This is the third of three exclusive PEMPix cases that will be posted online in advance of the 2019 Section on Emergency Medicine programming at the American Academy of Pediatrics National Conference and Exhibition.

This case was originally submitted by…

Jessica Barnes, DO

Sanford Children’s Hospital
Sioux Falls, SD

and

LeBonheur Children’s Hospital
Memphis, TN

Collaborators
Mindy Longjohn, MD
Timothy O’Conner, MD

The Case

A 17 year old male with with a chief Complaint of vomiting and abdominal pain presents to the Emergency Department with approximately nine hours of 10 episodes of yellow vomitus. He has a past medical history of cyclic vomiting and reports pain this time, that is a bit different than in the past. He denies fever, diarrhea, dysuria, scrotal pain, or penile discharge. His mother also interjects that it seems like he is having more severe abdominal pain with this episode than in the past.

His cyclic vomiting diagnosis diagnosis was Ade by pediatric gastroenterology two months ago, but symptoms were presents for months before that. he is not on any regular medicines and has had no prior surgeries. He denies drug use and is not sexually active.

Physical Exam

VS: T 36.8C, HR 86, RR 30, BP 130/62, O2 sat 100% on room air

General: Alert, Mild distress, Ill-appearing but not toxic

Skin: warm, dry, intact, no rash

CV: RRR, no murmur, capillary refill < 2 secs

Respiratory: clear to auscultation, non-labored, breath sounds are equal

GI: soft, non-distended, no organomegaly, diffusely tender worse in lower quadrants with rebound, normoactive bowel sounds

GU: normal male genitalia with no testicular tenderness

Neuro: Alert and Oriented X3 with PERRLA, EOMI, no focal deficits

Ext: Negative for lymphadenopathy

Evaluation

His initial workup included a CBC with differential that showed a slightly elevated WBC count. His electrolytes were normal, and he had a mild metabolic acidosis. His plain view abdominal X-Ray was unremarkable, but given the persistent pain a CT scan is obtained.

What is the diagnosis?

A. Acute appendicitis

B. Infectious colitis

C. Meckel’s diverticulum

D. Malrotation with volvulus

E. Superior mesenteric artery syndrome

Click here for the correct answer

C. Meckel’s Diverticulum

The CT showed a small bowel obstruction with a transition point in the right lower quadrant. The fecalization of the small bowel suggests that this is a subacute or chronic finding. Cue the flop sweat from that cyclic vomiting diagnosis…

The above image has the Meckel’s with the adhesive band circled. Surgery was consulted and elected to go to the OR for exploratory laparoscopic surgery. The postoperative course was uneventful. His prior diagnosis had included an ultrasound, along with some lab work. Ultimately, you will see many patients with vomiting. Trust the parent and the patient – especially if they know their symptoms well. Don’t ignore the “it feels different from their usual symptoms…”