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Virtual Pediatric Hospital: Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology: Case 24

Correlapaedia - a Correlative Encyclopedia of Pediatric Imaging, Surgery, and Pathology

Case 24

Michael P. D'Alessandro, M.D.,
Steven J. Fishman, M.D.,
Deborah E. Schofield, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Eleven year old female who had an appendectomy 3 months ago and now has abdominal pain and vomiting.

Clinical History:
The patient was an 11 year old female status post appendectomy 3 months ago. The patient presented with a two day history of crampy abdominal pain and a six hour history of vomiting. The patient denied fever and diarrhea. The patient has a past medical history remarkable for insulin-dependent diabetes mellitus which is poorly controlled and rheumatoid arthritis.

Clinical Physical Exam:
The abdomen was soft without rebound or guarding but with right sided tenderness.

Clinical Labs:
The white count was 10.2, with 56% polys and 35% lymphs.

Clinical Differential Diagnosis:
Gastroenteritis, small bowel obstruction due to adhesions

Imaging Findings:
An abdominal film from the day of admission was unremarkable. A repeat abdominal film from the second hospital day showed interval development of a complete small bowel obstruction, and this was confirmed on an upper GI exam the same day.

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Imaging Differential Diagnosis:
Partial distal small bowel obstruction.

Operative Findings:
In light of the patient's worsening abdominal symptoms and the upper GI findings, the patient was taken to the operating room the next day for an exploratory laparotomy via a small peri-umbilical midline incision. A small amount of serosanguinous fluid was seen in the abdominal cavity. The small bowel was dilated proximally. A volvulus was noted at the level of the terminal ileum, caused by adhesions from the cecum to the small bowel, forming a closed loop obstruction that was causing some bowel wall congestion. The patient underwent lysis of adhesions and had the volvulus corrected.

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Pathological Findings:
None

Final Diagnosis:
Small Bowel Obstruction

Follow-up and Prognosis:
The patient had an uncomplicated post-operative course.

Similar Cases:
Case 9, Case 55

References:

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