Hot Seat Case #103: 3 mo infant with bilious emesis
Posted on: November 27, 2017, by : Rachel O'Brian
Rachel O’Brian, MD Inova Children’s Hospital
with Karen O’Connell , MD Children’s National Medical Center
3 month ex FT male with no significant PMH presented with emesis. He was in his usual state of health until the day of evaluation when he was less active and more fussy. He was difficult to arouse after his morning nap and had 2 episodes of non bilious projectile emesis after feedings. Mother alternated between breastfeeding and Enfamil, but no recent changes and only noted one wet diaper today.
He was taken to his PMD where he had a witnessed episode of bilious emesis, thus advised to go to the ED. At the local ED, his workup was unremarkable and included: complete blood count, Pyloric US, Abdominal XR. He was transferred for further workup.
ROS: No fevers, cough, congestion, sick contacts, or recent travel. He has been growing and developing.
Birth Hx: FT, NSVD, GBS + and treated prior to delivery. Partial sepsis evaluation of infant negative. Unknown birth weight.
FHx: Paternal uncle: Hypertension, Maternal Aunt: Asthma
Meds: None
Exam: T 99.2 °F BP 100/56 HR 140 RR 48 O2sat 98% Wt 4.8 kg
General: Alert, well-appearing, comfortable in bed
HEENT: AFOF, PERRLA/EOMI, MMM, No LAD
CV: RRR nml s1, s2 no m/g/r, WWP, CR<2 sec, +2 pulses b/l
Pulm: CTA b/l – no wheezes/crackles/flaring/retractions
Abd: Soft abdomen, ND. No HSM appreciated. No flank/CVA/back tenderness.
No rebound or guarding.
MSK: Moves all extremities b/l, no deformity
SKIN: Moist. No rash, no pallor
NEUROLOGICAL: Alert, strong suck, normal tone
Labs return as:
BMP: 135/5.2/109/17/10/0.4
Glu 131
AST 27, ALT 8, alk phos 63, T bili 0.4, T protein 2.9, albumin 1.8
Upper GI shows significant gastroesophageal reflux. Structurally normal. Nonspecific bowel gas pattern. Parents attempt to feed patient after which he has a large volume NB/NB emesis.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
The physical exam findings on this child seem very reassuring. It sounds like we’ve ruled out major anatomic causes of bilious emesis in an infant – the normal ultrasound and upper GI series certainly make pyloric stenosis, obstruction, and malrotation unlikely. However, the case seems to raise the concern of persistent and severe symptoms, and given only one wet diaper today, I would err on the side of admission with observation of feeds / weight gain (without IV fluids).
This would also allow for further testing if warranted. If I remember correctly, persistent vomiting is usually associated with hypokalemia, not hyperkalemia. The low Na and elevated K could be associated with adrenal crisis. I would assume that there would be earlier findings of congenital adrenal hyperplasia, and there is no reported history of recent illness that could have precipitated an adrenal crisis, but it’s something to keep on the differential if symptoms persist and/or worsen.
This child is startlingly hypoalbumenemic. I don’t think I’ve heard of this being associated with reflux before, especially not reflux that that started 2 days ago.
Hypoalbuminemia is typically associated with malnutrition, protein loss, or inflammation (acute or chronic). This baby is just below the 10% for weight and we don’t know his birth weight, but he isn’t noted to be cachetic on exam, so malnutrition seems unlikely. This makes me worried for some sort of underlying inflammatory state (eosinophilic esophagitis?). That or the parents are quite poor historians and this baby has been throwing up for some time!
This finding, plus that the baby cannot tolerate feeds by mouth tell me he needs to be admitted.
So I agree with our astute colleagues that the physical exam and work up done so far are somewhat reassuring. Major metabolic arrangements and anatomic GI abnormalities do not appear to be the case here (so far- though I’m always cautious with a single lab value without a trend over time.) I was also surprised by the low albumin, which needs to be repeated or further worked up if it is a true value. It’s hard to say if this child is gaining weight and if the child is appropriately fed at home. The reported decreased urine output makes me wonder if the infant has not been taking enough PO over the previous 24 hours or is not making urine due to other systemic or renal causes. I agree that the symptoms may not have started on the day of presentation.
With that being said, I have a few other concerns when evaluating a patient of this nature. The initial complaint of being difficult to arouse after a nap is a bit unusual in this age, specially if that stands out to a parent. At three months most infants have established a routine of eating and sleeping and are easily arousable. The two episodes of non– bilious emesis are quite nonspecific: could be an early gastro, occult SBI (not febrile yet), early pyloric stenosis, overfeeding with an episode of reflux, early metabolic derangement, or an intracranial process (eg. – abusive head trauma.) My specific question to the mom would be about the quality of his suck/swallow and tone during the feed after his nap.
Once he had an episode of bilious emesis at pmd’s, he was appropriately referred.
In the OSH ED, the start of his work up was appropriate, but clearly needed to be transferred for an UGI to rule out malrotation with intermittent volvulus. If I was considering occult SBI (which is on my differential), I would add a blood culture and check UA/urine culture, and most definitely consider doing an LP given that mom was GBS+ despite being a well-appearing, afebrile infant. Late onset GBS is a force to be reckoned with. GBS meningitis remains the most common cause of neonatal sepsis and meningitis for non-preterm/non-low birth weight infants despite intrapartum prophylaxis and still accounts for up to 40% of all neonatal infections. Universal GBS screening and maternal antibiotics has reduced the incidence of early GBS infections over the course of the last 2 and 1/2 decades, but the incidence of late onset GBS remains unaffected [Berardi A et al, Pediatr 2013; Schrag SJ, Verani JR, Vaccine 2013]. One of several studies showed that up to 42% of infants with late onset GBS infection had maternal pre-treatment. [Glasgow et al. Pediatr 2005.]
This infant was well appearing and afebrile, so I’m not going to jump the gun and grab the LP needle quite yet! I do think he deserves an admission for IV fluids and observation for fever, mental status checks and for PO intake. Something about this case just does not add up- that is when my gut tells me to admit this child and watch for the development of worsening symptoms or disease progression.