Nonbilious Vomiting in a 26 day-old

Nonbilious Vomiting in a 26 day-oldmanagement?

Chief Complaint:

Vomiting

History of the Present Illness:

A 26 day-old white female presents with a history of nonbilious vomiting for the past two days. The mother states that the patient has thrown up all of her feedings during this time. She has also noticed a decrease in urine output with only one wet diaper in the past 24 hours. Appetite is good and the child seems to be very hungry today. There has been one bowel movement in the past two days. There is no history of fever, rash, congestion, cough, or irritability. The sleep pattern has been unchanged. There are no other family members who are ill at home. Past medical history reveals this patient to be the first born product of an uncomplicated full term pregnancy and spontaneous vaginal delivery.

Physical Examination:

Vital signs are Pulse: 140 beats/minute, respirations: 36 breaths/minute, temperature: 98.3 F (rectal), and weight: 3.9 kg. General impression upon entering the room is of a non-toxic appearing white female who has just vomited a small feeding. The anterior fontanel is slightly depressed. Tympanic membranes are normal in appearance. Nares are clear without congestion. The oral mucosa is slightly dry, pink and without exudates. Neck is supple without adenopathy or meningeal signs. Chest is clear, with normal heart sounds. Abdomen is soft nontender without palpable masses. However, serial physical exam reveals a visible mobile mass which traverses the abdomen in approximately one minute. The mass begins in the left quadrant and moves to the right towards the midline (see photographs). The mobile mass recurs about every 3-5 minutes and is more pronounced after a feeding. Genitalia and extremities are normal. Skin shows no rash or cyanosis.

Laboratory analysis:

Complete Blood Count: WBC: 9.0, HCT: , HGB:12.5 g/dl; Chemistry: Sodium: 134 mmol/l, Potassium: 5.1 mmol/l, Chloride: 95 mmol/l, C02: 31 mmol/l, BUN: 15 mg/dl, GLU: 71 mg/dl, CR: 0.4 mg/dl.

Diagnosis:

Hypertrophic Pyloric Stenosis

Discussion:

Epidemiology

Hypertrophic Pyloric Stenosis (HPS) is a common condition of young infants with an incidence of 1 in 250 live births1. Males are afflicted four times more frequently than females. Firstborn males are prone to developing HPS whereas firstborn females are not. A positive family history is commonly present. Up to 20% of sons and 7% of daughters may be afflicted if the mother has had HPS, compared with 5% of sons and 2.5% of daughters when the father is the affected parent2.

Pathophysiology

The classic picture of HPS results from hypertrophy of the circular musculature surrounding the pylorus causing severe constriction with subsequent gastric outlet obstruction and hyperperistalsis of the stomach. Although in the vast majority of cases HPS develops postnatally in a progressive manner, it has been documented in the newborn at birth3. This early occurrence has been cited as evidence that HPS may have a congenital rather than acquired etiology. A genetic defect with lack of nerve supply to the circular muscle and decreased levels of nitric oxide synthetase, an enzyme that relaxes smooth muscle, has been postulated as a possible underlying basis for the disorder4.

Clinical Findings

The diagnosis of HPS should be considered in any young infant who presents with nonbilious projectile vomiting5-9. However projectile vomiting may not be present early in the presentation since it usually develops over several days. The classical presentation is a 2-6 week otherwise healthy infant with nonbilious projectile vomiting after feeding5 . The infant appears hungry and will readily accept another bottle with subsequent postprandial emesis, often within 5-10 minutes. The degree of dehydration and electrolyte imbalance on presentation is variable, but may require rapid intervention depending upon the duration of symptoms. On physical exam, the diagnostic features of HPS include a visible peristalsis (Figure 2) and a palpable pyloric bulb or 'olive'. The peristaltic gastric wave may not be obvious if the stomach remains empty7. The olive is reported to be palpable in up to 85% of patients and may be found on gentle physical examination in the area of the epigastrium towards the right upper quadrant9. Success in palpating the olive is dependent on the thickness of the hypertrophied pylorus, the condition of the stomach at the time of exam (full vs. empty), and the skill of the examiner in obtaining a gentle exam. Placing the infant on his abdomen in the prone position and gently palpating upward in the right epigastrium is a recently revived technique which may improve detection10.

The usual presentation of HPS is less clear however, and the diagnosis often is confirmed with ancillary diagnostic imaging studies (see below). Persistent severe vomiting results in the loss of hydrogen and chloride ions, which are present in large amounts in gastric secretions. Additionally, the kidneys compensate by conserving sodium and wasting potassium in response to the volume loss from vomiting. Thus laboratory abnormalities, when present, typically show a hypochloremic, hypokalemic metabolic alkalosis1 .

Differential Diagnosis/Diagnosis

Although most etiologies are self-limited and benign, the differential diagnosis of emesis in the newborn period (or during early infancy) is broad and deserves consideration (see table9). Disorders which may be commonly confused with HPS include poor feeding technique, gastroesophageal reflux, gastroenteritis and pylorospasm7. The diagnosis of HPS is confirmed on physical exam with the classical physical findings noted above. When these are present, further diagnostic studies are unnecessary. In cases where the physical findings are not diagnostic, a period of observation is warranted with serial examinations and feeding the infant to watch for projectile vomiting. If the infant appears dehydrated, fluid resuscitation and laboratory analysis to guide therapy is indicated. Children with protracted symptoms may present with severe dehydration and require aggressive resuscitation and evaluation for sepsis. A child with mild symptoms of recent onset who, after observation, is able to tolerate PO, may be discharged with close follow-up to re-evaluate the course of the illness. For those without diagnostic physical findings, yet are observed to have persistent, nonbilious projectile vomiting, further workup with diagnostic imaging is indicated.

Diagnostic Imaging

When physical findings suggest but do not substantiate HPS, the diagnosis is confirmed with either barium swallow, which shows gastric outlet obstruction (elongated pyloric channel 'string sign') or ultrasonography (US). The latter, now almost universally available, is generally preferred because it is noninvasive and does not carry the risks of aspiration. However preferences for using US versus barium swallow may be institutionally based depending on cost and availability of resources. Ultrasound characteristically shows a target or bulls-eye lesion. Although the sonographic criteria for the diagnosis of HPS are generally accepted (pyloric muscle hypertrophy on both cross-sectional (overall diameter >8mm , wall thickness >3mm), and longitudinal images (canal length >15mm)3, there is some controversy in the relative utility of these measurements. There is evidence to suggest that the width (wall thickness) of the pylorus (>3.0 mm) is the most reliable sonographic measurement. However, in one series, up to 26% with a pyloric width between 2.0 and 3.0 mm were shown to have HPS as confirmed by a contrast study11. Consequently, babies in this equivocal zone are either observed with follow-up US examinations during conservative management, or a barium swallow is performed immediately after the initial US12.

Management

Emergency Department management consists of keeping the child NPO, replacing fluid and electrolyte deficits with an initial fluid bolus followed by maintenance fluids and obtaining early surgical consultation. Definitive treatment is elective pyloromyotomy1 .

Clinical Pearls

1. Clinical suspicion of Hypertrophic Pyloric Stenosis can be heightened with serial exams and observing the child after oral fluid challenges for persistent nonbilious projectile vomiting.

2. The diligent examiner may see gastric peristaltic waves periodically traversing the abdomen from the left quadrant to the midline as seen in the photographs.

3. Palpation of the 'olive', although sometimes difficult, is facilitated by examining the patient in the prone position, with an empty stomach, either immediately after emesis, or after emptying the stomach with a nasogastric tube.

4. Use normal saline for fluid boluses as lactated ringers solution may exacerbate or delay resolution of the alkalosis. Add supplemental potassium to maintenance fluids once intravascular volume had been restored.

5. Correction of electrolyte imbalance should occur prior to surgery, thus emergent surgery is contraindicated in the dehydrated, hypokalemic, hypochloremic alkalotic infant

An obviously intoxicated 50-year-old white male is brought to the emergency department after the car he was driving hit a telephone pole. He has a fracture of the femur, and is confused and uncooperative. He is hemodynamically unstable. Initial physical examination of his abdomen does not indicate significant intra-abdominal injury.

Which one of the following would be best for determining whether laparotomy is needed?


a.Peritoneal lavage
b.Contrast duodenography
c.Ultrasonography of the abdomen
d.An MRI scan of the abdomen
e.A CT scan of the abdomen

A

Physical examination of the abdomen is often unreliable for detecting significant intra-abdominal injury, especially in the head-injured or intoxicated patient. In a hemodynamically unstable patient with a high-risk mechanism of injury and altered mental status, peritoneal lavage is the quickest, most reliable modality to determine whether there is a concomitant intra-abdominal injury requiring laparotomy. Computed tomography of the abdomen and contrast duodenography may complement lavage in stable patients with negative or equivocal lavage results, but in an unstable or uncooperative patient these studies are too time-consuming or require ill-advised sedation. Ultrasonography may also complement lavage in selected patients, but its usefulness is limited in the acute situation. Magnetic resonance imaging is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma.

A 72-year-old white farmer presents to your office with an enlarging raised lesion on the dorsum of his hand. It appears to be arising from an area of actinic keratosis.

Due to its location you suspect which one of the following?

a.Squamous cell carcinoma
b.Psoriatic plaque
c.Malignant melanoma
d.Keratoacanthoma
e.Basal cell carcinoma

A

Squamous cell carcinoma is often seen on the dorsum of the hand, and may arise from an area of actinic keratosis. Although basal cell carcinoma and malignant melanoma are sunlight-related diseases, they are not often found on the dorsum of the hand and do not arise from actinic keratoses; this is also true of keratoacanthoma and psoriatic plaques.

While repairing a window, a 42-year-old white male suffers a puncture laceration to the palm, transecting the superficial flexor tendon of the ring finger with no other significant injury. To diagnose this tendon injury you should



a.observe the posture of the fingers of the supinated hand on the examination table
b.explore the wound using a bright light while an assistant sponges the wound dry
c.passively hyperextend the other fingers and ask the patient to actively flex the affected finger
d.ask the patient to flex the ring finger while resistance is applied to the volar surface of the distal phalanx

C

The injury described in this question is easily overlooked by the uninitiated. The intact superficial flexor tendon flexes the proximal interphalangeal joint independently when deep flexor function is inhibited, as it would be by passive hyperextension of the other fingers. Applying resistance to the volar surface of the distal phalanx would test deep flexor tendon function. Posture of the fingers may not be affected by this injury. Exploration of the palm should be done with a tourniquet, and is not generally done by family physicians.

A patient complaining of unilateral decreased vision is noted to have equal pupils in dim light. When you shine a bright penlight into the unaffected eye both pupils constrict briskly, but when you swing the light into the affected eye both pupils dilate.

This is a sensitive diagnostic indicator of which one of the following?


a.Optic nerve lesion
b.Anisometropia
c.Early glaucoma
d.Malingering
e.Cataract formation

A

It is helpful to decide whether patients with visual loss have a disease process involving structures of the globe or of the optic nerve and its central radiations. If loss of vision is secondary to an optic nerve lesion, there will be an afferent pupillary defect on the symptomatic side, demonstrated by the swinging light test. This failure to sustain pupillary constriction is sometimes referred to as the Gunn pupil sign. Visual loss of functional cause or that related to ocular disease rarely affects the pupillary light reflex. In elderly patients the cause may often be infarction of the optic nerve due to temporal arteritis, arteriosclerosis, or emboli. In young adults optic neuritis is often associated with multiple sclerosis.

A 23-year-old woman who was the driver of a car struck in the rear by another car while she was stopped at a red light presents to the emergency department with neck pain as well as discomfort in the axilla, upper arm, elbow, dorsal forearm, and index and middle fingers. Coughing exacerbates the pain. Neurologic examination reveals weakness in the right second and third fingers, forearm, and wrist. The right triceps reflex is diminished. The most likely diagnosis in this case is

A syringomyelia
B cervical sprain
C thoracic outlet syndrome
D cervical disk herniation
E brachial plexopathyA 23-year-old woman who was the driver of a car struck in the rear by another car while she was stopped at a red light presents to the emergency department with neck pain as well as discomfort in the axilla, upper arm, elbow, dorsal forearm, and index and middle fingers. Coughing exacerbates the pain. Neurologic examination reveals weakness in the right second and third fingers, forearm, and wrist. The right triceps reflex is diminished. The most likely diagnosis in this case is

A syringomyelia
B cervical sprain
C thoracic outlet syndrome
D cervical disk herniation
E brachial plexopathy

The answer is D
Herniation of a lower cervical disk may be due to trauma, especially in the setting of neck hyperextension. If the disk herniates laterally, it generally will compress the nerve route exiting the lower of the two vertebrae that account for the intervertebral space. For example, if the disk between the fifth and sixth cervical vertebrae herniates, the full syndrome will be characteristic of a C6 radiculopathy: pain in the trapezius, shoulder, radial forearm, and thumb; absent biceps reflex; and preserved triceps reflex. A C7 radiculopathy caused by a disk protruding between the sixth and seventh cervical vertebrae will produce the following: pain in the shoulder blade, pectoral and medial axillary region, upper arm, elbow, dorsal forearm, and index and middle fingers; paresthesia and sensory loss in the second and third fingers or the tips of all the fingers; weakness in forearm and wrist extension as well as hand grip; and a preserved biceps reflex but a diminished triceps reflex. Coughing and sneezing often exacerbate the pain caused by a herniated cervical disk. Unlike the lateral disk syndromes mentioned above, a disk that herniates centrally may be painless but cause symptoms in the lower extremities.

A 28-year-old African-American male is hemorrhaging massively from multiple injuries sustained in an automobile accident. He has responded only transiently to 8 liters of lactated Ringer's solution started by paramedics in the field and continued in the 20 minutes since his arrival in the emergency department. His blood pressure is 60/40 mm Hg. A surgeon is preparing for emergency abdominal exploration.

While the operating room is being prepared and the anesthesiologist is traveling to the hospital, you should administer



a.calcium bicarbonate
b.dopamine
c.type O whole blood
d.type-specific saline crossmatched blood
e.additional lactated Ringer's solution until fully crossmatched blood is available

D

When blood is administered, fully crossmatched blood is always preferable, but this takes an hour or longer. In patients with severe hemorrhage, type-specific saline crossmatched blood is usually available in less than 10 minutes and is the first choice for patients in life-threatening shock, in spite of the possibility of minor antibodies. If type-specific blood is unavailable, type O packed red blood cells are indicated. This patient is severely volume-depleted and vasopressors are not indicated, nor is there any reason to give calcium supplements

A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of.

In such cases the best approach would be to



a.freeze the site with liquid nitrogen
b.perform an elliptical excision as soon as possible
c.use electrocautery to destroy the lesion and the surrounding tissue
d.perform a shave biopsy, with a recheck in 2 months for signs of recurrence
e.perform a punch biopsy and have the patient return if the biopsy indicates pathology

B

Despite this individual's busy schedule, he has a potentially life-threatening problem that needs proper diagnosis and treatment. Though an excisional biopsy takes longer, it is the procedure of choice when melanoma is suspected. After removal and diagnosis, prompt referral is essential for further evaluation and therapy. A shave biopsy should never be done for suspected melanoma, as this is likely to transect the lesion and destroy evidence concerning its depth, thus making it difficult to assess the prognosis. A punch biopsy should be used only with discretion in suspected melanoma, when the lesion is too large for complete excision, or if substantial disfigurement would occur. Since this may not actually retrieve cancerous tissue from an unsampled area of a large lesion that might be malignant, it would be safest to refer such a patient. Neither cryotherapy nor electrocautery should be used for a suspected melanoma.

A 42-year-old white female has a 5.0x7.0-mm pigmented lesion removed from the skin of the dorsal thorax by excisional biopsy. The width of the surgical margins is 4.0 mm and the excision extends to the subcutaneous fat. There are no satellite lesions, no palpable regional lymph nodes, and no distant metastases. The pathology report reads, 'Malignant melanoma, 0.65 mm thick by Breslow measurement technique. All specimen margins are free of tumor.'

Which one of the following is most appropriate at this time?


a.No further treatment
b.Wide reexcision
c.Chemotherapy
d.Radiation therapy
e.Immunotherapy

B

Complete surgical excision remains the best hope for cure of early melanoma. A 3.0-cm margin is now the widest recommended, even for deep lesions. Shallower lesions such as this one (less than 0.8 mm thick) may even be excised satisfactorily with a 1.5-cm margin.
Immunotherapy is still investigational and is not used for lesions such as this in which metastases occur very rarely. Radiation therapy is not very successful in the treatment of melanoma. Its main use is palliation in disease metastatic to bones or the central nervous system. Chemotherapy is not very effective in melanoma, and is used only in widely disseminated cases.