Infants with vomiting

Prepared by.........Nuthapong Ukarapol , M.D.
CC : Two infants were referred to the hospital because of vomiting.
Clinical presentations
Case 1
Case 2
Age
3 weeks
4 weeks
Sex
Female
Male
Birth weight
2700 grams
2700 grams
Body weight on admission
3080 grams
2750 grams
Onset of symptoms
5 minutes after feeding
5- 30minutes after feeding
Characteristic of vomitus
Digested milk
Digested milk with bile
Abdominal mass
Negative
Negative
Abdominal distension
Present
Present
History of meconium passage
within 24 hours
within 24 hours
Feeding
Formula
Breast feeding
Initial investigations
Investigations
Case 1
Case 2
Sodium
141
139
Potassium
5.3
5.3
Chloride
109
108
TCO2
19
18
Plain abdomen dilated stomach with small air in the small intestine dilated stomach with fair amount of air in the small intestine

What are the differential diagnosis for an infant with vomiting?
Group
Diseases
GI obstruction

Pyloric stenosis
Duodenal obstruction
Malrotation with
intermittent volvulus
Hirschsprung's disease
GI disorders Gastroenteritis
Gastritis/duodenitis (CMA)
Eosinophilic/allergic
esophagitis
Gastroparesis
Achalasia
Neurologic conditions Hydrocephalus
Mass lesions
Infections Meningitis/sepsis
Urinary tract infection
Metabolic/endocrine disorders Urea cycle defect
CAH
Galactosemia
Organic acidemia
Toxic substances Iron
Vitamin A or D

What is/are the investigations for an infant with vomiting?
1.

Ultrasound abdomen: to evaluate the presence of hypertrophic pyloric stenosis
2. 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
3. Barium enema: to evaluate Hirshchsprung's disease
4. EGD: to evaluate mucosal diseases in the stomach e.g. cow's milk allergy, eosinophilic gastroenteritis, reflux esophagitis
5. Metabolic screening e.g. electrolytes, LFT, urine reducing substances in suspected cases
6. 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.
 

Suggested reading:
1. Millar PJ. Motor disorders including pyloric stenosis. In:Allan Walker W, et al. editors. Pediatric gastrointestinal disease: pathophysiology, diagnosis, and management. 3rd ed. Ontario: B.C. Decker Inc., 2000:415-23.
2. Gosche JR, Touloukian RJ. Congenital anomalies of the midgut. In: Wyllie R, Hyams JS, editors. Pediatric gastrointestinal disease: pathophysiology, diagnosis, and management. 2nd ed. Philadelphia: W.B. Saunders, 1999:505-14.
3. Alexander F. Pyloric stenosis and congenital anomalies of the stomach and duodenum. In: Wyllie R, Hyams JS, editors. Pediatric gastrointestinal disease: pathophysiology, diagnosis, and management. 2nd ed. Philadelphia: W.B. Saunders, 1999:207-20.
Diagnosis : Case no. 1: Hypertrophic pyloric stenosis; Case no. 2: Intestinal malrotation with Ladd's band

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