Pediatric Case of the Week 10 Big Time Vomit

You are working another overnight shift at a brand new, cutting edge, suburban Urgent Care / Emergency Department.

Around 2 am, just after calling to taunt a disgruntled colleague at the "mothership"; the nurse alerts you that your next patient just sprayed vomit across the waiting room.

"Literally ACROSS the waiting room"



The patient is a 4 week old male infant with a chief compliant of "vomiting for 4 days."  Mom says that the vomiting has gotten progressively worse and now seems to SHOOT out of  his mouth like a "fire hose." The vomiting seems to occur after feeding.  The caliber of vomit has increased and now seems to entail his entire meal.  The vomit is described as non-bilious/non-bloody.  After the episode the infant remains hungry and willing to feed. No history of fever, coughing, or diarrhea.  The infant was term. Mom also notes that he seems less active and has had fewer wet diapers and less stool.

VS: Temp 98.6   HR 171  BP 80/60   RR 49  Sat 99% RA     Ht 50%  Wt 25%  Length 50%

Physical exam: Well developed, well nourished, mild distress but consolable.  HEENT normal except for his lips which are a little dry.  Neck is supple. Heart tachycardia without murmur.  Lungs clear.  Abdomen is slightly distended with active bowel sounds, no palpable mass. No hernias and genitalia are normal. Skin is normal pink without tenting.



What is your differential diagnosis?

What kind of fluid would you give?

How much fluid would you give?

Would you get labs?

Would you get imaging?

If so, what test?





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WEEKEND UPDATE:




Ready, Fire, Aim 
Pyloric stenosis is correct! 

Most infants with pyloric stenosis present at 3-6 weeks (rarely after 20 weeks.)  The important history: projectile during or shortly after feeding.  The vomit is always described as nonbilous which reflects the location of the obstruction.

Warning, we are about to briefly review anatomy.  Those at risk for post traumatic med-school flashback phenomenon should avoid reading the following italicized text: The hypertrophied pylorus does not allow contents from the duodenum, which receives bile drainage from the ampula of vater, to pass retrograde into the stomach.  

If you have incredible tactile abilities, you may palpate an "olive shaped" mass.  But, in my experience, this is the stuff of unicorns and other mythical creatures.  What's more realistic are labs consistent with hypochloremic, hypokalemic, metabolic alkalosis.  Essentially this is the result of vomiting large amounts of stomach acid.

The  differential diagnosis for vomiting 2wk-12mo (according to the 6th edition, Textbook of Pediatric Emergency Medicine) is long and will be intentionally neglected.  Consider, however, pausing to entertain other sources of intestinal obstruction which include: Malrotation with or without volvulus, intussusception, incarcerated hernia, complications of meckel's diverticulum, and enteric duplications.  Occasionally pathology which normally presents during the neonatal period, such as Hirschprung's disease can present at several weeks to months of life.

I'd recommend getting an ultrasound (this is not one you will do yourself despite participation in the greatest Ultrasound Conference to ROCK the midwest during 2013: USE-IT MARCH 12TH/13th.)

(Some institutions start with upper GI series believing that it is more cost effective by limiting additional imaging procedures.)

If, in my opinion, you are trying to manage pyloric stenosis with atropine because you recently read about a "reinvestigation" of medical management, you might also want to start riding a horse and buggy to work.


Your job is to correct the dehydration that has likely developed.  Ultimately, these small human creatures need SURGICAL PYLOROTOMY by a small human creature surgeon.  IV, NS bolus 10-20 cc, and Admit.

See you next week.