Case 2: Progressive Abdominal Pain in a 3-year-old Boy with Repaired Congenital Diaphragmatic Hernia

Soham Dasgupta; Ha Nguyen; Buria Naeem; Olivia Ginnard; Vidit Bhargava; Lane Shirley

doi:10.1542/pir.2016-0205

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Soham Dasgupta, MD*
Ha Nguyen, MD*
Buria Naeem, MD*
Olivia Ginnard, MD*
Vidit Bhargava, MD*
Lane Shirley, MD*

^*Department of Pediatrics, University of Texas Medical Branch at Galveston, Galveston, TX

AUTHOR DISCLOSURE
Drs Dasgupta, Nguyen, Naeem, Ginnard, Bhargava, and Shirley have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 3-year-old boy presents to the emergency department (ED) with abdominal pain. His medical history includes a left congenital diaphragmatic hernia (repaired shortly after birth) and a small atrial septal defect. The generalized abdominal pain started 3 days ago and is associated with several episodes of nonbloody and nonbilious emesis. Evaluation at an outside ED 3 days ago included abdominal radiography (showing a large stool burden) and abdominal ultrasonography (showing a normal appendix). He was discharged with medication for constipation. However, he continues to have pain, emesis, and progressive abdominal distention. Radiographs at our ED today reveal unchanged stool burden as well as an incidental left-sided pleural effusion and lower lobe opacification (Fig 1), for which he is immediately admitted to the hospital for further evaluation.

Figure 1.

Chest radiograph shows left-sided pleural effusion, lower lobe opacification, and dilated loops of bowel.

Initial vital signs include a temperature of 96.6°F (35.9°C) (axillary), respiratory rate of 30 breaths/min, heart rate of 140 beats/min, blood pressure of 108/56 mm Hg, and oxygen saturation of 98% on room air. He exhibits respiratory distress, with grunting, subcostal retractions, and diminished air entry in the left lung base. There is significant abdominal distention, with diffuse tenderness, normal bowel sounds, and tympanic percussion from the …