Khin Thidar Oo, Ye Hla
Presentation
A four year and 10-month-old girl was admitted to Parami General Hospital on 16th April 2025 with chief complaints of vomiting and frequent vomiting, especially in the early mornings noticed since January 2025. Vomiting occurred daily, typically one or two times every morning, especially following breakfast. Vomitus contained ingested food or clear mucus, but not bile-stained.
Other associated symptoms are nausea, frequent or persistent, daily rise of low-grade fever, weight loss was present and growth and development faltered. Negative signs are the absence of abdominal pain or urinary symptoms nor headache or dizziness. Normal bowel opened daily.
History of past illness
History of intermittent vomiting since the age of two years. Weaning started at 8 month of age, symptom started from acute viral infection with vomiting, not associated with meal or weaning diet. It took place mostly in the morning immediately after waking up with or without food intake. Poor oral food intake was observed and no proper weight gain observed over time and the growth faltered.
Feeding time was very much prolonged and it took at least 2 hours for one-time feeding. No history of tuberculosis in the family or contact. No history of food allergies.
Birth history
The girl was born at 28th weeks of gestation and delivered by emergency LSCS and premature with birth weight of xx kg (preterm). She required hospitalization at YCH for 2 months for neonatal care.
Development history
No history of developmental delay
Immunization history is up to date by verbal response
No known drug allergy or Glucose 6-PD deficiency
There was history of taking antiemetic and pantocid at least one year off and on .
Family history: no relevant family history of similar illness or problem.
On examination general condition was good. She looked well and alert GCS- 15/15
Temperature was normal. Body weight was 14 kg and the child appeared thin for age.
Eye- no pallor, no jaundice and no signs of dehydration
Initial/working provisional diagnosis was Acute Viral Infection with vomiting Suspected of GERD (gastro-esophageal reflux disease) and Structural abnormality cannot be excluded
Laboratory examination
- CBC – all within normal
- C-Reactive Protein – 49
- Dengue serology – NS1, IgG and IgM negative
- Serum Amylase – 112
- Urea & Electrolytes: – normal range
- LFT – normal
- URE – normal
Imaging
Ultrasonography (abdomen) – No abnormality is detected
Barium meal follow-through results are as follows.
Opinion: there is no evidence of GERD , no obvious narrowing or dilatation is seen in the gastrointestinal tract visualized,
Ileal loop and ileo-caecal junctions appear high and abnormal in position
Impression: possible Ladd’s band or malrotation according to Ba meal follow-through where the bands located at the pylorus mentioned in post op note)
Treatment
1st Day of admission (16.4.2025)
IV DS (maint:) 52ml / hr
IV cefotaxime 500mg 8hrly (ATD)
NBM
Plan to operate
Operation was done on 20.4.2025
Operative findings
Malrotation was observed.
Caecum was located at right hypochondrium, (high positioned caecum).
Ladd’s bands(+++) are present stretching between and abdominal walls.
Duodenal Jejunal junction was in the midline.
Pyloric web was present at pylorus.
Procedure: Ladd’s procedure was done
Gastrointestinal diseases
GERD (gastro-esophageal reflux disease) commonly presenting as effortless vomiting, irritability, poor weight gain.
Congenital pyloric stenosis which is commonly seen in (2 – 8 week old infants presenting with non bilious projectile vomiting, palpable olive mass in the abdomen.
Malrotation with or without volvulus of the intestines, which presented as bilious vomiting, episodic pain and failure to thrive.
Intussusception presenting with bilious vomiting, abdominal distension and red currant jelly stool.
Constipation and faecal impaction which presented with chronic vomiting, distended abdomen and palpable fecal matter.
Esophagitis or gastritis Chronic vomiting, feeding aversion or dysphagia
Peptic ulcer diseases pain in epigastrium especially at time and vomiting
Neurological group
Increased intracranial pressures which presented as projectile vomiting, headache and impaired vision
Migraine presenting as headache, photophobia, headache and episodic vomiting may or may not be present
Metabolic causes
Diabetic ketoacidosis which present as vomiting, dehydration, acidotic breathing, fruity smell and high blood glucose level.
Vestibular disease which present as vomiting with vertigo or imbalance rare in young children
Adrenal insufficiency may present as vomiting, weight loss , electrolyte imbalance
Inborn errors of metabolism which may present ad vomiting with lethargy, failure to thrive, unusual smell or odours
Rumination: Effortless regurgitation after meals, especially in older children
Anxiety or stress related situational and may have problems at school
Eating disorders presenting with induced vomiting and weight loss
Infections and inflammatory causes are excluded as parasitic diseases, viral infections and common condition of urinary tract infections and lead poisoning which is sometimes common in children.
The above-mentioned conditions and disorders categorized by anatomical and pathological groups are filtered out and excluded by proper history taking and laboratory examination to clinch the diagnosis.
Malrotation was finally diagnosed by proved by radiology and surgical interventions and history of prolonged feeding time of the meals especially early feeds
Malrotation is a congenital anomaly which resulted from improper rotation and fixation of the intestines during fetal development.
The condition can lead to life-threatening complications like midgut volvulus and occurs in approximately 1 in 6000 live births.
Embryological and pathology
In the embryogenesis the midgut undergoes A 270°degree counterclockwise rotation around the superior mesenteric artery during early phases. But in the case of pathological Malrotation incomplete or incorrect rotation leads to abnormal positioning of the intestines and a narrow mesenteric base.
Figures showed the degree of rotation of the gut around the mesenteric artery base in respective degree. The transverse colon is coloured brown and intestinal loops in yellow.
Clinical presentation
In the neonates bilious vomiting, abdominal distension, feeding intolerance are presenting symptoms. Infants and children will have the symptoms of abdominal pain, vomiting, failure to thrive. Adults are often asymptomatic or present with chronic abdominal symptoms in some case.
Diagnostic Imaging
Upper GI series are the gold standard for diagnosis and reveals abnormal position of the duodeno – jejunal junction.
Ultrasonography USG may show “whirlpool sign” indicating volvulus.
Laboratory tests results are generally nonspecific; may show signs of dehydration or infection.
Surgical intervention : Ladd’s procedure is the standard treatment.
Steps in operative procedures consist of divisions of Ladd’s bands
(the colon or intestine and abdominal walls)
Widening of the mesenteric base.
Placement of intestine in a non-rotated position.
Appendectomy is carried out in order to prevent future diagnostic confusion.
Postoperative care and prognosis
Early diagnosis and treatment is associated with excellent outcomes. Symptoms for short bowel syndrome should be closely monitored (if resection needed). There is an increased risk of bowel necrosis and mortality. And there is a lifelong risk of obstruction from resulting adhesions. Complications that can follow are volvulus of midgut, leading to ischemia, necrosis and perforation of the intestines and colons. Sepsis and late diagnosis may lead to death.
Conclusion
Early recognition and intervention are important in order to prevent intestinal obstruction and volvulus.
Ladd’s procedure is lifesaving.
Need for awareness of the condition and timely referral for surgical interventions if required.
When a patient presents with minor or mild repeated, prolonged symptoms, we should keep in mind the possible hidden diagnosis including rare structural disease.
References
- George W. Holcomb I J. Patrick Murphy Shawn D. St. Peter (2019) Holcomb and Ashcraft’s Pediatric Surgery, 7th edition.
- John M. Hutson, Michael O’Brien, Alan A. Woodward, Spencer W. Beasley (2008) Jones’ Clinical Paediatric Surgery: Diagnosis and Management, 6th edition.
Author Information
Khin Thidar Oo, Ye Hla
- Senior Medical Officer, Parami General Hospital
- Department of Medical Research, Central Myanmar
