Healthy 17-month-old with vomiting

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 Healthy 17-month-old with vomiting. Have you seen one of these? 

It’s a busy night in the Pediatric ED. You seem to be running a special on gastroenteritis. Everybody and his brother has been vomiting this evening. You go down the hall to see your umpteenth vomiter, expecting to remain in your groove. But it was not to be. The child is a 17-month-old male. He is active and playful sitting next to his mother on the gurney. Mom says he has been constipated for 5 months. Mom has been using suppositories and small doses of miralax intermittently, but he passes stools very infrequently. They are hard balls, and he strains to pass them. A week ago, he developed pneumonia and was hospitalized at another institution. While in house, they noticed his dose of miralax was too small and increased it. However, Mom felt that he had abdominal pain after she gave him the larger dose, so she stopped it. The patient went home to continue antibiotics for his pneumonia. About two days ago he began vomiting. He is taking in liquids but refusing solids. The vomiting is nonbilious. Mom is concerned that he might be getting dehydrated.
The boy was born at term. Mom does not recall that he had any delay in the passage of his first meconium stool. He was admitted to the hospital at four days of age for hyperbilirubinemia. He has been healthy since. He is currently taking augmentin for the pneumonia. Developmentally, his speech has been a bit delayed. He lives with just his mother right now as his father is deployed in the military. There is a family history of constipation but no other gastrointestinal problems.
The child looks nontoxic and adequately hydrated. His exam is remarkable for a soft, but markedly distended abdomen. It is not tender. He has no midline defects on his back and tone, strength and reflexes of his lower extremities are normal.
At this point, you are concerned about obstruction. Maybe he has severe constipation and needs a clean-out. Maybe he has Hirschsprungs disease. Hirschsprungs patients have a congenital absence of the ganglion cells in the bowel wall, starting at the anus and extending proximally for varying distances. They frequently present with failure to pass stool in the first day of life, and can develop obstruction. Milder cases may come in with chronic constipation. When you suspect Hirschsprungs, you refrain from doing a rectal exam until after the abdominal films, so you won’t obscure a transition zone (the area where the normal colon gives way to the aganglionic segment. In the meantime, kid doesn’t look too bad. You order some labs, some fluids, and await developments.
alt The labs come back reassuringly normal. Surprisingly, the abdominal films come back with a nonspecific bowel gas pattern and a small amount of retained stool. So much for your clean-out. You perform his deferred rectal exam and his sphincter tone seems normal. OK, now you’re really not sure how to proceed. That big distended belly doesn’t look right and the story is worrisome. You decide to admit him for further evaluation.
The next day, you hear from the ward team. As part of his work-up, they had decided to get an upper GI with small bowel follow-through, looking for reflux, strictures, or perhaps intermittent volvulus. They hit pay-dirt – a large, gastric bezoar.
Bezoars are accumulations of undigestible matter that can get stuck in the stomach or intestine. There are 3 types. Trichobezoars are made up of hair. Phytobezoars contain plant material. Lactobezoars can occur with improperly mixed formula. They can be assymptomatic, or cause obstructive symptoms as in this child’s case. Sometimes they show up on plain films. Ultrasound or endoscopy can also detect them. Endoscopy can disrupt some bezoars although some require surgery. Lactobezoars can resolve by withholding feedings for 48 hours. So why the constipation? Maybe poor solid intake due to the bezoar gave this child “nothing to lose”. In ancient times, people felt that the bezoars from the bellies of goats were sacred. I doubt this mother wants this thing enshrined, however. This case is a reminder that kids do the darndest things. Sometimes, when you feel that you’re pursuing a hairball idea, maybe you are!
Amy Levine, MD, is an assistant professor of pediatric EM at UNC Chapel Hill 

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