Rachel O’Brian, MD  Inova Children’s Hospital

The Case:
3 mo ex-FT infant who presented with acute onset fussiness and emesis. Emesis was reportedly non bilious at home but a witnessed episode by the pediatrician was noted to be bilious. Initial workup at an OSH included an unremarkable complete blood count, abdominal xray, and pyloric ultrasound. Upon arrival to our center, he was notably comfortable with an unremarkable exam.

Here’s How You Answered Our Questions:

Discussion:

Vomiting is a sign that can range from a completely normal behavior for a newborn to an ominous sign. It is our job to make that distinction and sometimes not a very easy one. Especially when the appearance is questioned! Bilious or non bilious, that is the question. Although how comfortable can you really feel in trusting a lay person to distinguish between the two. My opinion is often times not! In fact, there was a study done in the UK in 2008 whereby the staff of a tertiary neonatal center were shown pictures and asked to decipher bilious vs non bilious. About 44.8% identified yellow aspirates as bilious emesis. Proving that it is not as straightforward as we believe it to be.

All in all, the polling showed that everyone was on the same page. The larger dilemma seemed to be whether people would choose to continue to allow this child to feed or remain NPO. As Dr. Chamberlain eluded, we have not yet proven this is not a surgical abdomen and although malrotation and volvulus have been ruled out with an UGI series, distal bowel obstruction is still on the differential. He advised that the patient be admitted NPO with an NGT/OGT placed and monitored for output with repletion as needed.

Dr. O’Connell reminded us that late onset GBS is in the running as a differential diagnosis and the complaint of “fussiness” from the parents should not be taken light heartedly. Late onset GBS sepsis should be considered from day 7 to 3 months of life. She also stated that by 3 months of age, most parents have a grasp of what is “normal” for their child and if they are saying something is off and can not quite describe it, they need to be heard. Parents intuition is real and should not be always be taken at face value. The complications from GBS meningitis can be devastating if missed and should be considered. Nonetheless, everyone was in agreement that this child needed to be admitted for further workup and observation as well as serial abdominal examinations to assess the progression of illness.

Denouement:

The patient was admitted to the hospital for further workup and evaluation after a failed PO trial in the ED. Radiology had suggested serial abdominal xrays to track the course of the contrast as it traverses the bowel. This revealed that contrast had partially traversed the small bowel, but did not extend into the distal colon.  The small bowel was extremely dilated and on exam the patient’s abdomen was distended but still soft and appeared to be tender to palpation.

The patient was taken to the OR for an ex-lap due to concern for small bowel obstruction and was found to have an incarcerated Meckel diverticulum with ischemic small bowel needing partial resection.

There was a case report published this year that described 2 case reports of children with bowel obstruction from a mesodiverticular band (MDB). A MDB is an embryologic remnant of the vitelline circulation and in the event of improper involution, a band persists and extends from the mesentery to the apex of the antimesenteric diverticulum. Thus, creating an opening through which bowel loops may herniate and become obstructed.

https://www.ncbi.nlm.nih.gov/pubmed/29145243

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