Labs: CBC, coags, liver fct Radiology: plain film, contrast radiography (interferes with endoscopy), nuc med scans Endoscopy: upper, lower, both surgery?

 Anatomic

abnormality

Arrest of nml rotation and mesenteric fixation or

embryonic gut (5-10th week) Colon on left side, narrow based mesentery fixed by adhesions called Ladd bands on right

http://www.pedisurg.com/pteduc/ma lrotation.htm

 1:200-500 live births, symptomatic 1:6000 Symptoms in first month in 64%, first year 82% Associated

anomalies: duodenal atresia (50%), jejunal atresia (33%), CDH, gastroschisis, omphalocele

 Can

cause

Obstruction impingement by Ladd bands Midgut volvulus twist on mesenteric stalk Both can occur intermittently
Diagnosis

High index of suspicion X-ray, UGI, CT, U/S, barium

enema
http://www.google.com/imgres?q=malrotation+with+volvulus&hl=en&gbv=2&tbm=isch&tbnid=NstGqHQ9cjt3ZM:&imgrefurl=http://www.ped iatricsurgerymd.org/AM/Template.cfm%253FSection%253DList_Of_Conditions%2526TEMPLATE%253D/CM/ContentDisplay.cfm%2526C ontentID%253D1567&docid=zTj1JmDIk3bKoM&w=200&h=327&ei=hJE4TqyBFobbiAKpqOXIDg&zoom=1&iact=hc&vpx=956&vpy=82&dur =50&hovh=261&hovw=160&tx=85&ty=132&page=1&tbnh=114&tbnw=70&start=0&ndsp=25&ved=1t:429,r:6,s:0&biw=1280&bih=551

 Treatment

Surgery Ladd procedure Lysis of adhesions, widening of mesenteric base, positioning in non-rotated position, appendectomy, resection of any necrotic bowel Should be done prophylactically if malrotation is dxd to prevent volvulus

http://www.ispub.com/journal/the_internet_journal_of_surgery/volume_26_numb er_1_1/article_printable/nonrotation-of-midgut-loop-a-rare-cause-of-recurrentintestinal-obstruction-in-adults-case-report-and-review-of-literature.html

Cribbs, R, et al. Gastric volvulus in infants and children. Peds in Review. 2008;122;e752. Hall, C, et al. Index of suspicion. Peds in Review. 2008;29;25-30. Lowers, J, et al. Visual diagnosis: four infants who have red, bloody stools. Peds in Review. 2009;30;146-149 Ramsook, C and E Endom. Diagnostic approach to lower gastrointestinal bleeding in children. Up-todate. September 30, 2010. Squires, R. Gastrointestinal Bleeding. Peds in Review. 1999;20;95-101.