Differential Diagnosis for a 20-month-old Girl with Bilious Vomiting
The clinical presentation of bilious vomiting, episodes of inconsolability with drawing legs up to the chest (suggestive of abdominal pain), and a bloody diaper in a 20-month-old girl suggests an intestinal obstruction or a condition affecting the intestines. The key to the diagnosis lies in the location and nature of the obstruction or condition. Here's a categorized differential diagnosis:
Single Most Likely Diagnosis
- Intussusception: This condition occurs when a part of the intestine telescopes into another part, leading to obstruction and potentially cutting off blood supply. The classic triad of intussusception includes abdominal pain (often intermittent), bilious vomiting, and bloody stools (classically described as "currant jelly" due to the presence of mucus and blood). The most common location for intussusception is at the junction of the ileum and ascending colon (also known as the ileocecal junction), which makes this the most likely anatomic location given the symptoms.
Other Likely Diagnoses
- Volvulus: This involves the twisting of a portion of the intestine around its base, which can lead to obstruction and ischemia. While it can occur at any level of the intestine, the symptoms could fit with a volvulus at various locations, including the junction of the transverse colon and ascending colon or the junction of the ileum and jejunum.
- Incarcerated hernia: Although less common in this age group without a history of hernia, an incarcerated hernia could cause similar symptoms if the hernia involves a portion of the intestine.
Do Not Miss Diagnoses
- Midgut volvulus: This is a life-threatening condition that requires immediate surgical intervention. It typically occurs due to malrotation of the intestine and can present with bilious vomiting. The location is often around the junction of the ileum and jejunum or more proximally.
- Intestinal malrotation with obstruction: Similar to midgut volvulus, this condition can lead to severe consequences if not promptly addressed. The obstruction can occur at various levels, including the junction of the ileum and ascending colon.
Rare Diagnoses
- Meckel's diverticulum: Although it can cause bleeding and occasionally obstruction, it's less commonly associated with the full spectrum of symptoms described. It is a congenital anomaly of the small intestine, typically located in the ileum.
- Colonic atresia or stenosis: These conditions are congenital and would likely have presented earlier in life. However, they could potentially cause obstructive symptoms if not previously diagnosed.
The clinical presentation strongly suggests an issue at the junction of the ileum and ascending colon, making intussusception the leading diagnosis to consider, given its classic symptoms and the age of the patient.