Snapshot A 10-day-old baby boy is brought to the emergency room for repeated episodes of vomiting. His mother describes the vomit as green and yellow. On physical exam, the physician has difficulty at first locating the heartbeat, but finally hears a heartbeat on the right side of the chest. Suspicious, he sends the baby for abdominal radiography and upper GI series. Imaging reveals dilated bowel loops and a “birds beak” appearance of bowel. Introduction Malrotation errors during development increases risk of midgut volvulus 1/3 of children with malrotation develop volvulus Midgut volvulus abnormal rotation of bowel due to pathologic adhesions fixating the bowel around itself twists around SMA compromises blood flow to bowel majority in ileum increased risk of bowel necrosis and perforation Epidemiology most common in newborns males > females 80% of cases are newborn elderly population can have malrotation, but volvulus is less often Associated conditions gastroschisis omphalocele situs inversus cardiovascular defects Hirschsprung disease heterotaxy Malrotation with midgut volvulus is a surgical emergency Presentation Symptoms neonates (majority of patients) bilious vomiting within first week of life colicky pain older patients nonbilious vomiting crampy abdominal pain change in bowel pattern nausea Physical exam abdominal distention abdominal tenderness acute abdomen shock Evaluation Imaging abdominal radiography multiple air fluid levels dilated loops of bowel with loss of haustra normal radiography does not exclude disease upper GI imaging with barium enema “bird beak” appearance at site of rotation “coffee bean” appearance of bowel failure of duodenum to cross midline = malrotation Differential Diagnosis Intussusception Intestinal atresia Treatment Malrotation without volvulus elective Ladd procedure Malrotation with volvulus (symptomatic or acute abdomen) emergent endoscopic decompression emergent surgical decompression Prognosis, Prevention, and Complications Prognosis most with resolution of symptoms after surgery good prognosis mortality rate 3-9%, worse with premature neonates bowel necrosis Prevention if patient has heterotaxy, screen for malrotation elective Ladd procedure if malrotation without volvulus Complications bowel necrosis and perforation sepsis
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.4688) A 5 day old neonate presents at night to the emergency room with "one day of green vomiting and a larger belly than usual" according to mom. The mother explains that the patient passed stool for only two days after birth and had been feeding well until this morning when the patient vomited after feeding and continued to vomit sporadically throughout the day. Newborn screening was normal for this patient, there were no pregnancy complications, the patient has been breastfeeding consistently with only some regurgitation, and the patient has no sick contacts. The abdomen is distended on physical exam without palpable masses, and there is no stool in the rectal vault. Upper gastrointestinal series film can be appreciated in Figure A. What is the most likely diagnosis of this patient? Review Topic | Tested Concept QID: 107531 FIGURES: A Type & Select Correct Answer 1 Duodenal Atresia 0% (0/0) 2 Mid-gut Volvulus 0% (0/0) 3 Pyloric Stenosis 0% (0/0) 4 Biliary Atresia 0% (0/0) 5 Meconium Ileus 0% (0/0) M2 A Critical Select Answer to see Preferred Response SUBMIT RESPONSE 2 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.GI.44) A 73-year-old woman with a history of diabetes presents to the emergency department with severe abdominal pain and constipation for 24 hours. Vital signs are T: 100.3 F, HR: 80 bpm, BP: 143/82 mmHg, RR: 24/min, O2 Sat: 95%. Abdominal exam is notable for diffuse abdominal tenderness to palpation, without rebound or guarding. Laboratory studies are notable for leukocytosis, though lactic acid is within normal limits. Abdominal x-ray is shown in Figure A. Which of the following are the best next management steps for this patient? Review Topic | Tested Concept QID: 103067 FIGURES: A Type & Select Correct Answer 1 Sigmoidoscopy and placement of a rectal tube for 48-72 hours 50% (1/2) 2 Barium Enema with abdominal xray 50% (1/2) 3 Immediate laparotomy with Hartmann's procedure 0% (0/2) 4 Immediate laparotomy with sigmoidectomy and primary anastomosis 0% (0/2) 5 NPO, NG tube decompression and neostigmine 0% (0/2) M2 A Critical Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.6409) A 74-year-old female presents to the emergency room with abdominal pain. She notes several days of constipation and most recently has not had a bowel movement in 3 days. She is unable to remember if she has passed gas. Her vital signs are BP 118/76 mmHg, HR 97 beats per minute, RR 17 breaths per minute, and T 99.4 degrees Fahrenheit, and her abdomen is noticeably distended. A barium enema radiograph is shown in Figure A. Which of the following is the best next step? Review Topic | Tested Concept QID: 106964 FIGURES: A Type & Select Correct Answer 1 Manual evacuation of rectal impaction 41% (34/83) 2 Administer large doses of laxatives 7% (6/83) 3 Laparotomy with sigmoid resection 18% (15/83) 4 Proctosigmoidoscopy and placement of a rectal tube 28% (23/83) 5 Observation 5% (4/83) M2 D Tested Select Answer to see Preferred Response SUBMIT RESPONSE 4