Denouement Hot Seat #15: Vomiting and Dehydration

by Sonny Tat with Shilpa Patel on the Hot Seat

This is a case of a 10 mo boy with trisomy 21 who presented with emesis and loose stools. For a complete case presentation, please click here.

Thank you to Dave, Paul, and Asha for their insights and clinical approaches. Please click here to see their comments (scroll up).

Here's how you answered our questions:
1. Would you give this patient ondansetron (along with the bolus) before you attempt PO challenge?

2. Based on current history, exam, and above x-ray, would you order further imaging?

One person commented, "What do you mean by equivocal? Between what and what? How is the child after the bolus? Tolerated PO? Is this Xray at 2am after bolus or before?" and another person said, "X-ray concering for intussception. Needs emergent US to confirm if radiology is equivocal on the Xray. Would require calling in the tech. Alternatively, strongly consider going straight to air-contrast enema." 
 
3. Assume he got ondansetron, further imaging is normal, and he has no more emesis would you d/c with Rx for ondansetron?

Hot Seat Response
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.

Hot Seat Denouement
by Sonny Tat

The patient received a normal saline bolus and ondansetron PO. The KUB was discussed with the overnight radiologist who felt that loop in the left upper quadrant was a non-specific finding but could not rule out malrotation without an upper GI series.

The patient tolerated PO, had urine output, and was observed in the ER for 4 hours with no further emesis. His abdominal exam remained stable. An upper GI was not performed based on his improved clinical status. He was discharged to home with instructions for PMD follow-up.

At 8 am, the attending radiologist called back with a concern about the left upper quadrant density on original KUB (click to see image). The differential included benign overlapping shadows or intussusception. The patient was called back and had an ultrasound and barium enema. His barium enema is below:

The patient was diagnosed with an intussusception and was effectively reduced by this barium enema. The patient was discharged to home that same day without complications.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are all actual cases and are written by PEM fellows at Children's National in Washington, DC. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.