Volume 3, Case 10
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
A 3-year old female is seen in the E.D. in the evening with a chief complain of stomach pains and vomiting. She vomited 5 times since yesterday. The pain is located in the epigastrium. The emesis is described as what she just ate, not bloody and not bilious. She has no diarrhea. Her last bowel movement occurred yesterday. She has no fever. Her parents describe her activity as decreased. She is taking Pepto-Bismol (bismuth subsalicylate) and Donnatal (phenobarbital, hyoscyamine, atropine. scopolamine). Her parents have not noticed any improvement with these medications.
Exam: VS T36.9 (tympanic), P98, R24, BP 114/62. Alert, active, cooperative, quiet, and sad-appearing. Eyes clear. Oral mucosa moist. TM's normal. Neck supple. Heart regular, grade 1/6 systolic ejection murmur. Lungs clear. Abdomen soft, flat, bowel sounds active. No hepatosplenomegaly. Mild diffuse tenderness. No rebound. No masses. No hernias. Normal female genitalia. No CVA tenderness. Color, turgor, and perfusion are good.
An abdominal series is ordered.
View abdominal series: Flat (supine) view.
View abdominal series: Upright view.
This abdominal series shows a normal pattern of gas distribution. There are no areas of excessive bowel dilation. There are no air fluid levels. There are no mass effects. There is a moderate degree of stool in the colon. There are also some faint calcifications best seen in the right upper quadrant on the upright view. To see this, you will have to enlarge the image, turn down the room lights, and adjust the contrast and brightness on your monitor. This is best seen on the focused magnified view below.
View calcification close-up.
This focused view of the right upper quadrant demonstrates faint calcifications which appear to be within the bowel lumen. The parents are asked for more details about her recent diet and nothing sounds unusual.
This "calcification" is actually not calcium. The bismuth in the Pepto-Bismol is slightly radiopaque. Patients who are taking Pepto-Bismol will have this finding on their abdominal radiographs. Other substances that may be radiopaque include ingested dirt, sand, and dental debris. Other agents that may be radiopaque include (C.H.I.P.E.S): Chloral hydrate/Calcium, Heavy metals (lead, arsenic, etc.), Iodides/Iron (vitamin pills), Phenothiazines and Psychotropics, Enteric coated tablets, and Slow-release capsules.
She is given an enema. She passes a large stool. Her abdominal pain resolves. She is discharged from the emergency department with the usual vomiting instructions to maintain her hydration and return if her condition worsens.