PO18 JUST NOT HYPERTROPHIC PILORY STENOSIS

Introduction: Recurrent abdominal pain is in most of case a functional disease. It has been consistently found that only 5 to 10% of children with RAP have an underlying organic process that contributes to their pain. A careful analysis of components of the clinical history, meticulous examination and laboratory findings are mandatory in order to minimize the diagnostic error, saving invasive procedures, without underestimating the continuous pain. Case report: A 10-year-old female, previously well, was admitted in hospital because of fever, vomiting and epigastric periumbilical abdominal pain. Pain was unresponsiveness to H2 receptor antagonist. She was 60 kg, in good general condition, no pain during abdomen palpation. During hospitalitation laboratory exams (fecal occult blood, and calprotectin, count blood cell, test for celiac disease) and instrumental examination (abdomen XR and ultrasound) were performed and they were negative. Because of persistent abdominal pain and constipation has performed psychosomatic counseling and started methyl bromide and diazepam therapy with improvement. After one month she turned back to hospital because of vomiting and abdominal pain. She was 47 kg, clinical examination was negative. Laboratory findings showed leucocytosis, and acute renal failure due to dehydration. Despite fluid resuscitation she had vomiting and persistent low potassium level. Abdomen XR was negative, but the patient refused to take the barium contrast medium for XR. For the suspicion of organic cause of anorexia she made cranial CT scan that was negative. Upper GI endoscopy revealed in the gastric cavity abundant secretions with bile and food residues, in the bulb and second duodenal portion a dystrophic whitish mucosa like a maceration; at the third duodenal portion accumulation of greenish liquid secretions likely substenosis of the distal intestinal tract. Finally, the abdominal CT shows gastrectasia, duodenum like corkscrew around the mesenteric vessels, hypervascular appearance of the mesentery, which argue for intestinal malrotation confirmed by radiographs obtained with barium administered. She subsequently underwent surgery. Conclusions: Malrotation may be manifested also in older children and adults (5,20−22). The clinical manifestations in older patients often are much less straightforward than are those in neonates and may include a wide variety of signs and symptoms like vomiting, constipation, failure to thrive, abdominal pain. They need surgical intervention.