For those of you that have followed the blog you’ll know that I showed this chest x-ray a few days ago. There’s an interesting case attached to the film that we presented this past week.
A six-week-old female presented to the emergency department with fussiness and emesis after every feed. Her past medical history was unremarkable, prenatal ultrasound was normal and there were no complications at delivery. Aside from occasional spitting up everything has been relatively normal per the parents up until two days prior to evaluation. Her weight gain have been excellent. The parents denied history of fever, cough, respiratory distress, diarrhea or rash.
On physical exam her vital signs were within normal limits and she was fussy but consolable. Her lungs were clear to auscultation bilaterally and her cardiovascular exam was normal including 2+ pulses and two second capillary refill. Her abdomen was soft, nontender with no masses or organomegaly.
In the emergency department feet was witnessed and she had emesis within two minutes after taking 1/2 ounce of breastmilk via bottle. The emesis was non-bilious and non-bloody.
Given the rapidity at which the emesis occurred after feeding the team elected to get chest and abdominal x-rays. The chest x-ray is the film of interest in this case.
Clearly this is an abnormal chest x-ray but what stands out? You can click on the image to enlarge it in your browser.
Look closely at the left hemi thorax.
Looks weird doesn’t it.
That’s because it is there’s bowel in the left hemithorax.
Despite the normal prenatal ultrasound the six-week-old has a congenital diaphragmatic hernia. Pediatric surgery was consult it she was admitted and repair was done that night.
Let’s take one more look at the x-ray this time with the abnormality in the left hemithorax outlined.
The moral of the story is to use radiographic studies to help define the anatomy in cases with the symptoms suggest obstruction or mechanical dysfunction. In this case she was having emesis after every feed because of the bowel dysmotility caused by having intestines were her lungs should be.
