Morning Report

Devin Horton, R3 March 2, 2012

HPI
CC: Bilious emesis

13 yo female presents with bilious emesis and abdominal

distension.

Three days ago she began having stomach pain and had 5
episodes of BRIGHT RED EMESIS!!

(however she reveals that she had just eaten a red slushee
and velvet cake).

Volume was about the size of a cereal bowl.

The following day she had bilious emesis x 1, and

continued to have stomach pain.

 The day before admission she had 3 episodes of

bilious emesis.

On the day of admission she woke up crying because

of stomach pain and had another episode of bilious emesis.

She describes the pain as pressure-like, constant,

and "all over".

She had a BM the day before that was not as soft as

tooth paste but not marbles and would not not further elaborate.

In the ED
In the ED she was tachycardia at 138 and was given
20cc/kg NS. Labs and imaging were done.

 PMH:
Anxiety disorder NOS with question of OCD Multiple UTIs including: Klebsiela, enterococcus faecalis,
citrobacter, VRE Sigmoid volvulus at 6 mo

Surg: Right hemicolectomy with ileotransverse

colostomy at 6 months.

Meds: none Vacc: UTD

 NKDA

Fam: DM in grandfather, ovarian and uterine cancer in

grandmother. No family history of GI, congenital, or childhood diseases.

Soc: 8th grader, likes school. Lives at home with

parents and siblings. 3 cats and 1 dog. No recent travel. No reptile or otherwise amphibious pets.

Differential
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Exam
VS: AF, 110, 116/76, 16, 98% RA

Gen: No distress whatsoever, Has iPad in one hand and cell

phone in other. Anderson in place. Pale.

HEENT: No lymphadenopathy, no OP exudate, MMM

CV: tachy, Regular rythym, no murmurs

Pulm: CTAB ABD: Distended, no bowel sounds, tympanic. Ex: no clubbing.

Labs
CBC: wbc: 9.5, hg 15.7, hct 45.3, plts 287, 5 bands, 71
neut, 16 lymph, 6 mono

CMP: na 142, k 3.3, cl 101, co2 26, bun 22, cr 0.76, ca

9.6, prot 8.2, alb 4.9, tb 0.4, alt/ast 16/31

CRP: neg UA: trace LE, neg nit, neg ketones>30wbc, 3+ bact, 0
epi

Urine Micro: >100,000 klebsiella

Imaging
KUB: Stool. Chronically dilated segments containing a few
small air-fluid levels

KUB: Gaseous distention of upper abdominal bowel loops

with a paucity of bowel gas in the lower abdomen.

CT abd:
MARKED GASTRIC DISTENTION. MARKED SMALL BOWEL DISTENTION WITHOUT
ABNORMAL WALL THICKENING OR FREE FLUID. NO PNEUMATOSIS. THESE FINDINGS ARE SUGGESTIVE OFSMALL BOWEL OBSTRUCTION. NO TRANSITION POINT IS IDENTIFIED NOT SUGGESTIVE OF SIGMOID VOLVULUS NO FREE AIR IS IDENTIFIED.

 Contrast enema:

No obstructive lesion is seen.

What I left out

PMH: Chronic pseudoobstruction requiring multiple
hospitalizations. Chronic constipation. Presumed bacterial overgrowth History of TPN requirement

Meds: gent, nystatin, erythromycin, flagyl, daily golytely. In the ED: 2L removed by anderson tube This was two admissions.

The Second Brain

Communicates through the parasympathetic (vagus)
and sympathetic (prevertebral ganglia)

GI nervous system can act autonomously.

Has efferent neurons, afferent neurons, interneurons,
capable of carrying reflexes and acting as integrating center in absence of CNS input. 90% of the bodies serotonin, 50% bodies DA Gangions Auerbachs and Meissners Plexuses

Mechanical, chemical, bacteria, enzymes.

Pseudobstruction
Spectrum from Slow transit constipation to Chronic intestinal pseudo-obstruction:
syndrome that suggests mechanical bowel obstruction in the
absence of an anatomic lesion Segments of affected bowel appear dilated on radiography.

Hirschsprungs, post viral gastroperesis, ogilvies

Problem with: 1. extrinsic nervous system (brain/spinal

cord.) 2. Enteric NS, 3. Smooth muscle.

Pathophysiology
Myopathic vs. Neuropathic vs. Both

Neuropathic: DM, amyloidosis, paraneoplastic, neuronal

dysplasia

Mutation in neural crest derived cells: Sox 10 gene:

hypoganglionosis, aganglionosis (hirschsprung), Hyperganglionosis of inhibitory.

Reduced denity/abnormal interstitial cells of cajal

(pacemaker cells)-slow transit constipation/pseudoobstrucion

Gene mutation: Waardenbarg-shah

 Presents

Distension 75 percent Abdominal pain 58 percent Nausea 49 percent Constipation 48 percent Heartburn/regurgitation 46 percent Fullness 44 percent Epigastric pain/burning 34 percent Early satiety 37 percent Vomiting 36 percent

DX/TX
Decreased motility -> distension -> stasis -> bacterial overgrowth > distension.

Imaging to r/o anatomical. Suspect: transit test or manometry

TX: Nutritional support Antibiotics Prokinetics G tube: venting Need to recognize.

59 pts for 4.6 years. 2.96 useless surgeries/pt before recognition.

THANKS
Dr. Jackson

Netters
Uptodate Gastroenterology, 2000 Clinical Gastroenterology Hepat, 2005