What is the likely diagnosis and recommended management for a 2‑year‑old girl with acute onset epigastric pain and vomiting after eating butong, now afebrile with persistent epigastric discomfort?

Likely Diagnosis and Management

The most likely diagnosis is acute viral gastroenteritis, which typically resolves spontaneously within 3-5 days, but you must immediately rule out foreign body obstruction (from the "butong") and assess for dehydration before attributing symptoms to a benign viral illness. 1, 2

Immediate Assessment Priorities

Rule Out Foreign Body Obstruction First

• The history of eating "butong" (likely a seed or nut) immediately before symptom onset is a critical red flag that cannot be ignored. 3
• Persistent epigastric pain for 5 days after foreign body ingestion raises concern for:
  • Esophageal or gastric foreign body causing mechanical irritation
  • Partial gastric outlet obstruction
  • Bezoar formation 3, 4
• Obtain plain abdominal radiographs (2 views) as initial imaging to evaluate for radiopaque foreign body or bowel gas pattern abnormalities. 3

Assess Hydration Status

• Use the four-item Clinical Dehydration Scale based on physical examination: 2
  • General appearance (normal vs. lethargic)
  • Eyes (normal vs. sunken)
  • Mucous membranes (moist vs. dry)
  • Tears (present vs. absent)
• Mild dehydration is likely given that the child is drinking small amounts and urinating, but vomiting 2-3 times daily for 3 days represents significant fluid loss. 2

Critical Red Flags to Exclude NOW

• Bilious vomiting (green/dark green) indicates possible malrotation with volvulus—a surgical emergency 3, 5, 4
• Peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds) suggest perforation with 30% mortality if delayed 6, 5
• Vital sign abnormalities: tachycardia ≥110 bpm, fever ≥38°C, hypotension 6, 5
• The vomitus is described as yellow (not bilious), which is reassuring but does not exclude obstruction 3

Differential Diagnosis in Order of Likelihood

1. Acute Viral Gastroenteritis (Most Likely)

• Norovirus causes 58% of pediatric gastroenteritis cases in the United States. 1
• Classic presentation: sudden onset vomiting, mild fever (now resolved), self-limited course of 3-5 days 1, 2, 7
• The timing fits: vomiting Friday-Sunday (3 days), now stopped on Monday—consistent with typical viral gastroenteritis duration. 2, 7
• However, persistent epigastric pain for 5 days is atypical for uncomplicated viral gastroenteritis and warrants further evaluation. 5, 7

2. Foreign Body-Related Complications

• Gastric foreign body or bezoar formation from "butong" can cause persistent epigastric pain even after vomiting resolves. 3, 4
• Seeds/nuts can form bezoars (lactobezoar mentioned in infants, but phytobezoar possible in toddlers) 3

3. Food Protein-Induced Enterocolitis Syndrome (FPIES) - Less Likely

• FPIES presents with repetitive vomiting 1-4 hours after specific food ingestion, absence of IgE-mediated symptoms (no rash/wheezing), and requires ≥3 minor criteria. 3
• This case has only ONE episode with one food, making FPIES diagnosis premature 3
• If "butong" is re-introduced and causes identical symptoms, FPIES should be reconsidered with oral food challenge under supervision. 3

4. Functional Dyspepsia - Unlikely in This Acute Setting

• Requires ≥6 months of symptoms (Rome IV criteria) or ≥8 weeks in clinical practice 5
• This is an acute 5-day presentation, not chronic 5

Management Algorithm

Step 1: Imaging to Rule Out Foreign Body (Do This Today)

• Obtain plain abdominal radiographs (AP and lateral views) immediately. 3
• If foreign body visualized or bowel obstruction pattern seen, obtain surgical consultation 3, 8

Step 2: Rehydration Strategy

For mild dehydration (most likely scenario given current intake): 2

• Start with half-strength apple juice or preferred clear liquids 2
• Advance to full-strength fluids as tolerated 2
• Oral rehydration therapy is as effective as IV rehydration for preventing hospitalization. 2

If persistent vomiting recurs or child refuses oral intake: 6, 1

• Ondansetron 0.15 mg/kg oral (maximum 8 mg per dose) every 4-6 hours 6, 5
• For a 2-year-old (~12 kg average), dose would be approximately 2 mg 6
• Obtain baseline ECG before ondansetron due to QTc prolongation risk 6, 5

Step 3: Symptomatic Management of Persistent Epigastric Pain

If abdominal X-rays are normal and viral gastroenteritis is confirmed: 6, 5

• Consider empiric acid suppression with omeprazole 1 mg/kg once daily (maximum 40 mg) for 2-4 weeks if epigastric pain persists beyond typical gastroenteritis course. 6, 5
• For a 12 kg child, this would be 12 mg daily 6

Step 4: Dietary Modifications

• Avoid re-introducing "butong" or similar seeds/nuts until symptoms completely resolve. 3
• If symptoms recur with "butong" re-introduction, consider FPIES and refer to allergist for supervised oral food challenge. 3
• Small, frequent meals rather than large volumes 3

Step 5: Red Flag Monitoring - When to Escalate Care Immediately

Return to emergency department or urgent care if: 6, 5, 8

• Vomiting resumes and becomes bilious (green/dark green)
• Development of peritoneal signs (rigid abdomen, severe tenderness)
• Fever returns or vital signs deteriorate
• Hematemesis or blood in stool
• Inability to tolerate any oral fluids for >6 hours
• Decreased urine output (no wet diaper in 8 hours)
• Lethargy or altered mental status

Step 6: Follow-Up Timeline

• Recheck in 48 hours if epigastric pain persists despite normal X-rays and adequate hydration. 5, 7
• If pain continues beyond 2 weeks total duration, obtain complete blood count to check for anemia and consider referral to pediatric gastroenterology. 6, 5
• Endoscopy is indicated only if alarm features develop or symptoms persist beyond 4-8 weeks despite empiric PPI therapy. 5

Common Pitfalls to Avoid

• Do not assume viral gastroenteritis without obtaining abdominal X-rays given the foreign body ingestion history—missing a gastric foreign body or bezoar can lead to perforation. 3, 4
• Do not use loperamide or other antimotility agents in children under 18 years—they do not reduce symptoms and can cause serious side effects including ileus. 1
• Do not attribute persistent epigastric pain (now 5 days) to simple viral gastroenteritis without considering other diagnoses—typical viral gastroenteritis pain resolves within hours to 2 days after vomiting stops. 5, 2, 7
• Do not diagnose FPIES based on a single episode—this requires either recurrent episodes with the same food or confirmation via supervised oral food challenge. 3
• Recognize that 2-year-olds cannot reliably localize pain, so "epigastric" localization reported by parents may actually represent more diffuse discomfort—repeated examination by the same physician is valuable. 8, 4