PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s visual diagnosis competition. It is held annually at the National Conference and Exhibition. This year, all ten finalists will be posted online on PEMBlog.com and at PEMPix.com, one a day with voting opening to AAP Section on Emergency Medicine members thereafter. I hope you enjoy this online-only format, and hope that it will serve to highlight some of the fantastic learning cases that our colleagues submitted this year. It was again very difficult for the panel of judges to select the finalists and I could not have done it without their assistance. As a special treat I’ve included a musical selection form the 1980s as an optional “hint,” and to serve as a soundtrack for your learning.

This PEMPix case was submitted by:

Jimmy Rudloff, MD, Pediatric Chief Resident along with Matthew Lipshaw, MD, Assistant Professor of Pediatrics from the Division of Emergency Medicine at Cincinnati Children’s

Click here to reveal the hint

The final plot twist

A 23-year-old female with a past medical history of CHARGE syndrome, non-verbal global developmental delay, Chiari II malformation, dysphagia, and recurrent pneumonia presented to the Emergency Department for respiratory distress and increased work of breathing. On the day of presentation she was noted to have a productive cough, increased work of breathing, and low-grade fevers to a maximum of 100 degrees Fahrenheit. At a regional adult hospital Emergency Department, a urinalysis was notable for small leukocyte esterase. Complete metabolic panel and CBC were both unremarkable. She received a normal saline bolus, and oral levofloxacin prior to her transfer to the referral childrens’s hospital Emergency Department.

On arrival her heart rate was in the 130-140 beats/min range. Her “normal” heart rate per caregivers is around 110 when awake. She does not require home oxygen, but was placed on nasal cannula therapy for desaturations. Her respiratory rate ranged from 22-45 breaths/minute. She was not hypotensive, but this non verbal patient was somnolent and only responded to noxious stimuli. Her lung exam revealed wheezes and crackles throughout with an increased work of breathing improved after oxygen was applied. Her abdomen was soft with no peritoneal signs, non-tender, but slightly distended. Bowel sounds were heard throughout. Her extremities were warm and well perfused.

CBC, lactate, and procalcitonin were all reassuring. She received another normal saline bolus. all within normal limits. The chest radiograph did not show obvious pneumonia. The attending Radiologist recommended abdominal radiographs to evaluate an abnormality seen on the chest radiograph.

What is the diagnosis?

A. Gastric volvulus

B. Diaphragmatic hernia

C. Toxic megacolon

D. Duodenal web

E. Epiphrenic diverticulum

Click here to reveal the correct answer

A. Gastric volvulus

Gastric volvulus occurs when the stomach twists >180 degree on its mesentery leading to bowel obstruction. This rare diagnosis presents with variable, nonspecific clinical symptoms though some patients may have the classic triad of Borchardt:

Severe sudden epigastric pain
Intractable retching without vomiting
Inability to pass a nasogastric tube

However, this young woman was non-verbal and developmentally delayed, which made the diagnosis more challenging. The X-Ray showed massive dilation of the “upside-down” stomach with compression of the small bowel. Ultimately surgical consult, CT scan, then laparoscopic gastropexy lead to an eventual complete recovery after a 20-day hospitalization. The image from two years prior did show a dilated stomach. Gastric volvulus can be seen in children less than one year of age and in older adults, especially those who older than 50 years. There is no predilection for either gender or race. The most common cause in both children and adults is a paraesophageal hernia.