What is the best course of action for a 10-month-old male presenting with daily vomiting for 15 days, liquid stools, passing gas, a distended stomach, and poor oral intake, with concerns for bowel obstruction?

Immediate Management of 10-Month-Old with Prolonged Vomiting and Suspected Bowel Obstruction

This infant requires immediate emergency department evaluation with IV rehydration, imaging to confirm or exclude bowel obstruction, and surgical consultation if obstruction is confirmed. Given the 15-day duration of vomiting, liquid stools, abdominal distension, and poor oral intake over 3 days, this child is at high risk for moderate-to-severe dehydration and potential bowel obstruction requiring urgent intervention 1.

Initial Assessment and Stabilization

Assess Hydration Status

The clinical examination should focus on specific dehydration markers:

• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, dry mucous membranes, decreased urine output 1, 2
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool and poorly perfused extremities, decreased capillary refill, rapid deep breathing indicating acidosis 1
• Rapid deep breathing, prolonged skin retraction time, and decreased perfusion are more reliable predictors than sunken fontanelle or absent tears 1

Immediate Rehydration Protocol

For moderate dehydration: Administer oral rehydration solution (ORS) containing 50-90 mEq/L sodium at 100 mL/kg over 2-4 hours 1, 2

For severe dehydration or inability to tolerate oral intake: Begin IV rehydration immediately with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1

Given this infant's 3 days of poor oral intake and ongoing vomiting, IV rehydration is likely necessary 1.

Diagnostic Imaging for Bowel Obstruction

Initial Imaging Approach

Plain abdominal radiograph should be the first imaging study to assess for bowel obstruction patterns 1, 3. This will help determine if there is:

• Dilated bowel loops with air-fluid levels
• Transition point between dilated and normal bowel
• Free air suggesting perforation 1, 3

Advanced Imaging if Needed

CT scan with IV contrast is the gold standard if plain films are inconclusive or show concerning findings, with >90% diagnostic accuracy for determining obstruction severity, location, and complications like ischemia 1, 3, 4.

Ultrasound is an excellent alternative in infants to minimize radiation exposure, with 90% sensitivity for small bowel obstruction (dilated loops >2.5 cm proximal to collapsed loops with decreased peristalsis) 1, 3.

Critical Red Flags Requiring Urgent Surgical Consultation

The following findings mandate immediate surgical evaluation 3, 4, 5:

• Bilious vomiting (suggests malrotation with volvulus or other high-grade obstruction) 1
• Signs of bowel ischemia: Fever, peritonitis, elevated lactate, marked leukocytosis >10,000/mm³ 3, 5
• Complete obstruction on imaging with transition point 3, 4
• Abdominal distension with absent bowel sounds or high-pitched rushes 4

Management Based on Findings

If Bowel Obstruction Confirmed

• NPO (nothing by mouth) with bowel rest 3, 4
• Nasogastric tube decompression to prevent aspiration and reduce proximal bowel pressure 3, 4
• Continue IV fluid resuscitation with crystalloids 3, 4
• Non-prokinetic antiemetics only (ondansetron or prochlorperazine) - never metoclopramide, which is contraindicated in obstruction as it increases bowel motility and perforation risk 3, 6
• Surgical consultation for definitive management 3, 4

If Gastroenteritis Without Obstruction

• Continue ORS rehydration: 10 mL/kg for each diarrheal stool, 2 mL/kg for each vomiting episode 1, 2
• Resume feeding immediately upon rehydration: Breastfed infants continue nursing on demand; bottle-fed infants receive full-strength lactose-free or lactose-reduced formula 1, 2
• Replace ongoing losses throughout treatment 1

Common Pitfalls to Avoid

Do not delay imaging when bowel obstruction is suspected - the 15-day duration of symptoms with recent worsening (3 days poor intake) is concerning for evolving obstruction 1, 4.

Do not use metoclopramide or other prokinetic agents until obstruction is definitively excluded, as they can worsen mechanical obstruction and cause perforation 3, 6.

Do not rely solely on plain radiographs - they cannot exclude obstruction, and CT or ultrasound may be needed for definitive diagnosis 1, 4.

Do not give enemas if obstruction is suspected, as they increase perforation risk 3.

Monitor for deterioration: Mortality increases significantly when surgical intervention is delayed in the presence of ischemia (up to 25%) 3.