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Vomiting in a Teenager with Down Syndrome

2016; Elsevier BV; Volume: 174; Linguagem: Inglês

10.1016/j.jpeds.2016.03.061

1097-6833

Senthil S. Gunasekaran, Michele E. Cho, Thirumazhisai S. Gunasekaran,

Intestinal and Peritoneal Adhesions

A 16-year-old boy with Down syndrome (Trisomy 21) and mild developmental delay was evaluated following 1 week of recurrent, nonbilious vomiting. He continued to pass stool and flatus and had no fever or previous abdominal surgery. His weight was 42.4 kg and height 146 cm (both 5th percentile). The patient's abdomen was non-distended and soft without palpable mass or tenderness. Abdominal radiograph at initial presentation demonstrated a non-obstructive bowel gas pattern with a round foreign body in the right upper quadrant (Figure 1; available at www.jpeds.com). Complete blood count, serum electrolytes, urea, and creatinine were normal. He was admitted for rehydration with intravenous fluids, later tolerated a general diet, and was discharged home in stable condition to be followed in clinic. He remained asymptomatic, passing flatus and stools, but did not expel the foreign body. The patient was readmitted 5 days later with another bout of vomiting. His physical examination was unchanged except for mild fullness in the upper abdomen. Abdominal radiograph demonstrated a typical "double bubble" bowel gas pattern with air in the distal small bowel and colon along with round foreign bodies in the projection of the proximal duodenum (Figure 2).1Traubici J. The double bubble sign.Radiology. 2001; 220: 463-464Crossref PubMed Scopus (37) Google Scholar This bowel gas pattern was classic for duodenal stenosis; the dilated stomach as proximal bubble and the dilated duodenum is the distal bubble. The fact that the patient presented with a proximal small bowel obstruction further confirms this diagnosis, as a foreign body of that size should typically pass without intervention in a 16-year-old boy.2Webb W.A. Management of foreign bodies of the upper gastrointestinal tract: update.Gastrointest Endosc. 1995; 41: 39-51Abstract Full Text Full Text PDF PubMed Scopus (477) Google Scholar The foreign bodies were three coins stacked one on top of the other and are seen on the right lateral decubitus radiograph (Figure 3; available at www.jpeds.com). Endoscopy confirmed and demonstrated approximately 70% duodenal stenosis and 3 coins (US penny, nickel, and dime) at the dilated proximal duodenum. The patient underwent successful foreign body retrieval and later duodenoplasty with resolution of symptoms. At 6-month follow-up, he remained asymptomatic. Patients with Down syndrome have a higher incidence of congenital gastrointestinal anomalies. In a large population-based ethnically diverse survey of 1892 infants with Down syndrome, congenital gastrointestinal defects were present in 6.7%. Theses defects include esophageal atresia/tracheoesophageal fistula (0.4%), duodenal stenosis/atresia (3.9%), Hirschsprung disease (0.8%), anal stenosis/atresia (1.0%), and pyloric stenosis (0.3%).3Freeman S.B. Torfs C.P. Romitti P.A. Royle M.H. Druschel C. Hobbs C.A. et al.Congenital gastrointestinal defects in Down syndrome: a report from the Atlanta and National Down Syndrome Projects.Clin Genet. 2009; 75: 180-184Crossref PubMed Scopus (70) Google Scholar Although foreign bodies in the gastrointestinal tract are common, this case is atypical with unique findings on radiograph, which should alert the clinician to suspect an underlying anatomical anomaly. Figure 3Radiograph of the abdomen; lateral view with foreign bodies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)