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A case of abdominal pain and vomiting

A case of abdominal pain and vomiting. Dr charles panackel. Demography. 14 year old boy. Presenting complaints. Abdominal pain since early childhood Vomiting of 2 months duration. History of presenting complaints.

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A case of abdominal pain and vomiting

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  1. A case of abdominal pain and vomiting Dr charlespanackel

  2. Demography 14 year old boy

  3. Presenting complaints • Abdominal pain since early childhood • Vomiting of 2 months duration

  4. History of presenting complaints Complaints started as recurrent attacks of abdominal pain since early child hood. Severe Colicky pain, lasting for 15- 20 mts. Periumblical in location. No radiation of pain. Pain aggravated by food intake. Relieved by injections and medications from local hospital. .

  5. Patient used to have 2-3 episodes per year. Each episode used to last for 1-2 weeks and relieved with treatment from local hospital. Evaluated with x-rays and USG abdomen and no definite diagnosis made.

  6. History of presenting complaints Presently patient has abdominal pain for last 2 months. Colicky pain lasting for 15-20mts. Periumblical in location. No radiation. Pain was aggravated by food intake There was no associated fever, jaundice. No dysuria, hematuria. No Steatorrhea

  7. History of presenting complaints Associated bilious vomiting and pain was relieved by vomiting 2-3 episodes per day. Occurs ½-1 hour after food intake. There was no delayed or stale food vomiting. Patient had associated ball rolling sensation.

  8. There was no abdominal distension or borborygmi. There was no associated constipation. There was no hematemesis, melena or hematochizia. There was no associated postural symptoms or oliguria.

  9. No autonomic symptoms like excessive sweating, postural syncope or palpitation • No purpura, urticaria, vesicular / bullous eruptions, • No arthritis/oral ulcers • No history of pica. • Was admitted and evaluated in local hospital treated symptomaticaly with no relief of pain or vomiting and referred here.

  10. Past history • Second borne of a nonconsanguinous marriage. Normal developmental mile stones and scholastic performance. • No history of steatorrhea, respiratory symptoms, jaundice. • No history of tuberculosis • No history of any anorectal, renal or cardiac anomalies. • No history of surgery

  11. Family history • No family history of Similar abdominal pain • No history of pancreatitis, skin lesions, psychosis, tuberculosis • Was on treatment from local hospital for abdominal pain.

  12. DD • 14 year old boy with recurrent periumblical colicky abdominal pain from early childhood now presenting with sudden aggravation of pain and bilious vomiting of 2 months duration.

  13. Differential diagnosis Malrotation with mid gut volvulus Congenital band Meckelsdiverticulum with mid gut volvulus Annular pancreas Intussuception Recurrent pancreatitis Congenital biliary defects

  14. Examination • No dehydration • PR-78/’ BP- 110/70 no postural fall • RR -16/’ • Moderately built and poorly nourished for the age • Ht 142 cm Wt 32 kg BMI 15.8 • No pallor /No jaundice / edema / lymphadenopathy

  15. No stigmata of malabsorption like phrynoderma, bitots spots, glossitis, cheilitis, bone tenderness No perioral or pigmentation, no skin lesions like purpura, vesicles, ulcers, No skeletal anomalies, ptosis, ophtalmoplegia No skin or joint laxity No anorectal or external genitalia abnormalities

  16. Oral cavity- Normal. No perioral pigmentation • Abdomen – Not distended/ No visible peristalsis/ dilated veins /swelling/ abdominal wall defects • Liver was palpable 3cm below the right costal margin. Span 12cm. Soft, nontender, rounded margins and smooth surface • Spleen was not palpable • No mass palpable • Normal bowel sounds • P/R – Normal • Hernial orifices normal

  17. Chest - Normal • CVS; S1 and S2 normal.No murmur • CNS –No ptosis, ophthalmoplegia, myopathy or neuropathy • Fundus; normal

  18. Differential diagnosis Malrotation with recurrent gut volvulus Congenital ladds band Meckelsdiverticulum with mid gut volvulus Annular pancreas Intussuception

  19. Investigations • Hb 11.8 TC 6700 DC P68 L30 E2 • ESR 22 • RBS 82 • S.Na 142 • S.K 3.7 • S.Ca 8.2 • BU/Cr- 15/0.7 • Bb 0.7 SGOT /PT 32/23 ALP 72 TP 6.8 Alb 3.2

  20. USG • Dilated stomach with stasis no other abnormality noted • OGD • Esophagus was normal. Stomach, D1 and D2 were dilated with stasis. Scope was not introduced beyond D2.

  21. CT – Suggestive of intestinal malrotation with midgutvovulus

  22. Surgery • Duodenum dilated upto D3 • Band from transverse colon to D3/D4 jn---released the band • Volvulus 1/4th rotation – No strangulation -Untwisted the bowel • Small bowel put on the right side • Large bowel put on the left side • Inversion appendicectomy done

  23. Final diagnosis Intestinal Malrotation Partial intestinal obstruction at D3 level with Ladds bands and MidgutVolvulus

  24. Malrotation of midgut • Occurs in 1/1600 live births • Normally midgut goes out of the abdominal cavity during 4 th week of gestation • Comes back inside by the 10 th week • Midgut rotates around the axis of SMA for an angle of 270degrees

  25. Initial 90 degree rotation takes place outside the abdominal cavity • Second stage inside the abdomen –rotates through 180 degrees • Third stage is the descend of cecum

  26. Anomalies • Non rotation (most common) • Malrotation • Reverse rotation

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