Hot Seat #21 Denouement: Fever and Abdominal Pain

by Fareed Saleh, Children's National
with Thuy Ngo, Johns Hopkins, on the Hot Seat

The Case
This is a case of a 3 mo girl with fever, vomiting, loose stools, and abdominal pain on exam. For a complete case presentation, click here.

Clinical Pearls
This case generated a lot of excellent commentary. Thank you to Dewesh, Moh, Jamil, Rasha, Dave, Maybelle, and Paul for your comments and thinking out loud. And thank you to Thuy for a thoughtful Hot Seat Response. Click here to read them.

• "Fever, tender belly, vomiting and the X-ray with ?pneumatosis in a 3 month old deserves a CT abdomen to assess for NEC, volvulus or other surgical badness. Don't waste time with US or UGI, in my opinion, especially if the lytes/I-Stat demonstrates an acidosis." -Dewesh, Children's National

• Not sure if the birth history of decreased activity is significant, as it is not clear what this means. the non-bloody, non-bilious emesis potentially goes against a mid-gut volvulus, and the presence of loose stools suggests that there is some passage of material through the entire GI system. But, I am with Dewesh on the BMP --> CT First. -Moh, Children's National

• Not sure I would jump to CT, it would probably require sedation for this little tot. Probably would discuss with radiology given my concern for malrotation but also possible NEC, what imaging they would recommend. Probably UGI, keep NPO, IVF hydrate. -Jamil, Children's National

• The lack of air in the RLQ bowels is tricky on 1 view, so yes, we need more views. Note, most of the time a KUB is ordered, especially in this age group, 2 views or more are recommended. -Rasha, Children's National

• The other thing not mentioned would be appendicitis. It presents atypically in this age group (well, we think it is atypical!) and it's very easily missed. I'm not sure how sensitive an U/S for appy is at this age. But a CT would be a next step to consider. -Rasha, Children's National

• The XR is going to guide this case. Pneumatosis or free air takes us down a different path than "air not filling in RLQ". US is good for more than just intussusception, remember. a good ultrasonographer can see the position of the SMA to assess for malrotation. So not an unreasonable adjunct here. I vote no CT until there is more information. even pneumatosis (full term NEC) without perforation doesn't always need advanced imaging. -Dave, Children's National

• DDx: appy, stones, UPJ obstruction, malro, intussusception (tho xrays not hugely suggestive of the last two, tho remember intermittent malro can present with diarrhea). My brazen-anecdotal-non-ebm-supported experience:

-3 wk old with colicocolic intussusception.
-6 wk old with NEC.
-6 wk old with appendicitis.
-4 wk old with internal hernia (exploding baby belly appearance) 
-Maybelle, Inova Fairfax

• When I read "E.coli in a neonate", the neuron that fired "galactosemia" was thankfully still working. It would explain the (?hemolytic) anemia, the v/d, and e.coli; some kids have other classic signs early (eg cataracts) but there is clinical heterogeneity with delayed presentations as well. For those of us who can't afford Isabel, I did an OMIM search for "e. coli sepsis" and a short list of syndromes came up, mostly dysmorphic ones and galactosemia was the only one relatively "normal" looking. All that said about Zebras... most likely diagnoses in the "real world" would be gastroenteritis (bacterial or viral), intuss, malro, appy. -Paul, Children's National

Here's how you answered our questions:

In addition to the lab work above, which ONE additional study would you order? 

Nobody was interested in getting an amylase/lipase.
 
What is your ONE NEXT diagnostic step?

Nobody was interested in getting an ECG for this patient. The person who said, "other" did not specify the "other" so it will forever remain a mystery.

The Hot Seat Response
by Thuy Ngo, Johns Hopkins

Thank you for an interesting case, Fareed. How often do we see an infant with loose stools and emesis in the PED? Our patient has a history of E.coli bacteremia during the neonatal period, treated presumably without incident and this history of intermittent (impressive) tachycardia. It’s unclear what the work-up for this tachycardia was but I’m assuming an EKG was done which showed upright p-waves thus the diagnosis of sinus tachycardia. 

Today, she presents with labs and we have a CBC which shows anemia with a hemoglobin of 9, low for 3-month old. We would expect the physiologic nadir around 6-8 weeks of life. The remainder of the labs appear to be within normal limits. She is febrile, tachycardic, tachypneic, and slightly hypotensive, with a distended and possibly tender abdomen to palpation. The 1-view abdominal x-ray shows distension within the small bowel and a linear lucency extending from the RUQ to the RLQ concerning for free air. I would repeat this study and obtain a 2-view study: flat view in addition to an upright/cross-table lateral view to discern if this is free air or a trick played on my aging eyes. 

Given her current symptomatology, I would double check that there are blood and urine cultures pending at the other facility, or send them now and I would also want a venous/arterial blood gas with electrolytes and a lactate to see if she is acidotic and if imminent doom is on the horizon. I would also guaiac the stools to see if it’s positive as we do not have an explanation for why she is anemic.

If the repeat abdominal x-rays come back and show free air, I would be concerned about:

NEC - she’s is a bit old for this

Malrotation/volvulus – the presence of loose stools makes a complete obstruction unlikely.

Intussusception with bowel necrosis – this is highest on my differential at this time given the intermittent fussiness, abdominal tenderenss, and emesis/diarrhea. Bowel necrosis can lead to bowel ischemia and then bacterial translocation. A plausible explanation for our patient presenting with fever, tachycardia, hypotension, anemia, abdominal pain, and fussiness.

I always like to add a “miscellaneous” category to my differential to cover any and all other bases.

In addition to antipyretics and IV fluids and possibly broad spectrum antibiotics, I would start with an abdominal ultrasound, especially if I’m able to get it in a timely fashion and if I’m confident in my sonographer. If not, then I would consider an IV/PO contrast abdominal CT but that will also take some time.

Now, if the repeat x-rays come back negative, I would want to increase my differential and take a look at this history of tachycardia. I would wonder if this is an odd presentation of heart failure with a patient’s heart beating at 240 and getting tired of doing so for prolonged periods of time. Also, given her current symptoms and her history of E.coli bacteremia, I would keep galactosemia in the back of my mind although there is no mention of a non-routine birth, abnormal newborn screen in the history, and no evidence of the patient failing to thrive, making this unlikely.

The Denouement
by Fareed Saleh, Children's National

The patient's abdominal XR showed nonspecific gaseous distention of loops of small and large bowel with multiple air-fluid levels suggestive of enteritis. Due to continuing abdominal tenderness an ultrasound was done which showed no free fluid, no signs of intussusception and a partially visualized appendix that was normal. The patient was admitted for further management with IVF and NG tube placed. PO trials were started on HD #2 but the pt was noted to have increasing abdominal distention with limited PO intake and pt again made NPO with NG tube reinserted.

On HD #7, pt was advanced to PO feeds but noted to have 2-3 episodes of bilious vomiting. Surgery was consulted due to concern for obstruction. An abdominal XR was done (pictured here).

The XR was read as 'dilated air-filled loops of bowel in the upper abdomen, fluid levels on the cross-table lateral film; also, a small amount of gas is seen distally within bowel with findings concerning for a proximal bowel obstruction. There is no evidence for free intraperitoneal air.' An upper GI series was done showing tortuous duodenum and high grade jejunal obstruction.

Pt was then taken to OR with noted perforated appendicitis; an appendectomy was performed w/o complications. Following surgery pt continued to be on antibiotics with supportive care. On POD #6 pt was able to tolerate PO w/o issue and discharged home with surgery follow-up as outpt.

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 written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.