Tennessee Medicine E-Journal


We present the case of an 8-month-old male who presented to the emergency department (ED) following 3 days of vomiting. Of note the patient had been seen in the ED a day prior with symptoms consistent with upper respiratory infection and at the time review of symptoms (ROS) had no pertinent positives per the ED note. At the initial visit, physical examination was remarkable for elevated BP (112/77) and tachycardia (144bpm) thought to be secondary to agitation, but was otherwise negative. Initial workup was negative, including RSV and Influenza screen and chest xray. A KUB showed a moderate amount of stool throughout the colon. The patient passed an oral challenge and was sent home. On his return 24 hours later, his mother complained of continued emesis described as milk-colored initially then later became green in color, aggravated by any attempted oral intake. Physical exam was significant for diffuse abdominal tenderness on palpation. Chemistry panel demonstrated hyponatremic hypokalemic hypochloremic metabolic alkalosis. A venous blood gas confirmed purely metabolic alkalosis. Abdominal ultrasonography revealed a partially visualized fluid-filled distal stomach and dilated fluid-filled proximal duodenum. An upper gastrointestinal series was interpreted as impressive for malrotation with completely obstructing midgut volvulus. The patient had emergent surgical exploration with findings negative for volvulus or malrotation, and significant finding of duodenal web. His post-operative course was complicated by a PICC line infection. He was discharged home 3 weeks later. In this case report, we hope to highlight the need for complete history and physical examination, as well as the role for differentials in the discussion and management of a patient who presents in a similar fashion.