Case 2: Acute Onset of Vomiting, Abdominal Pain, and Constipation in an 18-month-old Girl

Presentation

An 18-month-old girl presents to the emergency department with a 4-day history of postprandial emesis. The patient was seen 2 days earlier for the vomiting episodes and was discharged from a community emergency department after a normal saline bolus. The mother returns with the patient because of continued episodes of nonbloody, nonbilious emesis with decreased fluid intake and decreased urine output. The patient has also been complaining intermittently of abdominal pain and has had no bowel movement for the past 5 days. She has been afebrile throughout. Her medical history is notable for prematurity of 33 weeks, with a 1-month NICU hospitalization for feeding difficulties, with no known abdominal complications of prematurity. There is no medical history of constipation.

On presentation, she is afebrile and tachycardic to 150 beats/min. Other vital signs are appropriate for age. The patient has dry mucus membranes with preserved skin turgor, and capillary refill is less than 3 seconds. Abdominal examination reveals substantial abdominal tenderness, especially in the right lower quadrant and suprapubic region, with no rebound and voluntary guarding. There are no peritoneal signs. There are no palpable masses, but marked diffuse distention is present in the lower quadrants bilaterally. Bowel sounds are hypoactive. External genitalia are normal, and findings from the rectal examination are normal. …