Infants with vomiting

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

GI disorders

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. 2. 3. 4. 5. 6. Ultrasound abdomen: to evaluate the presence of hypertrophic pyloric stenosis UGIS: to evaluate mechanical obstruction e.g. achalasia, pyloric stenosis, duodenal web, duodenal stenosis, anular of pancreas, malrotation with ladd's band, volvulus, and jejunal or ileal atresia Barium enema: to evaluate Hirshchsprung's disease EGD: to evaluate mucosal diseases in the stomach e.g. cow's milk allergy, eosinophilic gastroenteritis, reflux esophagitis Metabolic screening e.g. electrolytes, LFT, 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). However, because there was neither physical finding (abdominal mass) nor electrolyte abnormality (hypochloremic hypokalemic metabolic alkalosis) characteristic of hypertrophic pytoric stenosis, and because of the fact that the patient was a female other differential diagnoses should be considered. These include cow's milk allergy and eosinophilic gastroenteritis. An ultrasonography was performed and showed mild thickening of pyloric muscle (3.8 mm)(Fig. 1). During admission, the patient developed upper GI hemorrhage, therefore EGD was done to evaluate any feasible GI mucosal disorders. Reflux esophagitis and prolapse gastropathy were responsible for upper GI bleeding, The scope could be forcefully passed into the duodenum. There was a pyloric obstruction noted during the procedure. The pathology revealed no evidence of cow's milk allergy or eosinophilic gastroenteritis. An UGIS was finally confirmed the diagnosis of hypertrophic pyloric stenosis (Fig. 2).

Figure 1 An ultrasonography scans pyloric region. The markers are measuring the thickness of pyloric muscle, which is 3.8 mm.

Figure 2 An upper GI series demonstrates pyloric obstruction with a string sign. The findings are consistent with pyloric stenosis.

Case 2: Because of billous vomiting, an UGIS was carried out first. The intestinal malrotation is demonstrated as in figure 3 and figure 4.

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, which is supposed to be at the same level of the duodenal bulb. The finding indicate intestinal malrotation.

Diagnosis: Case no. 1: Hypertrophic pyloric stenosis; Case no. 2: Intestinal malrotation with Ladd's band Treatment: Case no.1: pyloromyotomy; Case no. 2: Lysis band Points of discussion
1. Vomiting during newborn period should be considered as pathological condition until proved otherwise. 2. Poor weight gain is an important clinical clue to exclude overfeeding or problems in feeding techniques. As noted

in our cases, both of them had failure to thrive. 3. Mode of inheritance in pyloric stenosis is multifactorial with male predominance (4-6:1). However, when female is affected, recurrence rate in all offspring is much higher than when male is affected (13% vs. 2.5-4%). Therefore, careful genetic counseling is very crucial. 4. A palpable abdominal mass in pyloric stenosis may be difficult to detect because of an overlying, dilated antrum. However, it can be more easily palpated after vomiting and gastric decompression. Overall, an experienced examiner could palpate a mass in only 60-80% of cases. 5. Electrolyte abnormality might not be present in all cases, particularly in a patient with short duration of the disease. 6. Billous vomiting is an important history that leads us to investigate for small bowel obstruction rather than gastric outlet obstruction. Therefore, the ultrasonography would not be useful in such case.