Another Day, Another GI Bug

This chapter presents 3 cases of vomiting in children and explores less common diagnoses not to be missed by the astute clinician. The first case of a child with recurrent progressive vomiting has unusual lab abnormalities which leads to the final diagnosis of an inborn error of metabolism. The second case presents a child with several Emergency Department visits for vomiting and a skin finding leads to a final diagnosis of non-accidental trauma. The final case reviews a vomiting child with electrolyte abnormalities and an abnormal radiograph, leading to a diagnosis of malrotation with volvulus. Each case gives the clinician key pearls to distinguish these high risk cases from everyday gastroenteritis.

Use of routine chest radiography in the evaluation of fever in neutropenic pediatric oncology patients.

Evaluation of febrile episodes in children who have become neutropenic during treatment for malignant disease has traditionally included radiography of the chest. It has been our impression that the yield of such examination is low. To test this hypothesis we reviewed all chest radiographs (CXRs) obtained in the above setting in our institution over the last 3 years. These radiographs were independently reviewed by two of us (R.C., J.F.). Sixty-one patients experienced 134 febrile neutropenic episodes for which a CXR was obtained. Only eight (6%) of these films revealed any abnormality. After careful review it was apparent that four of these radiographs did not represent a infectious process. Thus only four of 134 films (2.9%) indicated pulmonary infection as the probable cause of fever in the patient. All four of these patients had prominent respiratory signs or symptoms. Of patients who were febrile but without pulmonary signs/symptoms, only one of 49 had an abnormal radiograph. We feel that such a low yield (at most 2%) calls into question the routine practice of obtaining a CXR in the febrile neutropenic child who is otherwise asymptomatic.