a twisting tale…

the case.

It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem to ever get any shorter….

At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…

She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).

You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.

Despite further boluses of morphine, she continues to vomit and complain of severe pain…

[DDET …so you order a plain X-ray]

[/DDET]

The Questions

What’s going on here ?
What are you going to do now ??

The Discussion

[DDET Evidence based thinking]

Upon reviewing the film, my immediate concerns was of a closed-loop obstruction. On further questioning, the young patient had not opened her bowels for 2 days, and had not passed flatus for at least 24 hours. Our surgical registrar agreed to review the patient….

Paediatric Bowel Obstruction.

The symptoms are generally non-specific with irritability, persistent vomiting, abdominal pain and distention. There are many different causes and pathological processes behind paediatric bowel obstruction. They include the following….

Congenital Causes.

• atresia (duodenum, jejunum, oesophagus)
• pyloric stenosis
• meconium ileus
• aganglionic megacolon
• malrotation
• constriction bands
• intraabdominal hernias

Intussusceptions.

• Ages 3 months – 6 years.
• Requires a lead point (only found in 2-8% of cases)
  • Viral illness / gastroenteritis / rotavirus –> lymphoid tissue swelling.
  • Meckel’s
  • Peutz-Jaghers Syndrome

Incarcerated Hernias.

• Umbilical – very common. rarely incarcerate.
• Inguinal – very common. 10x more common in boys. more common in prematurity.
• Femoral – rare in children. females >> males.

Malrotation with midgut volvulus.

• 1 in 500 infants.
• Error of rotation around the SMA axis.

Postoperative Adhesions.

• Responsible for 3-8% of intestinal obstructions in infants/children.
• Incidence lower after laparoscopic procedures than after laparotomy.

Annular Pancreas.

• Rare congenital anomaly
• Pancreatic tissue fully encircles the 2nd part of duodenum (leaving a non-distensible ring and a functional stenosis).

the conclusion.

The surgical registrar is agreeable with suspicion of bowel obstruction & the patient is consented for a diagnostic laparotomy. As the patient rolls off to theatre, I go home to bed….

My phone beeps midway through the day and I receive the following picture in an MMS.

Following surgical release, her bowel immediately reperfused & remained viable. She is discharged home 4 days later without complication…

my thoughts…

In the ED, we are often faced with a never-ending ‘To-Do’ list and are asked to meet time-lines for decisions and dispositions that seem to be getting shorter & shorter…

For me, this case is a reminder that if your patient:

1. isn’t following the expected path of the proposed diagnosis
2. isn’t getting better with the therapy instituted to date.

Take a step back and start from scratch, reviewing the case from the very beginning…

 

[/DDET]