SRP Discussion
Case Takeaways
The cases presented here present more challenging diagnostic dilemmas, with one case involving an atypical presentation of bowel obstruction and pneumatosis intestinalis, and another case involving a meconium pseudocyst that was later identified as an enteric duplication cyst requiring surgical intervention.
Baby's Bilious Vomiting Mystery
Discussed was a case of a baby who was born term and presented with bilious vomiting after the mother changed the baby's feeding from exclusive breastfeeding to mixed breastfeeding. The baby was admitted to the NICU and underwent various tests, including an upper and lower GI study and an echocardiogram, which showed atrial septal defect. Despite initial concerns about midgut volvulus, the baby was treated for cow's milk protein intolerance and discharged from the NICU after 5 days. The baby's lactate level was initially high, but later normalized, and the diagnostic uncertainty led to a trial of feeds, which the baby tolerated well.
Atypical Bowel Obstruction in Infant
A challenging case of a term infant with an atypical presentation of bowel obstruction and pneumatosis intestinalis was presented. Initial imaging showed dilated bowel loops, questionable pneumatosis, and a high-riding cecum, leading to a contrast enema to investigate for Hirschsprung disease. Despite the pneumatosis, a contrast study was deemed safe due to the asymptomatic presentation and the need to rule out partial obstruction. The enema revealed a high-riding cecum with no other abnormalities, suggesting a diagnosis of atypical malrotation or short mesentery. The infant was initially treated with antibiotics, which were discontinued after 4 days when symptoms improved. Thirteen days later, the infant was readmitted with reduced feeding and regurgitation, prompting further imaging and surgical consultation.
Unusual Meconium Pseudocyst Case
The team discussed a complex case involving a baby with an atypical presentation of a meconium pseudocyst, which was later diagnosed as an enteric duplication cyst after surgical intervention. The patient's clinical course was unusual, as the baby remained stable despite imaging suggesting obstruction, and the cyst's appearance on ultrasound was more defined than typically seen with meconium pseudocysts. During surgery, the cyst was found to be partially intramural at the ileocecal junction, and the team performed a laparoscopic resection with an extracorporeal anastomosis through a small umbilical incision. Pathological examination revealed calcifications within the cyst, though the exact cause of these calcifications remains unclear.