1. Pediatrics Presentation VS 吳孟書 R1 鄭千威 November 27th, 2007

2. General Information 13 d/o male new born 2007/11/07 16:18 3175 grams Term neonate, 40 weeks of gestational age Left intraventricular hemorrhage, grade 1

3. Present Illness & Past History Projectile vomiting after milk feeding since last night (within 10 min)  non bilious content Fever (-) Hiccup frequency Constipation (-) Stool passage about 10 times per day. soft and yellowish. Activity: irritable crying ; appetite: good but vomit easily after feeding Past history: normal NB screen, neonatal ICH Just discharge 5 days ago due to ICH.

4. Physical Examination PAT: apperance: fair – breath smooth, no retraction – circulation stable Conscious clear Conjunctiva: not injected, not pale HEENT: Throat: injected(-), ulcers(-) – tonsil enlarge(-), exudate(-) Anterior fontanel: not bulging or sunken or tense posterior fontanel: <1 f.b. Neck supple, no LAP Chest: breath sound clear – RHB, no murmur Abdomen soft and mild distension – no tender ? – normoactive bowel sound Extremities: Freely movable, focal weakness(-) Skin rash(-)

5. More to ask in history and PE? Is it persistent vomiting or only after feeding? Irritable crying during feeding or after feeding? Is there a mass in abdominal area?

6. Initial Impression? Vomiting – r/o IHPS – r/o feeding intolerance – r/o GERD – r/o congenital megacolon – r/o sepsis – r/o IICP

7. Lab Ordered CXR Plane abdomen CBC/DC Sugar BUN, Cr Amylase, lipase AST ALT Bil D, Bil T Ca Inorganic P Na K CRP ABG IVF: N/S run 150 ml/hr Admission to Pediatrics ward

8. What else could be done? Echo become the diagnostic modality of choice – characteristic findings in IHPS of a thickened pyloric wall (greater than 3 mm) with a lengthened canal (greater than 15 mm). Should arrange for echo exam

9. Lab Results I WBC 12.9 RBC 4.18 HBG: 15 HCT: 44 PLT: 326 Seg: 39 Lym: 47 Mono: 11 Eosinophil: 2 Atypical L: 1 Sugar 84 BUN/Cr 6/0.3 Amylase/lipase <5/16 AST/ALT 31/26 Na 139 K 4.7 Ca 9.8 Cl 105 Inorganic P 7.8 CRP <0.5

10. Lab Results II pH 7.531 PCO2 27.7 PO2 154.2 HCO3 20.7 Sat 100%

13. Abdominal Echo on 11/12 Did not show increase in wall thickness and lengthened canal of pyloric sphincter IHPS not likely

14. Impressions Nausea and vomiting favored ileus r/o feeding intolerance r/o GERD Patient AAD on 11/08 after vomiting stopped after feeding

15. Discussion Vomiting in Neonates

16. What to Ask? Appearance of vomitus Age Associated GI s/s – Abdominal pain – Stool passage – diarrhea Degree of illness & Extra-abdominal presentations

17. Physical Exam Advised Mass in abdomen, inguinal area Bowel sound Localization of abdominal pain Meningeal sign Fontanel NE Feeding amount and timing

18. Vomitus Appearance Undigested food  suggest reflux from the esophagus or stomach – Causes: esophageal atresia (in the neonate), gastroesophageal (GE) reflux, or pyloric stenosis. Bilious vomitus  suggests obstruction distal to the ampulla of Vater, Fecal material  obstruction of the lower bowel Hematemesis  bleeding site in the upper GI tract

19. Common Cause of Vomiting

21. Vomit in Newborn I (0-2wk) Onset on first days of life  always suspect congenital GI anomalies – esophageal atresia – intestinal atresia or web – malrotation – meconium ileus – Hirschsprung's disease

22. Vomit in Newborn II Malrotation and volvulus diagnosis by abnormal X-ray, upper GI series and contrast enema Endoscopy used to assess esophagitis, stricture, web, atresia

23. Duodenal atresia: double air bubble

24. Duodenal atresia

25. Corkscrew Showing intestinal obstruction

26. Vomit in Newborn III Physiologic regurgitation or reflux  nearly 20% of infants reflux Exclude birth history, perinatal course, weight gain, PE, and NE are all normal Cause: – improper feeding techniques, such as failure to burp the baby, using nipples with holes that are too small, overfeeding Outgrow regurgitation by 6 to 9 months old 95% have resolution of symptoms by 12 months. Trial feeding at ED to r/o

27. Vomit in Newborn IV GERD a more severe form of LES dysfunction  less common (1:500) 24-hour intraesophageal pH meter  most sensitive diagnostic test

28. Vomit in Newborn V Uncomplicated GERD – reassurance – postural management – dietary measures For more severe symptoms or with complications – histamine H2 antagonists (ranitidine or cimetidine) – gastric acid secretion inhibition with a proton pump inhibitor (omeprazole or lansoprazole). Complicated/severe GERD and anatomical abnormalities are corrected surgicall y

29. Key to remember Time of vomit and its relations to feeding Appearance of vomitus give clue to level of obstruction Detail PE and history can differentiate most of the neonatal causes of vomiting

30. Thank You for Your Time!