The Emergency department gets a pre arrival call from a GP. He is sending in a sick looking 10 year old who has been vomiting overnight. He thinks this may be gastro.

History:

  • 12 hours of vomiting – non bilious, no haematemesis
  • Abdominal pain
  • Normal stools
  • Afebrile

On examination

  • pale
  • mottled
  • barely responsive
  • RR  40/min
  • HR 140/min
  • BP 80/59
  • capillary refill 4 sec
  • saturating 100% on 15 l with a non rebreathing mask.

His abdomen is generally tender, slightly distended  but not peritonic.

Resuscitation is commenced immediately with iv fluids and bloods are taken.

The Emergency Physician performs a Point of Care abdominal ultrasound

 

 

llops-of-bowel-2

 

It is clear that the abdomen is full of free fluid. This is not gastroenteritis but a possible surgical emergency.

Bloods:

  • pH 7.32, PCO2 30, HCO3 15, BE -10, lactate 5.7, glucose 4.4
  • WCC 29.7, Neut 20.2, lymph 6.2, Hb 141, plt 406
  • Na 138, K 5.2, CL 102, HCO3 14, Urea 12.9, Creatinine 119

He is acidotic, has a neutrophilia and has acute renal impairment.

He continues to get further fluid boluses of 20mls/kg.

His level of consciousness improves .

His lactate is repeated and is now 11.

Likely diagnosis is an ischemic gut.

Chest Xray and abdominal pain unremarkable.

The child is transferred  to a paediatric hospital for urgent laparoscopy which shows a left internal paraduodenal hernia with ischaemic bowel.

A laparotomy is performed and 120 cm of ischaemic gut is found. 8 cm of full thickness ischaemic bowel is  removed.

He makes an excellent recovery.

What is an Internal Hernia ?

The incidence of internal hernias is very rare. Possibly less than 1% of causes of acute bowel obstruction.

They are defined as the protrusion of bowel through a normal or abnormal mesenteric opening within the peritoneal cavity. This opening can either be acquired (post surgical – common in adults) or congenital.

internal-hernia

The clinical picture is non specific ranging from mild abdominal discomfort to acute intestinal obstruction. Intestinal obstruction is associated with a high mortality, up to 50% in one case series. In children the most common type of type of intestinal hernia is paraduodenal.

Paraduodenal internal hernias can be divided into 2 types, left and right, the left being more common. The bowel prolases through Landzert’s fossa, a congenital opening in the mesentery present in approximately 2% of the population.

Differential Diagnosis of a Child with Vomiting and Shock

Remember that vomiting and diarrhoea do not always indicate gastroenteritis.

Consider:

  • Myocarditis
  • Septic shock
  • Diabetic ketoacidosis
  • Intussusception
  • Volvulus
  • Toxic ingestion
  • Adrenal crisis
  • Severe pneumonia
  • Congenital heart disease (particularly in infants)

POCUS can  be helpful at quickly differentiating between these diagnoses.