What is the likely diagnosis and recommended emergency management for a previously healthy 2‑year‑old girl with sudden epigastric pain and vomiting after eating butong, now afebrile with persistent epigastric discomfort and limited oral intake?

Likely Diagnosis and Emergency Management

The most likely diagnosis is foreign body ingestion (butong) causing gastric irritation or gastritis, with the vomiting pattern and resolution suggesting the foreign body has likely passed into the intestine, but persistent epigastric pain warrants urgent evaluation to exclude gastric perforation or obstruction. 1, 2

Immediate Assessment for Life-Threatening Complications

Check vital signs immediately for the following red flags that predict serious pathology:

• Tachycardia ≥110 bpm 2
• Fever ≥38°C (currently afebrile is reassuring) 2
• Hypotension or signs of shock 3

Perform focused abdominal examination looking specifically for:

• Peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds) which indicate perforation with mortality reaching 30% if treatment is delayed 2, 4
• Localized epigastric tenderness (present in this case, suggesting organic pathology) 2
• Palpable mass or "olive" (less likely given age and presentation) 1

Critical pitfall: Foreign bodies, including bezoars, are uncommon but serious causes of vomiting and epigastric pain in young children that can lead to gastric ulceration or perforation 1

Differential Diagnosis Priority

Based on the history of butong ingestion followed by acute symptoms:

1. Foreign body-induced gastritis or gastric ulcer - The temporal relationship between butong ingestion and symptom onset is highly suggestive 1, 4

2. Gastric perforation (if peritoneal signs develop) - Requires immediate surgical consultation 2, 4

3. Gastric outlet obstruction - Persistent vomiting for 3 days raises this concern 1

4. Viral gastroenteritis - Less likely given persistent localized epigastric pain and lack of diarrhea 1, 5

Emergency Management Algorithm

Step 1: Stabilization and Symptom Control

Assess hydration status clinically:

• Mild dehydration: oral rehydration 50 mL/kg over 2-4 hours 6
• Moderate dehydration: oral rehydration 100 mL/kg over 2-4 hours 6
• Severe dehydration: IV boluses of 20 mL/kg normal saline until perfusion normalizes 6, 3

For persistent nausea (though vomiting has stopped):

• Ondansetron 0.15 mg/kg (maximum 8 mg) sublingual every 4-6 hours 2, 6
• Obtain baseline ECG before administration due to QTc prolongation risk 2, 6

Step 2: Urgent Imaging

Abdominal radiograph (X-ray) is the initial imaging study to evaluate for:

• Radiopaque foreign body 1
• Free air indicating perforation 1, 2
• Bowel gas pattern suggesting obstruction 1

If abdominal X-ray is non-diagnostic but clinical suspicion remains high:

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear 2
• CT identifies perforation with 97% sensitivity (extraluminal gas), fluid/fat stranding (89%), and ascites (89%) 1, 2
• CT can detect gastric wall thickening, mucosal hyperenhancement, and focal ulceration 1, 4

Step 3: Empiric Acid Suppression

Start high-dose proton pump inhibitor therapy immediately:

• Omeprazole 1 mg/kg/day (maximum 40 mg) once daily 2, 4
• This provides 70-90% healing rates for peptic ulcers and protects against further gastric injury 2, 4

Step 4: Determine Need for Urgent Endoscopy

Urgent upper endoscopy is indicated if ANY of the following are present:

• Hematemesis or blood in vomit 2, 6
• Peritoneal signs develop 2, 4
• Persistent vomiting beyond symptomatic treatment 2, 6
• Weight loss or failure to thrive 2, 6
• Anemia on complete blood count 2, 6
• Symptoms persisting beyond 8 weeks with epigastric tenderness 2
• Imaging shows gastric wall abnormality or foreign body requiring removal 1, 4

Endoscopy allows:

• Direct visualization of foreign body and removal if still present 4
• Assessment for gastric ulceration or perforation 4
• Tissue biopsy for histopathology 4

Observation and Follow-Up

If no alarm features and imaging is reassuring:

• Observe for 24-48 hours with serial abdominal examinations 5, 7
• Continue oral rehydration and PPI therapy 2, 6
• Advance diet slowly as tolerated 6
• Repeat examination is critical - significant pathology eventually reveals itself 7

Return immediately if:

• Vomiting resumes 2
• Fever develops 2
• Abdominal pain worsens or becomes generalized 3
• Blood appears in vomit or stool 2, 6
• Signs of dehydration worsen 6

Critical pitfall to avoid: Do not attribute persistent epigastric pain to simple gastroenteritis when there is a clear history of foreign body ingestion - this requires systematic evaluation even if initial workup is negative 8, 7