with Pavan Zaveri, Children's National, on the Hot Seat
7 week old full term boy with no medical or family history presents with 1 week of projectile vomiting. Emesis is largely formula, non-bloody, non-bilious and within 15 minutes after every feed. The patient has had decreased urine output today. He had an abdominal ultrasound at day 2 of vomiting by an outside hospital that showed “pyloric muscle diameter of 5 mm and channel length of 10 mm, no pyloric stenosis.” They have seen their PMD twice in the last week, starting ranitidine and simethicone yesterday.
The patient returns today for fussiness and persistent vomiting.
Developmentally, the patient is on target and gets regular PMD follow-up (at Kaiser).
Examination
Weight 5.6 kg T 36.8 rectal HR 140 RR 42
GEN: Alert, fussy but consolable
Head: NC/AT, AFOFS, PERRL, tracking, slightly tacky mucous membranes
Chest: CTAB, no retractions
CV: RR, no murmurs, +DP pulses, CRT <2 data-blogger-escaped-br="" data-blogger-escaped-sec="">Abd: ND, soft, no masses, liver edge 0.5 cm below CM at mid-clavicular line
Neuro: moving all extremities with crying, normal tone
Skin: No rashes
Labs
Na 134 K 4.5 Cl 100 CO2 25 BUN 8 Cr 0.4 Glu 104
Your repeat limited abdominal ultrasound is normal. The patient is given a NS bolus based on history and now has taken PO in the ED with a witnessed spit up event and no projectile vomiting in the 1 hour after feed. The parents seem reliable, appropriately concerned, and have ready access to their Kaiser PMD.
It is now 5 pm and time to sign out to your colleague.
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About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series but she is on a well-deserved leave. During July, August, and September guest faculty from Children's National, Inova Fairfax, and Johns Hopkins will serve as case mentors. Paul Mullan, Children's National, edited this case.
my favorite part was the measurement of the liver edge in 1/2 cm units. :)
ReplyDeleteRealistically, I would observe this kid for about 5 minutes of non-fussiness in the ED and then call it colic.
In this situation, I first want to know if the child is losing weight. Vomiting or spitting up in the absence of clinical dehydration and weight loss is totally uncompelling. Without weight loss, I think of early pyloric, overfeeding, colic, mild-mod GER.
With weight loss, I want to expand my ED evaluation. Think about things like: milk protein enterocolitis, malrotation, upper duodenal obstruction, metabolic causes, renal disease, late pyloric, severe GER, etc.
But then don't forget about the fussiness. I try to accumulate enough data to say that it's not intracranial. Fontanelle? Head Circumference? Tachycardia/Bradycardia? Not calming down? fussiness and vomiting can be colic......or aqueductal stenosis, or post-hemorrhagic hydrocephalus, or abusive head trauma. So don't forget about the head !
But this kid has colic.
I'm definitely less cavalier than Dave. I worry about sending home a fussy 7 week-old who has been vomiting for a week now after numerous (I count 3) MD visits. Additional history I'd like to obtain: (1) change in weight between 2 PMD visits -- if gaining weight, I'd be much less concerned; (2) has there been progression of symptoms over the course of the week?; (3) what is meant by term "projectile"?, is it the same as that witnessed in the ED?; (4) did the "limited" US in the ED assess the pylorus specifically and the kidneys?. An US with normal pylorus measurements on day 2 of illness does not r/o pyloric stenosis, and the textbooks state to repeat the US if symptoms persist. If the repeat "complete" (not "limited") US is negative, I'd suggest getting an UGI (despite the h/o non-bilious emesis), especially if the child has been losing weight in the past week.
ReplyDeleteThis baby could be discharged after the one feed if if if... the baby hasn't been losing weight; the fussiness is not irritability (can't be consoled by parent); there aren't additional symptoms; I can talk to the PMD to check on growth parameters; and we have a game plan for what we do next- what is the decision tree for next steps. The differential is as above: anatomic anomalies of GIT, metabolic abnormalities, increasing intracranial pressure.
ReplyDeleteHaving said all that, I feel quite strongly that if a baby this young got dehydrated enough to require a fluid bolus, the baby should be kept in house. GER can cause weight loss and so probably dehydration, but this is rare. So, if the baby was estimated to be sufficiently dry to need iv insertion, I would admit. But I would also have a plan of care in mind when I call the hospitalist.
The 'worst case scenario' things I worried about when reading the case were some sort of anatomic thing (malro) or something in the head. However, I'm not THAT worried about them if the child is consolable (fussy is such a subjective word) and has not lost weight, as others have mentioned. I would have a nice discussion with the PMD before making a dispo decision on this baby, but would be leaning towards d/c with good f/u. If the pmd couldn't reassure me or gave me addn'l hx that was concerning I'd start with an UGI.
ReplyDeleteHot Seat Response:
ReplyDeleteAhh, the 7 week old...older than a newborn, but not quite a "reliable" infant (>3 mos). A case like this always is a dilemma wanting to ensure you're not missing something but not overdoing it. The others have gone through the differential quite nicely and I have little more to add there.
There has also been a great commentary on what "fussy" means, how important connecting with primary care is and the challenge of multiple visits. So, what can I impart here?
A commentary on risk: As you can see all of us draw our line in the sand at very different places. At this time, I'd like to share an exercise Christina had the faculty do at a recent retreat at her house: Place yourself somewhere on the continuum for a variety of concepts. Most interesting was risk-averse and risk-tolerant. What surprised me most was that experience (ie years post-fellowship) did not necessarily correlate to anything. There are many factors that influence where we fall on this continuum: personal experiences, training environments (residency and fellowship), mentors (or, broadly who we look [up] to), malpractice cases, depth of reviewing the literature, understanding of statistics and many more. What's more important to keep in mind is that any of these factors can push us in either direction on this line. And, as you move along you can look at the same info incorporating something new and flip your position on a given topic.
We all will set our risk-tolerance at a certain place, test/evaluate/reassess to that point to make a decision to discharge, admit or keep watching. For this infant, it is a case of it depends. Fussy? Projectile? Head size? Follow-up? Rapport? Setting all of these straight also affect your tolerance of risk. Once all these i's are dotted and t's are crossed, it may very well be discharge. But, I personally would probably go down the UGI route to ensure there's not anatomic concerns (duodenal web, etc) before discharging and a good talk with this child's PMD, if possible, not just the Kaiser hospitalist who will put a note in the system....
Let's see what turns out.
Agree with above. For sure, if this were the first time this kid presented like this, I would dx with colic and arrange f/up. But given this 3-4 visits for the same issue, I am a little more concerned. I think about if I got this kid on signout with the info above. Despite the fact that he has had a po trial and now not having further projectile emesis, I can't help but think that something looked awry for you to give a bolus in the first place (or was it just cuz you wanted to use that IV after the bloodwork was drawn?). What path was this kid headed on without that bolus? I am leaning towards a period of observation for at least 24hrs to observe parental interaction, a few feeding episodes, and to get that upper GI. Something is concerning for these parents who keep presenting with their baby so many times. I'd want to feel a bit more reassured than observing one feed. (If this is a Monday and I speak to Kaiser PMD who is on top of things, I would be willing to d/c to home -- if this is Friday night, I would keep during my shift in Obs -- if sig emesis, I would admit for further work up).
ReplyDeleteHmm. Having just written a chapter on malrotation and volvulus, and reviewing the literature, I would want to rule that out. Vomiting associated with malrotation is not always bilious, as malrotation is just that until there is volvulus.
ReplyDeleteOther causes that I would be concerned about, would also include intracranial masses/ abuse.
So I vote for an UGI study and a period of observation. If the UGI is negative, doppler the cranium, MRI if necessary.