Ultrasound images Sanjay Ramrakha. Text Genevieve Carbonatto and Katherine Bennett
The Emergency department gets a pre arrival call from a GP. He is sending in a sick looking 10 year old who has been vomiting overnight. He thinks this may be gastro
On arrival a pale, mottled, barely responsive child is wheeled into the resuscitation area. His respiratory rate is 40/min, heart rate 140/min, BP 80/59, capillary refill 4 sec, saturating 100% on 15 l with a non rebreathing mask.
His abdomen is generally tender, slightly distended but not peritonic.
The story is this. He developed acute onset vomiting the night before and vomited all night. No haematemesis or bilious vomiting. He complained of abdominal pain. He had opened his bowels the day before and his stool had been normal. He had been afebrile and was afebrile on arrival to the Emergency Department.
Resuscitation is commenced immediately with iv fluids and bloods are taken.
The Emergency Physician performs a Point of Care abdominal ultrasound
It is clear that the abdomen is full of free fluid with loops of bowel floating in this fluid.
The bloods come back
- pH 7.32, PCO2 30, HCO3 15, BE -10, lactate 5.7, glucose 4.4
- WCC 29.7, Neut 20.2, lymph 6.2, Hb 141, plt 406
- Na 138, K 5.2, CL 102, HCO3 14, Urea 12.9, Creatinine 119
He is acidotic, has a neutrophilia and has acute renal impairment.
He continues to get further fluid boluses of 20mls/kg. His level of consciousness improves . His lactate is repeated and is now 11. An IDC is inserted, the surgeons are contacted. It is likely that this boy has an ischaemic gut. A chest Xray and abdominal Xray are done – both are unremarkable. He needs to be transferred to a specialised pediatric hospital. The retrieval team is contacted. The amount of fluid on the ultrasound examination is described and explained.
The child is transferred , goes to theatre and is found to have at laparoscopy a left internal paraduodenal hernia with ischaemic bowel. A laparotomy is performed and 120 cm of ischaemic gut is found. 8 cm of full thickness ischaemic bowel is removed.
He makes an excellent recovery.
What is an Internal Hernia ?
The incidence of internal hernias is very rare. Possibly less than 1% of causes of acute bowel obstruction.
They are defined as the protrusion of bowel through a normal or abnormal mesenteric opening within the peritoneal cavity. This opening can either be acquired (post surgical – common in adults) or congenital.
The clinical picture is non specific ranging from mild abdominal discomfort to acute intestinal obstruction. Intestinal obstruction is associated with a high mortality, up to 50% in one case series. In children the most common type of type of intestinal hernia is paraduodenal.
Paraduodenal internal hernias can be divided into 2 types, left and right, the left being more common. The bowel prolases through Landzert’s fossa, a congenital opening in the mesentery present in approximately 2% of the population.
Teaching point: Any child with abdominal pain and free fluid in their abdomen on bedside ultrasound is a surgical emergency unless proven otherwise. No other explanation for this should be entertained until a surgical cause has been properly excluded.