Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome: Two case reports and review of literature.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient. CASE SUMMARY: Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position. CONCLUSION: The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Horizontal and vertical beam radiographs in vomiting dogs to diagnose mechanical gastrointestinal ileus: A diagnostic imaging comparative study.

Background: The horizontal beam (HB) view has been used in the identification of pneumothorax, pleural effusion, and pneumoperitoneum in small animals. Based on the literature, there were no published data evaluating the utility of HB radiography in vomiting dogs to differentiate between patients with or without mechanical gastrointestinal ileus. Aim: The purpose of this prospective pilot study was to determine the utility of HB radiograph as an additional view in vomiting dogs to differentiate patients with or without mechanical gastrointestinal ileus; and describe if there are any radiographic image characteristics associated with the HB view for patients with mechanical gastrointestinal ileus. Methods: A prospective study was carried out on dogs presented with acute vomiting. For all dogs, four radiographic views [ventrodorsal (VD), right lateral, left lateral, and left-to-right lateral HB in sternal recumbency] of the abdomen and abdominal ultrasound were obtained. If a mechanical ileus was detected ultrasonographically, an exploratory laparotomy or endoscopy was performed, otherwise medical treatment was elected. Results: A total of 22 patients were recruited, 11 diagnosed with mechanical ileus and 11 without mechanical ileus. Three blinded reviewers independently assessed the radiographs in three sets: vertical beam (VB) views, HB view alone, and a combination of both views. No statistical difference was found in the differentiation between patients with or without mechanical gastrointestinal ileus between HB views alone or added to VB views. Conclusion: This study suggests that the HB view in sternal recumbency may be an alternative for patients who are not stable enough to be positioned in lateral or VD recumbency.

Vomiting-induced costal cartilage fracture: a case report.

The use of ultrasonography as a first line imaging test in cases of possible costal cartilage fracture can be pivotal. In this case report, we present the case of a patient with a suspected atraumatic vomiting-induced costal cartilage fracture. The costal cartilage fracture was non-displaced and incomplete, thus not visible in a Computed Tomography scan. When Ultrasound imaging was employed at the area of tenderness, soft tissue edema and hematoma around the cartilage were visualized. High level of suspicion for a cartilage fracture in this case revealed a subtle osseous injury.

Pregnancy and brain tumors; a systematic review of the literature.

The incidence of primary brain tumors during pregnancy is uncommon. The etiology of these can range from different genetic syndromes such as Li Fraumeni, neurofibromatosis type I, and hormonal associated tumors. The number of meningiomas gradually tends to increase during pregnancy, suggesting a relationship between non-malignant meningiomas and hormonal changes. Clinical features are non specific or can be misinterpreted with pregnancy symptoms such as headache, vomiting and dizziness. It is worth mentioning that the symptoms due to intracranial tumors are no different in pregnant compared with non pregnant patients. However, retrospective studies in glioma behavior suggested that both tumor volume and growth, increased during pregnancy. These changes were correlated with clinical worsening and increased frequency of seizures. The diagnosis requires a proper neurologic exploration and the support of imaging studies. Treatment of tumors is very controversial since we look for the preservation of both mother and fetus. In theory, the best therapy for the mother will also be the best therapy for the fetus. During pregnancy, ideally the treatment is symptomatic, to preserve the fetus, and definite treatment may be performed after birth; the latter is not always accomplished since patients may present with impending herniation or a malignant tumor for which immediate management is necessary. We intend to give an updated review in the literature on the adequate treatment of brain tumors during pregnancy and the anesthetic management during the definite treatment. Literature data was obtained from Pubmed using the search terms: "Pregnancy", "Brain", "Tumors". A total of forty-three articles were selected.

ACR Appropriateness Criteria® Vomiting in Infants.

Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Imaging of the Infant with Vomiting.

Infants with vomiting is a common problem for which families seek pediatric advice or treatment. Determining which children need testing versus reassurance depends on the onset, quality, frequency, and associated symptoms. Vomiting may result from a congenital atresia, an error in embryonic rotation, or may be secondarily acquired. [Pediatr Ann. 2020;49(9):e374-e379.].

Quantitative electroencephalogram analysis of frontal cortex functional changes in patients with migraine.

The functional abnormality of brain areas accounting for the migraine remains to be elucidated. Most related studies have used functional magnetic resonance imaging to investigate brain areas involved in migraine. However, the results are heterogeneous. In this study, we used a convenient tool to explore the brain regions involved in migraine. In this study, 40 children with migraine and 40 sex- and age-matched health controls were enrolled, and electroencephalogram was used to explore the functional abnormal areas of migraine through electroencephalogram bands and low-resolution electromagnetic tomography analysis. The results revealed that spectrum edge frequency 50 in all electroencephalogram channels in patients with migraine were lower than those in controls. Significant differences were discovered over frontal areas. In addition, significantly higher current density over the frontopolar prefrontal cortex and orbitofrontal cortex and higher connectivity over the left prefrontal cortex were observed in patients with migraine. We suggest that functional disturbance of the prefrontal cortex may play a potential role in children with migraine, and that low-resolution electromagnetic tomography is a reliable and convenient tool for studying the functional disturbance of migraine.

Autonomic function in gastroparesis and chronic unexplained nausea and vomiting: Relationship with etiology, gastric emptying, and symptom severity.

BACKGROUND: Autonomic dysfunction can be present in patients with idiopathic and diabetic gastroparesis. The role of autonomic dysfunction relating to gastric emptying and upper gastrointestinal symptoms in patients with gastroparesis and chronic unexplained nausea and vomiting (CUNV) remains unclear. The aim of our study is to evaluate autonomic function in patients with gastroparesis and CUNV with respect to etiology, gastric emptying and symptom severity. METHODS: We studied 242 patients with chronic gastroparetic symptoms recruited at eight centers. All patients had a gastric emptying scintigraphy within 6 months of the study. Symptom severity was assessed using the gastroparesis cardinal symptom index. Autonomic function testing was performed at baseline enrollment using the ANX 3.0 autonomic monitoring system which measures heart rate variability and respiratory activity measurements. KEY RESULTS: Low sympathetic response to challenge (Valsalva or standing) was the most common abnormality seen impacting 89% diabetic and 74% idiopathic patients. Diabetics compared to idiopathics, exhibited greater global hypofunction with sympathetic (OR = 4.7, 95% CI 2.2-10.3; P < .001) and parasympathetic (OR = 7.2, 95% CI 3.4-15.0; P < .001) dysfunction. Patients with delayed gastric emptying were more likely to have paradoxic parasympathetic excessive during sympathetic challenge [(Valsalva or standing) 40% vs. 26%, P = .05]. Patients with more severe symptoms exhibited greater parasympathetic dysfunction compared to those with mild-moderate symptoms: resting sympathovagal balance [LFa/RFa 1.8 (1.0-3.1) vs. 1.2 (0.6-2.3), P = .006)] and standing parasympathetic activity [0.4 (0.1-0.8) vs. 0.6 (0.2-1.7); P = .03]. CONCLUSIONS: Autonomic dysfunction was common in patients with gastroparesis and CUNV. Parasympathetic dysfunction was associated with delayed gastric emptying and more severe upper gastrointestinal symptoms. Conversely, sympathetic hypofunction was associated with milder symptoms. INFERENCES: Gastroparesis and CUNV may be a manifestation of GI autonomic dysfunction or imbalance, such that sympathetic dysfunction occurs early on in the manifestation of chronic upper GI symptoms, while parasympathetic dysfunction results in more severe symptoms and delayed gastric emptying.

A man with intolerant vomiting.

Case presentationA 57-year-old man was in a healthy state until 6 hours before presenting to the emergency department, when he suffered from more than 10 episodes of vomiting after a large meal at lunchtime. On physical examination, vital signs were unremarkable. Tenderness was noted over the epigastrium on palpation. Point-of-care ultrasound (POCUS) of the abdomen is shown in figure 1 and online supplementary video 1.DC1SP110.1136/emermed-2019-208863.supp1Supplementary video emermed;37/1/41/F1F1F1Figure 1Transverse (A) and longitudinal (B) ultrasonography of the epigastrium. QUESTION: What is the most likely diagnosis?Hypertrophic pylorus stenosisAortic dissectionSuperior mesentery artery (SMA) syndromeVolvulus For answer see page 2.

Vomiting and Dehydration in a 2-Year-Old.

A 2-year-old girl with a past medical history of cutaneous mastocytosis and eczema presented with 1 day of yellow-green, nonbloody vomiting, bradycardia, and listlessness. She was evaluated by her pediatrician and sent to the emergency department because of concern for dehydration. In the emergency department, she improved with fluid rehydration but still had decreased energy and bradycardia. Her electrocardiogram revealed sinus bradycardia, and laboratory results did not reveal any electrolyte abnormalities. Glucose levels were normal. An abdominal radiograph revealed a moderate-to-large stool burden, and the results of a computed tomography scan of the head were normal. An abdominal ultrasound was obtained to evaluate for intussusception. The ultrasound revealed a blind-ending tubular structure in the right-lower quadrant with adjacent free fluid, which was concerning for appendicitis. The patient was admitted to the surgical service for further management and was taken to the operating room, where a definitive diagnosis was made.

Understanding the Constipation Conundrum: Predictors of Obtaining an Abdominal Radiograph During the Emergency Department Evaluation of Pediatric Constipation.

OBJECTIVES: Many children with constipation who are evaluated in emergency departments (EDs) receive an abdominal radiograph (AR) despite evidence-based guidelines discouraging imaging. The objectives of this study were to identify predictors associated with obtaining an AR and to determine if ARs were associated with a longer length of stay (LOS) among children with constipation evaluated in the ED. METHODS: A review of billing and electronic health records was conducted in an academic pediatric ED for children ages 0 to 17 years who had a primary discharge diagnosis of constipation from July 2013 to June 2014. Logistic regression was used to identify predictors for obtaining an AR. Differences in mean LOS were analyzed using linear regression. RESULTS: In total, 326 children met inclusion criteria, and 60% of the children received an AR. In logistic regression, significant predictors included age (odds ratio [OR] = 1.1/year of age, P = 0.004), presenting with abdominal pain as chief complaint compared with constipation (OR = 4.4, P < 0.0001), and history of emesis (OR = 2.8, P = 0.001) after controlling for provider type and previous constipation medication use. In linear regression, the adjusted mean LOS for those with an AR was 163 minutes compared with 117 minutes for those without after controlling for age, provider type, and history of constipation medication use (P < 0.0001). CONCLUSIONS: Abdominal radiographs were used frequently in the ED diagnosis and management of constipation, particularly in older children and those with abdominal pain and emesis. Abdominal radiographs were associated with increased LOS.

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients.

BACKGROUND: Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied. OBJECTIVES: We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield. MATERIALS AND METHODS: Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18 years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records. RESULTS: Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2 years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11 months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively). CONCLUSION: The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.