S/p Pyloromyotomy and Vomiting Again

1Elmhurst Hospital Center/Icahn School of Medicine at Mount Sinai, Elmhurst, NY

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 262

Case Presentation:

BB is a 4mo boy born FTNSVD with PMH of pyloric stenosis, s/p pyloroplasty at 20 do who presents with NB/NB emesis, abdominal discomfort, and decreased PO intake x 2d. No fever, no BM since day prior (usual 1‐2/d), no bloody stools, frequent wet diapers. VSS: T99, HR138, RR40, O2 Sat RA100%. PE was significant for a soft abdomen but distended and tender to palpation which worsened over time. Abdominal US showed gallstones, no dilation of biliary tract, a normal pylorus, and dilated fluid filled bowel. KUB showed distended large bowel and no free air. A crosstable lateral abdomen showed air fluid levels signifying small bowel obstruction (SBO). An UGI suggested possible midgut volvulus so he was taken to the OR for laproscopy. Ischemic bowel was seen and an open procedure was necessary. Operative finding was an ischemic Meckel’s Diverticulum (MD) draped over the small bowel causing the SBO. He tolerated the procedure well, fed on POD#3 and was d/c home POD#5

Discussion:

Vomiting and abdominal distention raises a concern for SBO. In infants, possible causes of vomiting with abdominal distention are intussusception, malrotation with volvulus, and incarcerated hernia. Malrotation and volvulus classically present in the neonatal period but can appear at any age. Idiopathic intussusception is common 6mo – 2yrs of age. SBO is not a complication of pyloromyotomy. Vomiting is common in the immediate post‐op period but typically resolves in 24hrs. Rare causes of SBO include extrinsic strangulation of bowel by webs, bands, or a MD.

MD is caused by failure of obliteration of the vitelline duct. MD occurs in about 2% of the population and is mostly asymptomatic, often an incidental finding at laparotomy for some other pathology. 5‐16% of children with MD have symptoms, highest before 2yo, while adults are usually asymptomatic.

In children, the most common presentation is intermittent and painless rectal bleeding due to the presence of ectopic mucosa in the diverticulum. The second most common presentation is SBO including those secondary to volvulus, adhesions, intussusceptions, fibrous bands or incarceration within internal herniation, and twisting of MD at its base. In those cases, the SBO is what brings the child to medical attention and the MD as the cause is an operative finding, as in this case. The unique aspect of this case was the MD wrapped around the small bowel. MD with or without perforation can also mimic appendicitis.

Although symptomatic MD should be excised surgically, the management of asymptomatic MD remains controversial. The higher morbidity and mortality associated with symptomatic versus asymptomatic diverticulectomy has led many surgeons to recommend routine diverticulectomy in all children less than 8 years old, including asymptomatic ones, in the absence of absolute contraindications such as severe peritonitis or malignancies.

Conclusions:

MD can present in many ways, including SBO. Although vomiting immediately post pyloroplasty is common, vomiting even days later should be evaluated as a separate event.

To cite this abstract:

Rauch D, Ballestas M. S/p Pyloromyotomy and Vomiting Again. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 262. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/sp-pyloromyotomy-and-vomiting-again/. Accessed March 30, 2020.

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