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.

Upright 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 
fluid levels.
     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 
bowel gas.
     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