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Clinical Case 127: What’s in a Spew?

Hi all,

Here is a classic case from the Broome Docs Archive.

I will give you the story and the exam and you can let me know what you think is going on, what you would do next and how.

Your patient is Tristan – he is a 2 week old (yes, 14 days out) baby boy.  He has been brought into ED at midnight by his concerned parents with “vomiting”.

So immediately all of that neonatology and Paed Surgery starts drifting up from the dim recesses of your hindbrain.  This could be really bad… or completely benign.  Actually, that is the general theme of all Neonatology pretty much!  On with the story.

On further questioning Mum says he has been vomiting for about 3 days on and off.  Initially it was just a few little chucks AKA ‘Mum badges’.  But in the last 24 hours he has had larger vomits.  “It seems like all his feeds are coming up”, says Mum.  The vomiting is post-feeds usually 20- 30 minutes.  He has been difficult to settle after feeds.  And as is now traditional Dad produces an iPhone with a photo of one of the vomits – it does have a very faint streak of red in the mucus.  Hence the visit to the ED.

On careful questioning – the vomitus is always white / milky or a little bit yellowish – but NOT green.  [See this great post from Nat May on Emesemantics here]   The vomiting is non-projectile, it falls onto he chest of whomever is holding Tristan – it doesn’t travel over the shoulder or bed.

Both parents agree that his abdomen seems a little distended compared to usual – tho he is only 10 days out of the ward.  Speaking of which…

A quick glance through the birth records describes the following.

  • Uncomplicated pregnancy – primigravida
  • Term birth after ARM in early labour
  • Vaginal birth with Apgars 9 & 9.  Birth weight 4.000 kg
  • Tristan was slow to feed and developed a bit of jaundice on day 3, this did not ned intervention other than “top-up feeds”
  • He lost 8% of birth weight by day 3 and stayed in an extra day to get him feeding at the breast.  Nadir weight: 3680 g
  • He was still having top ups on discharge.  Discharge weight: 3700 g
  • He was weighed at home on day 7 and weighed 4010 g
  • Tonight he weighs in at 4600 g

On examination Tristan is pink, well perfused with no appreciable jaundice remaining.

His Obs are normal for age.  Normothermic, brisk cap refill, no obvious birth defect  /syndromic traits.

He seems a bit irritable… then has a vomit and settles quite quickly.  The vomit is milky, and non-projectile.

His belly is mildly distended.  There is no visible peristaltic movement and he has no palpable “tumour” in the RUQ.

So….  what is going on?

3 Questions as always

  1. Vomiting in a well looking baby – could be a lot of things… but the 600g weight gain is highly suggestive of excessive feeding / top-ups. It could be heart failure I guess, but they usually fail to feed well and put on weight as they go into pulmonary edema.
    ?
  2. Vomiting is the least specific symptom.. but consider: Sepsis / occult infection eg. UTI, pneumonia… Pyloric stenosis GI malrotation / volvulus Heart failure
  3. The “test feed” is an easy test to do at anytime. US can help look for pyloric tumour and other dilated loops / obstruction. A VBG might help if you are thinking PS as it should show a hypochloremic metabolic alkalosis Obviously a septic screen if you feel sepsis is on the cards

Let me hear your thoughts, share your wisdom and educate us all..

Casey

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