A case of abdominal pain
and vomiting
Dr charles panackel
Demography

14 year old boy
Presenting complaints
Abdominal pain since early childhood
 Vomiting of 2 months duration

History of presenting complaints
Complaints started as recurrent attacks
of abdominal pain since early child hood.
 Severe Colicky pain, lasting for 15- 20
mts.
 Periumblical in location.
 No radiation of pain.
 Pain aggravated by food intake.
 Relieved by injections and medications
from local hospital.

Patient used to have 2-3 episodes
per year.
 Each episode used to last for 1-2
weeks and relieved with treatment
from local hospital.
 Evaluated with x-rays and USG
abdomen and no definite diagnosis
made.

History of presenting complaints
Presently patient has abdominal pain for
last 2 months.
 Colicky pain lasting for 15-20mts.
Periumblical in location. No radiation.
 Pain was aggravated by food intake
 There was no associated fever, jaundice.
 No dysuria, hematuria. No Steatorrhea

History of presenting complaints
Associated bilious vomiting and pain
was relieved by vomiting
 2-3 episodes per day.
 Occurs ½-1 hour after food intake.
 There was no delayed or stale food
vomiting.
 Patient had associated ball rolling
sensation.

There was no abdominal distension or
borborygmi.
 There was no associated constipation.
 There was no hematemesis, melena or
hematochizia.
 There was no associated postural
symptoms or oliguria.

No autonomic symptoms like excessive
sweating, postural syncope or
palpitation
 No purpura, urticaria, vesicular / bullous
eruptions,
 No arthritis/oral ulcers
 No history of pica.
 Was admitted and evaluated in local
hospital treated symptomaticaly with no
relief of pain or vomiting and referred
here.

Past history
Second borne of a nonconsanguinous
marriage. Normal developmental
mile stones and scholastic
performance.
 No history of steatorrhea, respiratory
symptoms, jaundice.
 No history of tuberculosis
 No history of any anorectal, renal or
cardiac anomalies.
 No history of surgery

Family history
No family history of Similar abdominal
pain
 No history of pancreatitis, skin
lesions, psychosis, tuberculosis
 Was on treatment from local hospital
for abdominal pain.

DD

14 year old boy with recurrent
periumblical colicky abdominal pain
from early childhood now presenting
with sudden aggravation of pain and
bilious vomiting of 2 months
duration.
Differential diagnosis
Malrotation with mid gut volvulus
 Congenital band
 Meckels diverticulum with mid gut
volvulus
 Annular pancreas
 Intussuception
 Recurrent pancreatitis
 Congenital biliary defects

Examination
No dehydration
 PR-78/’ BP- 110/70 no postural fall
 RR -16/’
 Moderately built and poorly nourished
for the age
 Ht 142 cm
Wt 32 kg BMI 15.8
 No pallor /No jaundice / edema /
lymphadenopathy

No stigmata of malabsorption like
phrynoderma, bitots spots, glossitis,
cheilitis, bone tenderness
 No perioral or pigmentation, no skin
lesions like purpura, vesicles, ulcers,
 No skeletal anomalies, ptosis,
ophtalmoplegia
 No skin or joint laxity
 No anorectal or external genitalia
abnormalities









Oral cavity- Normal. No perioral pigmentation
Abdomen – Not distended/ No visible
peristalsis/ dilated veins /swelling/ abdominal
wall defects
Liver was palpable 3cm below the right costal
margin. Span 12cm. Soft, nontender,
rounded margins and smooth surface
Spleen was not palpable
No mass palpable
Normal bowel sounds
P/R – Normal
Hernial orifices normal
Chest - Normal
 CVS; S1 and S2 normal.No murmur
 CNS –No ptosis, ophthalmoplegia,
myopathy or neuropathy
 Fundus; normal

Differential diagnosis
Malrotation with recurrent gut
volvulus
 Congenital ladds band
 Meckels diverticulum with mid gut
volvulus
 Annular pancreas
 Intussuception

Investigations
Hb 11.8 TC 6700 DC P68 L30 E2
 ESR 22
 RBS 82
 S.Na 142
 S.K
3.7
 S.Ca 8.2
 BU/Cr- 15/0.7
 Bb 0.7 SGOT /PT 32/23 ALP 72 TP
6.8 Alb 3.2

USG
 Dilated stomach with stasis no other
abnormality noted

OGD
 Esophagus was normal. Stomach, D1
and D2 were dilated with stasis.
Scope was not introduced beyond
D2.


CT – Suggestive of intestinal
malrotation with midgut vovulus
Surgery
Duodenum dilated upto D3
 Band from transverse colon to D3/D4
jn---released the band
 Volvulus 1/4th rotation – No
strangulation -Untwisted the bowel
 Small bowel put on the right side
 Large bowel put on the left side
 Inversion appendicectomy done

Final diagnosis
Intestinal Malrotation
 Partial intestinal obstruction at D3
level with Ladds bands and Midgut
Volvulus


Malrotation of midgut
Occurs in 1/1600 live births
 Normally midgut goes out of the
abdominal cavity during 4 th week of
gestation
 Comes back inside by the 10 th week
 Midgut rotates around the axis of
SMA for an angle of 270degrees

Initial 90 degree rotation takes place
outside the abdominal cavity
 Second stage inside the abdomen –
rotates through 180 degrees
 Third stage is the descend of cecum

Anomalies
Non rotation (most common)
 Malrotation
 Reverse rotation

Symptoms
Most patients have symptoms within
the first month
 Recurrent vomiting
 Abdominal pain
 Malabsorption
 Chylous ascites
 Asymptomatic

Associations

30 to 60%
Omphalocoele
 Gastroschisis
 Diaphragmatic hernia
 Duodenal or jejunal atresia
 Hirshsprung’s disease
 Esophageal atresia
 Biliary atresia
 Annular pancreas
 Meckel’s diverticulam
 Mesenteric cysts
 Congenital cardiac defects

Imaging modality
Plain radiograph
Upper GI contrast study
Barium enema
Ultrasonography
Findings suggestive of malrotation
Nasogastric or orogastric tube that extends
into an abnormally positioned duodenum
The "double-bubble"sign of duodenal
obstruction
A clearly misplaced duodenum (ie, ligament
of Treitz on the right side of the abdomen)
that has a "corkscrew" appearance
Duodenal obstruction, which may appear
similar to that seen with duodenal atresia or
may have more of a "beak" appearance if a
volvulus is present
Complete obstruction of the transverse
colon, particularly if the head of the barium
column has a beaked appearance
Abnormal position of the superior
mesenteric vein (either anterior or to the
left of the superior mesenteric artery)
Dilated duodenum (indicating duodenal
obstruction)
The "whirlpool" sign of volvulus (caused as
the vessels twist around the base of the
mesenteric pedicle)
Treatment

Surgery
Thank you