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Child with chronic vomiting

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Case Name: Omar Mohamed Helmy Mohamed
Birth Date: 13/07/2009
Nationality : Egyptian

Brief description from parents:
Our boy is suffering from vomiting in daily bases and stomach pain.
1-The problem started since he is 1 year and 6 months old.
2-The feedback of his doctor were describing the case as a nerves stomach
3-We did not start to do any analysis till he reached 4 years old, because at that time he used to stop eating to avoid the vomiting.
4-we start our deep investigation doing speculum(upper GI endoscopy) (attached CD and report)
5-based on the speculum the doctor described to him two types of medicines for 6 months
(Nexium 20- pentaza ) those two medicines taken for two weeks with average result
6-later on we went to another doctor to get his opinion he asked us to do barium ray, when we got the result doctor said he has (Hernia Palmri)
7-doctor described new medicines for 6 months (nexium 20 for 3 months and Gaviscon for 6 months) during the initial course the case of Omar becomes good
8-after stopping medicine 1 (nexium 20 ) after 3 months the case returned to be more or less the same as before with abdominal pain.
9-we went back to doctor and he asked us to repeat the barium ray ,then when we got the result he mentioned that the old (Hernia Palmri) finished and he extend the old course of medicines (nexium 20-gaviscon) for another 3 months .
Now we are confused and we need your opinion about our boy case whatever needed we will do.
Thanks for your kind support
Parents of Omar

Category: Pediatrician

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Category: ICU/ Critical Care Specialist
Dr. Saptharishi L G is online now

Expert:  Dr. Saptharishi L G replied 4 Days.

Dear parent,

Thank you for your consult at DoctorSpring.com.

I understand your concerns. Your child as well as the two of you seemed to have suffered significantly from this distressing problem of chronic vomiting. You have got your child extensively evaluated as well (I have seen the attached reports). In situations such as these, no amount of theoretical advice can replace a through history and examination of the child. Does your son grow normally? What is his height and weight at 4.5 year? Growth failure can be an important clue in the diagnosis of many conditions. He does not appear to be significantly anaemic (Hb of 12)

Some of the investigations that may be useful in your child include:

1. Absolute eosinophil counts, Serum IgE levels, Food allergy tests - skin prick and patch tests
(If there is a strong clinical suspicion of allergic enteritis, 'Six food elimination diet' can be tried after medical advice from a pediatric gastro-enterologist. This involves avoiding milk, soy, wheat, egg, peanuts and other nuts. Many people have symptomatic benefit from this regimen)

2. Stool examination for malabsorption as well as parasites and cysts can be useful for ruling out related conditions of the gastrointestinal tract. Your child has chronic enteritis on all his intestinal biopsy specimens. This suggests chronic inflammation in the gut. The cause of this chronic inflammation could be infections, auto-immune as well as idiopathic conditions. Hence, it is important to get these stool tests.

3. MR enterography and capsule video endoscopy can be considered as options to evaluate the whole gastrointestinal tract. It could be useful in the diagnosis of CROHN's disease and inflammatory bowel diseases.

4. Is your child neurologically normal for a four year old. Does he have any developmental delay? Does he have any history of seizures or neck pain or migraine. Though unlikely in your child, chronic vomiting due to extra-abdominal causes, including central nervous system lesions like ARNOLD-CHIARI malformation or hydrocephalus and functional causes are also known.

Regarding the treatment of such conditions, proton pump inhibitors (esomeprazole - Nexium) and similar compounds can help in a wide variety of disorders and hence are widely prescribed. Till, a more definitive diagnosis can be made, it would not be wrong to continue Omar on these drugs for symptomatic therapy.

I hope that my clarifications were of some use. In case you have any follow-up queries, please feel free to revert back.

Wishing OMAR a speedy recovery.
Take care
Dr. Saptharishi L G

Dr. Saptharishi L G
Category: ICU/ Critical Care Specialist
Senior Residency: DM,  Pediatric Critical Care, PGIMER

Residency: MD, Pediatrics, Postgraduate Medical Education & Research (PGIMER), Chandigarh, 2013

Internship: JIPMER, 2009

Medical School: MBBS, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, 2008
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