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Prepared by.........Nuthapong Ukarapol , M.D.
CC : Two infants were referred to the hospital because of vomiting. Clinical presentations Age Sex Birth weight Body weight on admission Onset of symptoms Characteristic of vomitus Abdominal mass Abdominal distension History of meconium passage Feeding Initial investigations Investigations Sodium Potassium Chloride TCO2 Plain abdomen Case 1 141 5.3 109 19 Case 2 139 5.3 108 18 Case 1 3 weeks Female 2700 grams 3080 grams 5 minutes after feeding Digested milk Negative Present within 24 hours Formula Case 2 4 weeks Male 2700 grams 2750 grams 5- 30minutes after feeding Digested milk with bile Negative Present within 24 hours Breast feeding
dilated stomach with small air in the dilated stomach with fair small intestine amount of air in the small intestine
What are the differential diagnosis for an infant with vomiting?
Group GI obstruction Pyloric stenosis Duodenal obstruction Malrotation with intermittent volvulus Hirschsprung's disease Gastroenteritis Gastritis/duodenitis (CMA) Eosinophilic/allergic esophagitis Gastroparesis Achalasia Diseases
because there was neither physical finding (abdominal mass) nor electrolyte abnormality (hypochloremic hypokalemic metabolic alkalosis) characteristic of hypertrophic pytoric stenosis. reflux esophagitis Metabolic screening e. However.g. LFT. pyloric stenosis. achalasia. cow's milk allergy. eosinophilic gastroenteritis. malrotation with ladd's band. Reflux esophagitis and prolapse gastropathy were responsible for upper GI bleeding. 2. 6.8 mm)(Fig. and because of the fact that the patient was a female other differential diagnoses should be considered. There was a pyloric obstruction noted during the procedure.Neurologic conditions Infections Metabolic/endocrine disorders Hydrocephalus Mass lesions Meningitis/sepsis Urinary tract infection Urea cycle defect CAH Galactosemia Organic acidemia Iron Vitamin A or D Toxic substances What is/are the investigations for an infant with vomiting? 1. The scope could be forcefully passed into the duodenum. and jejunal or ileal atresia Barium enema: to evaluate Hirshchsprung's disease EGD: to evaluate mucosal diseases in the stomach e.g. 2). During admission. urine reducing substances in suspected cases Neuroimaging studies: to evaluate increased intracranial pressure in suspected cases Discussion and disease progression Case 1: This was a female newborn presenting with nonbillous vomiting. The initial diagnosis was gastric outlet obstruction (hypertrophic pyloric stenosis). . These include cow's milk allergy and eosinophilic gastroenteritis. 4. duodenal web. An ultrasonography was performed and showed mild thickening of pyloric muscle (3. therefore EGD was done to evaluate any feasible GI mucosal disorders. An UGIS was finally confirmed the diagnosis of hypertrophic pyloric stenosis (Fig. The pathology revealed no evidence of cow's milk allergy or eosinophilic gastroenteritis. anular of pancreas. volvulus. 1). the patient developed upper GI hemorrhage. 3. 5. electrolytes. Ultrasound abdomen: to evaluate the presence of hypertrophic pyloric stenosis UGIS: to evaluate mechanical obstruction e. duodenal stenosis.g.
Vomiting during newborn period should be considered as pathological condition until proved otherwise. As noted .8 mm.Figure 1 An ultrasonography scans pyloric region. which is 3. Figure 2 An upper GI series demonstrates pyloric obstruction with a string sign. 2: Lysis band Points of discussion 1. 2: Intestinal malrotation with Ladd's band Treatment: Case no. The markers are measuring the thickness of pyloric muscle.1: pyloromyotomy. The intestinal malrotation is demonstrated as in figure 3 and figure 4. which is supposed to be at the same level of the duodenal bulb. Case no. 2. Fig 3 An upper GI series reveals a point of obstrution at the fourth part of the duodenum Figure 4 An upper GI series demonstrates malposition of the DJ junction. 1: Hypertrophic pyloric stenosis. The finding indicate intestinal malrotation. Case 2: Because of billous vomiting. Poor weight gain is an important clinical clue to exclude overfeeding or problems in feeding techniques. Case no. The findings are consistent with pyloric stenosis. Diagnosis: Case no. an UGIS was carried out first.
However. Therefore. Mode of inheritance in pyloric stenosis is multifactorial with male predominance (4-6:1). 5. However. recurrence rate in all offspring is much higher than when male is affected (13% vs. 2.5-4%). both of them had failure to thrive. careful genetic counseling is very crucial. A palpable abdominal mass in pyloric stenosis may be difficult to detect because of an overlying. dilated antrum. Electrolyte abnormality might not be present in all cases. an experienced examiner could palpate a mass in only 60-80% of cases. 6. the ultrasonography would not be useful in such case. particularly in a patient with short duration of the disease. it can be more easily palpated after vomiting and gastric decompression. Therefore. when female is affected. . Billous vomiting is an important history that leads us to investigate for small bowel obstruction rather than gastric outlet obstruction. 4.in our cases. Overall. 3.