Failure To Thrive and Vomiting in a 1-Month Old
Radiology Cases in Pediatric Emergency Medicine
Volume 3, Case 16
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 1-month old male who was seen by his
pediatrician in a rural town with poor feeding and
occasional emesis. His weight gain was not
satisfactory though his exact weight was not specified.
He was hospitalized for observation in a rural hospital
with a diagnosis of failure to thrive. His birth history
was unremarkable. His birth weight was 2.9 kg (6
pounds, 7 ounces).
On the third day of hospitalization, his emesis
became bilious. Radiographs of his abdomen were
View abdominal series: Flat (supine) view.
These radiographs show an obvious bowel
obstruction. The bowel is distended. The bowel walls
are smooth losing the normal plicae appearance due to
distention. The upright view shows many obvious air
Intravenous fluids were started at a maintenance
infusion. A nasogastric tube was inserted and transfer
to a children's hospital was arranged. There was no
history of fever.
Upon arrival at the children's hospital, he was
evaluated by a surgical resident. Exam: VS T37.4
(rectal), P146, R42, BP 96/49. Weight 3.7 kg. Alert,
not toxic. HEENT normal except for an NG tube in
place. Mucosa moist. Neck supple. Heart regular
without murmurs. Lungs clear. Abdomen soft, slightly
distended, hypoactive bowel sounds. No masses. No
hernias. Stool in the diaper (loose, brown), guaiac
positive. Pulses good.
He was assessed as having a bowel obstruction due
to intussusception or a malrotation. A barium enema
was ordered. An abdominal series was repeated prior
to the barium enema.
View second abdominal series.
This second abdominal series shows the same
findings as the radiographs taken at the rural hospital.
During the process of inserting the rectal tube for the
barium enema, the infant was crying and the
radiologist noticed an inguinal bulge. He contacted the
surgeon to evaluate the patient. The surgeons at this
point acknowledged that the infant had an incarcerated
right inguinal hernia. This was reduced with moderate
difficulty. The barium enema was then completed
which failed to show any evidence of intussusception or
malrotation. The infant's symptoms resolved. A
follow-up abdominal series taken the next morning
showed a normal abdominal gas pattern with resolution
of the obstruction. The inguinal hernia was repaired
and the infant was discharged home.
In retrospect, it is highly likely that the incarcerated
hernia was present during the initial examinations since
the obstruction resolved after the hernia was reduced.
Specifically checking for inguinal hernias in any patient
with vomiting would prevent one from missing this as a
cause of the vomiting. In chubby infants, an
incarcerated inguinal hernia may not be visibly obvious.
Palpating the inguinal region would immediately reveal
a hot-dog shaped mass in the inguinal region. A
thickened cord can sometimes be appreciated, but this
by itself would not indicate the presence of an
incarcerated inguinal hernia. Female infants will often
incarcerate an ovary instead of bowel. This would not
yield a cylindrical mass, but a spherical mass of rubbery
or grape-like consistency.
When bowel is incarcerated in an inguinal hernia,
irritability and signs and symptoms of a bowel
obstruction will develop. Radiographic signs of a bowel
obstruction may be absent if the duration of the
incarceration is short. Bowel gas may be visible in the
groin region, but the absence of this does not rule out
an incarcerated inguinal hernia. Review our patient's
initial supine abdominal film again.
There is a pattern of air in the infant's left groin
region. In this case, this air is probably due to a skin
fold since clinically the infant's hernia was on the right.
Additionally, this air does not show a pattern resembling
Most parents will seek medical attention when the
inguinal bulge is noted before a bowel obstruction
becomes obvious. Others will present with symptoms
of a bowel obstruction. A delay in diagnosis can lead to
bowel ischemia, necrosis, and perforation.
It is often difficult to distinguish a tense hydrocele
from an incarcerated hernia. Hydroceles are commonly
referred to pediatric centers because they are often
difficult to distinguish from an incarcerated hernia or an
acute scrotum. A hydrocele transilluminates fully.
Typically, a spherical or oval mass is palpable in a
hydrocele, while the mass is usually banana or hot-dog
shaped in an incarcerated inguinal hernia. The
hydrocele mass is within the scrotum, while the mass of
an incarcerated inguinal hernia extends from the
internal ring to varying depths into the scrotum.
Unless the child is very ill or bowel necrosis is
suspected, a manual reduction of the incarcerated
hernia is indicated. Rather than attempting to push the
hernia through the ring, it is more optimal to squeeze
gas or fluid out of it longitudinally from the tip back
toward the abdominal cavity. If reduction is not
attempted or unsuccessful, a surgeon should be
consulted to perform the reduction or to repair the
Schnaufer L, Mahboubi S. Abdominal Emergencies.
In: Fleisher GR, Ludwig S (eds). Textbook of Pediatric
Emergency Medicine, third edition. Baltimore, MD,
Williams and Wilkins, 1993, p. 1316-1317.
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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine