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A male infant aged 49 days, was brought by his mum for abdominal distension and poor weight gain.
History reveals a moderately well followed up G1P0 pregnancy in a private clinic, no abnormal obstetric ultrasounds.
Normal vaginal delivery at term, spontaneous crying at birth, with birth weight of 2050g.
Was on exclusive breastfeeding until about his third week of life, when he was placed on artificial milk for about a week while his mum was on a journey. During this time, the baby developed distended abdomen, diarrhoea and fever for which oral antibiotics (ATBs) were prescribed in a nearby clinic but never initiated as most symptoms regressed.
The mother noticed poor weight gain at 6 weeks with persisting abdominal distension, rare passage of  stool and frequent greenish vomiting leading to consultation and hospitalization in our unit.

STOP, THINK AND DIAGNOSE…

Working diagnosis was Intestinal pseudo-obstruction probably due to a late bacterial neonatal infection. Differential was a mechanical intestinal obstruction. Blood culture, Urine culture, Full Blood Count, C-Reactive Protein and Plain abdominal X-ray were requested.
Enteral feeding was stopped, nasogastric tube placed, and Empirical intravenous ATBs were started. Abdominal X-ray did not seem in favour of intestinal obstruction. C-reactive protein level was elevated and Full Blood Count showed moderate normocytic anemia.
Two days later, no more vomiting, clear gastric fluids, regular stool passage, slightly reduced abdominal distension.
Oral feeding was re-initiated and seemed well tolerated.
The Pediatric surgeon was sought for a review of the patient 3 days later. The long history of the abdominal symptoms from week 3 of life, the history of bilious vomiting, physical exam showing ill-looking baby with persistent abdominal distension difficult to palpate, were all considered and their working diagnosis was Volvulus on malrotation leading to the request of a Doppler abdominal ultrasound.
The Doppler ultrasound showed distorted mesenteric vascularisation around the duodenum highly indicative of a volvulus on malrotation. No other signs in favour of an intestinal obstruction were seen in the abdominal ultrasound.
Surgery was programmed.
Peropearative findings revealed a stricture at the angle of Treitz and distended D3-D4 portions with surrounding mesenteric small to medium lymphadenopathies. Stricture was dissected and a biopsy of ADPs was sent for histopathology.
Feeding was started on Day 2 post-operative and baby was discharged on Day 6 post-op with stable vitals, feeding well, no more vomiting, non-distended abdomen and normal stool passage.

Key Points:
-We learnt that a Doppler ultrasound was needed in addition to the simple abdominal ultrasound and X-ray usually done for such diagnoses in our context.
(NB: This case comes after two near-misses of Malrotation with normal abdominal ultrasounds, whose diagnoses  were finally made per-operatively after exploratory surgery was decided given recurrence of symptoms of intestinal obstruction)

-Consider getting a surgeon’s opinion in cases of intestinal obstruction even if symptoms seem to be regressing.

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Clinical signs of neonatal intestinal obstruction with near normal abdominal X-ray