Hot Seat Response #15 – Vomiting and Dehydration

By Shilpa Patel

We are presented with the case of a 10-month old male with Trisomy 21 who has had multiple episodes of vomiting, some perhaps bilious, over the past 12 hours and a “loose” stool prior to all of this - all of this with essentially a normal exam.

Differential diagnosis:  Early gastroenteritis, intussusception, obstruction/malro with volvulus, incarcerated hernia, testicular torsion, appendicitis (very unusual)

Management: I agree with the comments (Dave, Paul and Asha) that the degree of dehydration is difficult to ascertain in these children.  I would consider a BMP, ETU (or a longer observation period), UA and an abdominal XRays (including a lateral decub as was done).

The age and story certainly make me worry about intussusception and I don’t know what to make of the “alert..slightly tired” child on exam.  It's 2 am and he is dehydrated or is it more than that? The one view of the XR we are given has a questionable paucity of the gas in the right upper quadrant surrounding an area that could be considered the “soft tissue mass like structure” seen in intussusception. We also do not have another view to see if this was present then and then persisted on the lateral decub view shown. As mentioned by Paul, I would discuss the XR with the radiologist and ask them to see if there was air in the ascending colon on both views as two views with air in the ascending colon may make me feel better about waiting on the US (PEC radiology reference).

I would also consider doing a hemoccult stool (Kupperman and PEC Intussusception reference).  If either the hemoccult were positive, the child did not seem to be improving with fluids or the radiologist was concerned. I would push for radiology to come in to do an ultrasound of the abdomen to r/o intussusception overnight and consult surgery. If not, I would obs the child overnight with continued PO trial and consider a sono in the morning if he continued to vomit. 

Though if we apply the criteria from the recent Pediatrics study with information we already  have (Weihmiller et al, 2011) and call this a “questionably positive” AXR.  This AXR with our patient not meeting other “low risk criteria” (age less than or equal to 5 mo, presence of diarrhea, absence of bililous emesis) make it difficult to exclude intussusception and we should get an ultrasound. 

Regarding malrotation – given that these children sometimes have the most benign presentation (especially outside the newborn period) if the our infant with Trisomy 21 continued to vomit and the am ultrasound was negative for intussusception I would admit and consider an UGI.

Click here for another reference on the etiology of bilious emesis in the PED from one of our past fellows.