Patient Presentation
A 5-year-old male came to the emergency room with nausea, vomiting and lower abdominal pain that had been increasing for 5-6 hours. He was well overall when he started to have right lower abdominal pain that increased in intensity. He became nauseous and had 3 separate episodes of emesis of food that was non-bloody and non-bilious. He had no fever, rash, rhinorrhea or cough. He had awoken normally and had eaten breakfast without incident. His last bowel movement was possibly the night before and he had urinated in the morning. He didn’t know if he was passing gas. His parents were worried that he had appendicitis. The past medical history was non-contributory.

The pertinent physical exam showed that he was afebrile, with a heart rate of 115 beats per minute, blood pressure of 95/62, respiratory rate of 24 per minute and an oxygen saturation of 98% on room air. His abdominal examination was normal including no pain at McBurney’s point. His genitourinary examination showed a bulging right inguinal area with a very tender palpable mass in the inguinal canal. The left inguinal canal was normal. His testes were both palpable, non-tender and in the appropriate scrotal location.

The diagnosis of an incarcerated inguinal hernia was made. Ice was applied to the area and pain medication given. Emergency room personnel were able to reduce the hernia with pressure. Surgery was consulted and after discussion with the parents and several hours monitoring in the emergency room he was discharged home with strict instructions for monitoring and return. He underwent laparoscopic repair 11 days later without complications and did not have a contralateral hernia.

Discussion
Inguinal hernia repair is one of the most common surgical procedures. Incarceration rates for pediatric patients are between 2-30%, with 6-18% commonly cited and higher rates of up to 30% in infants especially premature infants. Presentations include irreducible bulging in the inguinal area that is often erythematous and/or painful, emesis and nausea, inguinal or abdominal pain, abdominal distention, and lack of bowel function including lack of flatulence and/or bowel movements.

Incarceration complications include bowel compromise and/or necrosis, sepsis, and potential risk for severe morbidity and/or mortality. Damage to other structures that could be incarcerated includetestes, ovaries, uterus and bladder among others. This could cause organ atrophy and/or necrosis necessitating resection.

Rates of complications are low for all types of surgical procedures and potential complications of hernia repair include:

• Iatrogenic injury to the groin and abdominal structures
• Testicular atrophy
• Acquired ascending testis
• Pneumonia
• Wound infection
• Wound disruption with needed additional repair
  

Premature infants commonly have inguinal hernias and the optimal timing for treatment is controversial as the risk of potential incarceration with the operative, post-operative and needs to be balanced again the increased risk of respiratory complications (especially apnea) in this age group. Early treatment appears to have lower risk of incarceration but increased risk of respiratory complications. Both early and delayed treatment had similar surgical complications in one study.

Learning Point
Evaluation and management for possible incarcerated inguinal hernia includes several steps and decision points, along with many factors such as age. It is not a “one-size fit most” situation either and needs to be tailored to the patient and their risk factors.

• Patients need a complete history and physical examination
  • Laboratory testing for other diagnoses as well as pre-surgical testing should be considered
  • Imaging, using ultrasound or computed tomography, may be used if the physical examination is inconsistent or non-diagnostic
  • Patients should be provided with fluid resuscitation if needed, and medications for pain relief. Ice to the site also helps to decrease edema
• Attempted hernia reduction using gentle pressure after diagnosis of inguinal hernia and pain relief provided
  • If hernia reduction is not successful, then immediate surgical treatment is needed
  • If hernia reduction is successful, the patient may be monitored in the hospital or discharged home. Elective repair is then usually scheduled within a short time (usually a few days)
• Operative repair
  • Immediate surgical repair may be done using open surgical procedures or using laparoscopic surgical techniques. Traditionally open procedures are the standard but laparoscopic surgery or combinations of both may be used. Robotic surgery is less common.
  • Both open and laparoscopic procedures evaluate the structures that are incarcerated especially the bowel to make sure it is viable. Bowel resection or treatment of other structures may be necessary.
    • Open procedures do not need specialized equipment and the anatomy is usually relatively straight forward to analyze and repair. Unusual anatomy or organs entrapped and their potential complications can be visualized and managed.
      There are risks for iatrogenic complications which may be higher than laparoscopic techniques.

    • Laparoscopic techniques have the major advantage of being able to evaluate the contralateral side for possible contralateral inguinal hernia and possibly its simultaneous treatment (especially if performed electively). Laparoscopy has lower complication rates for certain risk groups, and may in some circumstances decrease operative time and hospital length. This may be due to easier pain control for laparoscopic procedures.
      Laparoscopic techniques require additional equipment, incisions to use the equipment with inherent but low potential risk for abdominal organ damage, need for pneumoperitoneum which may be contraindicated for some patients or which may increase potential respiratory problems for some patients
  • Elective repair is usually done within a few days and may be done using open, laparoscopic or robotic surgical techniques.
    • Timing depends on risk factors, and type of technique planned. There is always a risk of re-incarceration during this time period with 3% of pediatric patients re-admitted during the waiting period in one study. However, patients who are not treated at the original admission may have lower complication rates. L and robotic techniques usually involve the evaluation of the contralateral side and repair of both if needed
• Post-operative management
  • Decreasing increased intra-abdominal pressure is important to maintain the repair and allow for healing
    • Pain control including medication and/ice for a week or longer may be needed
    • Stool softener to decrease valsalva maneuvers
    • Activity limitation such as not lifting weights or daily items (i.e. backpacks, groceries etc.)
  • Routine followup care and surgical planning for contralateral inguinal hernia repair if appropriate
    • Most patients can be released to regular activities around 6 weeks post-operatively

Questions for Further Discussion
1. How common is incarcerated umbilical hernia? A review can be found here
2. What causes testicular pain? A review can be found here
3. What are spermatic cord hydrocoeles? A review can be found here

Related Cases

Disease: Inguinal Hernia | Hernia

Symptom/Presentation: Mass or Swelling | Abdominal Pain

Specialty: Emergency Medicine | Surgery

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Hernia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Choo CS, Chen Y, McHoney M. Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis. Journal of Pediatric Surgery. 2022;57(11):527-533. doi:10.1016/j.jpedsurg.2022.07.001

Zubaidi SA, Ezrien DE, Chen Y, Nah SA. Laparoscopic versus Open Incarcerated Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg. 2023;33(05):414-421. doi:10.1055/a-1958-7830

Ramsey WA, Huerta CT, O’Neil CF, et al. Timing of Pediatric Incarcerated Inguinal Hernia Repair: A Review of Nationwide Readmissions Data. Journal of Surgical Research. 2024;295:641-646. doi:10.1016/j.jss.2023.11.059

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
An 11-year-old healthy female came to clinic after having noticing a “bump” in her vaginal area after taking a shower. Her mother was uncertain what it was and so had made the appointment. She denied having any significant pain, itching, discharge or actual bleeding. She was premenarchal. She had normal bowel movements and urination. She denied any trauma to the area or potential sexual abuse. The past medical and family histories, and review of systems were non-contributory.

The pertinent physical exam showed a healthy female with normal vital signs who was tracking at the 75-90% for growth parameters. Her abdominal and spine exams were normal. Her genitourinary examination showed a small slightly elevated hematoma at the posterior fourcette. Areas of the labia major and minora looked to have thinned tissue and there was hypopigmentation that was linear around the edges of the labia minora and which extended along the center of the perineal body. There was some minor erythema of the areas around the hypopigmentation. There were other areas of hypopigmentation that were 3-5 mm in size on the labia majora and minora. The hymen was intact and the tissues and anatomy otherwise appeared normal.

The diagnosis of possible lichen sclerosis et atrophicus (LSA) was made. In retrospect, she said that she had had some pruritus in her genital area for the past few days and had been itching the area more. Pictures were taken for the medical record. The pediatrician checked the medical literature which recommended strong steroid treatment but possibly biopsy before treatment, so gynecology was consulted. They agreed that this was LSA and recommended steroid use without a biopsy. They would see the patient in about 3-4 weeks for followup.

Discussion
Lichen sclerosis et atrophicus (LSA) is a chronic inflammatory disease with a strong autoimmune association but its cause is unknown. Usually seen in middle-aged women (40-60 years), it can occur in females and males of all ages, but prepubertal females are more common in the pediatric age group. Treatment includes stronger steroid medications or anti-inflammatory medications and pediatric patients usually have resolution with time. The classic presentation of LSA are genital lesions that are hypopigmentation in an hour-glass or a figure of 8 distribution for females as it involves the vulva, perineum and anal areas. Tissues appear thinned and there can be some erythema as well. Patients can be asymptomatic, have some pruritus or pain. Extra genital lesions can also be seen. A review of LSA can be found here

Learning Point
The differential diagnosis of white vulvar lesions includes:

• Hypopigmentation
  • Normal variant
  • Post-inflammatory including general vulvovaginitis
  • Vitiligo
• Angioedema
• Atopic dermatitis
• Psoriasis
• Seborrheic dermatitis
• Lichen sclerosis et atrophicus
• Lichen planus
• Lichen simplex chronicus
• Morphea or localized sclerosis
• Mycosis, ex. tinea versicolor
• Ulcer
• Lipschultz
• Herpes simplex
• Syphilis
• Other infections

Trauma

• Scratching
• Tight clothing
• Burn
• Sexual assault

Systemic autoimmune

• Bechet’s
  Scleroderma

Malignancies – very rare

• Basal cell carcinoma
• Squamous cell carcinoma
• Leukemia/lymphoma

Xanthoma

Questions for Further Discussion
1. What is a Lipschultz ulcer? A review can be found here
2. How are straddle injuries treated? A review can be found here
3. What are some presentations for child sexual abuse? A review can be found here

Related Cases

Disease: Lichen Sclerosis et Atrophicus | Vulvar Disorders | Skin Diseases

Symptom/Presentation: Rash | Urticaria and Pruritis

Specialty: Obstetrics / Gynecology | Dermatology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Vulvar Disorders and Skin Conditions.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Resende FS, Conforti C, Giuffrida R, de Barros MH, Zalaudek I. Raised vulvar lesions: be aware! Dermatol Pract Concept. 2018;8(2):158-161. doi:10.5826/dpc.0802a16

Charamanta M, Soldatou A, Michala L. Vulvar Ulcers in Children: Dramatic But Self-Limited. Pediatric Emergency Care. 2021;37(2):70. doi:10.1097/PEC.0000000000002004

Orszulak D, Dulska A, Nizinski K, et.al. Pediatric Vulvar Lichen Sclerosus – A Review of the Literature. Int J. Environ. Res. Public Health. 2021:18;7153.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 13-year-old female came to clinic after a 12 hour emergency room visit for severe emesis, nausea, headache and abdominal pain 2 days previously. She had about 2 hours of nausea, milder abdominal pain and headache that was frontal with radiation to bilateral temples. She had no photophobia or phonophobia. She then began to have multiple episodes of emesis over the next 2-3 hours and her nausea, headache and abdominal pain became worse. After another 4 hours, she began to feel better and was much improved after sleeping. The emergency room diagnosed her with a severe migraine as she didn’t have or develop any infectious symptoms and her laboratory testing showed electrolytes that were consistent with emesis and dehydration. Her abdominal and head computed tomographic studies were negative. The first day after the emergency room visit she was more tired, but in the office she and her mother deny any problems. The past medical history showed that she had some intermittent headaches and these mainly occurred with illnesses or with poor sleep. She had started her menses about 7 months previously and they were intermittent. The family history is strongly positive for migraines on the maternal side including her mother, older sister and maternal aunt. This maternal aunt’s daughter has cyclic vomiting syndrome, and her other son had migraines.

The pertinent physical exam showed normal vital signs and her weight was back to her pre-emesis weight. Her examination was unremarkable.

The diagnosis of a likely first migraine was made. Her mother had many questions about potential treatment and also cyclic vomiting syndrome. “They only recently diagnosed her cousin with the cyclic vomiting after a long time having lots of problems. They are looking at my nephew too. I just want to be proactive about this if she is going to have a lot more problems,” her mother stated. The pediatrician acknowledged the mother and patient’s concerns by saying, “With this family history we’ll need to be really aware. Maybe you’ll never have another episode like this one, but we need to start keeping track of the symptoms early on, so we can see if there are any patterns. If you have more it may be migraine but it could be cyclic vomiting. I’m going to go over using a symptom diary. It’s an important part of the evaluation for these types of problems. It’s just like keeping track of sugar measurements for people with diabetes. It helps us figure out problems and how to treat them. Also treatment for migraines and cyclic vomiting is similar. Healthy lifestyle changes like making sure you have consistent sleep, exercise, and don’t get dehydrated are really important. If you have more episodes we can talk about maybe starting a medicine to prevent them. If you start to feel that nausea, headache or abdominal pain again, then you can use a medicine to try to stop it before it starts like your mom does. It’s called a triptan and I’ll go over how to use it,” she counseled.

The patient’s clinical course showed another episode in the next 4 months that responded to triptan use and did not require an emergency room visit.

Discussion
Cyclic vomiting syndrome (CVS) “…is characterized by episodic attacks of intense nausea and emesis, with predictably cyclic timing of episodes, and complete resolution of symptoms between attacks.” It can be very difficult to diagnose and likely is underreported. Incidence is thought to be around 3.5/1000,000 persons. There are four phases to the clinical syndrome:

• Prodromal phase is often brief (1-2 hours) where patients can have intensive nausea, abdominal pain, pallor and tiredness
  • Other symptoms may include headache, mood changes, phono- or photophobic, yawning, and systemic autonomic nervous symptoms. These can continue through the vomiting and recovery phases as well.
• Vomiting phase
  • Lasts usually hours
  • First hour has the most emesis (6+ times) that usually wanes over the next 4-8 hours
  • May need intravenous hydration in many cases or hospitalizations
• Recovery phase begins with when the nausea remits and continues until the patient has recovered their appetite, body weight lost during vomiting phase and strength. Patients usually sleep during this period. This is also usually a brief period of about 6 hours, but symptoms can linger for up to 1 week.
• Interepisodic phase where patients are symptom free

It can be difficult to tell if the episodes are recurrent emesis or an episodic attack. While the symptoms patients experience and the timing and duration are different, they are often stereotypical for an individual patient. “Attacks can last from hours to days (between 1h and 10 days, mean 2 days). Typically, attacks have a predictable periodicity…[and t]his periodicity is the discriminating criterion for …classification [as CVS]. This periodicity is variable for each patient.”

Symptom absence between episodes is also a key feature.
Some patients may be able to recognize potential triggers such as lack of sleep, exercise, excitement/stress, menstruation, and potentially certain foods (i.e. cheeses, chocolate, acidic or salty foods).
Natural history is that symptoms may resolve within 10 years (about 60% of children). About 50% go on to have a migraine syndrome. CVS is thought to be linked to migraine by several mechanisms mainly as both are primary brain disorders. The differential diagnosis of CVS includes:

• Central nervous system
  • Migraine
  • Epilepsy/seizure
  • Intracranial masses
  • Cannabis-induced hyperemesis syndrome
  • Autonomic dysfunction
• Gastrointestinal
  • Gastroesophageal reflux disease
  • Obstruction
  • Inflammatory bowel disease
  • Celiac disease
  • Cholecystitis
  • Peptic ulcer disease
• Metabolic
  • Inborn errors of metabolism
  • Mitochondrial disease gastrointestinal problems including gastroesophageal reflux disease, obstruction, inflammatory bowel disease
• Renal
  Hydronephrosis

If the patient does not have resolution of their symptoms between attacks or has other central nervous system (CNS) problems such as developmental or intellectual problems, seizures, evidence of encephalopathy, or it appears that the attacks may precipitate CNS problems, or that there are additional gastrointestinal symptoms (i.e. gastrointestinal bleeding) then these are red flags that should be evaluated.

Learning Point
Treatment for CVS includes:

• Lifestyle changes – consistent food and fluid intake, sleep, and exercise
• Interepisodic phase
  • Prophylactic medication for those that are severe (> 2 day duration, hospitalization) or frequent (> every 4-6 weeks)
  • < 5 years old = cyproheptadine
  • > 5 years old = amitriptyline. This is the most effective agent overall
  • Consider propranolol as second line
  • There are other options if these are not tolerated or give insufficient control
• Prodromal phase
  • Triptans used as an abortive medication – sumatriptan, rizatriptan, zolmitripan
  • Benzodiazepines may be helpful for panic anxiety or anticipation of vomiting phase
• Vomiting phase
  • Intravenous fluids with glucose to provide energy
  • Intravenous, rectal or dermal formulations of
    • Antiemetics – ondanstron, granisetron
    • Analgesics – ketorolac
    • Sedatives – z, diphenhydramine
  • Environment that is dark, quiet
• Recovery phase
  • Management of symptoms as needed

Questions for Further Discussion
1. Explain the physiology that causes emesis? A review can be found here
2. What are different types of headaches? A review can be found here
3. What causes vomiting? A review can be found here

Related Cases

Disease: Cyclic Vomiting Syndrome | Nausea and Vomiting | Migraine

Symptom/Presentation: Vomiting | Headaches | Abdominal Pain

Specialty: Emergency Medicine | Neurology / Neurosurgery

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Nausea and Vomiting and Migraine.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Donnet A, Redon S. Cyclic Vomiting Syndrome in Children. Curr Pain Headache Rep. 2018;22(4):30. doi:10.1007/s11916-018-0684-6

Li BUK. Managing cyclic vomiting syndrome in children: beyond the guidelines. Eur J Pediatr. 2018;177(10):1435-1442. doi:10.1007/s00431-018-3218-7

Kovacic K, Li BUK. Cyclic vomiting syndrome: A narrative review and guide to management. Headache. 2021;61(2):231-243. doi:10.1111/head.14073

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 15-month-old male came to the emergency room because of diarrhea for < 24 hours that was not improving, fever to 100.8°F and fatigue. He had loose, watery non-bilious, non-mucous stools that would come out of his diapers. He had been trying to drink and had not vomited but was taking less and less orally over the day. His father was not able to tell when his last urine was because of the diarrhea. "There was an email yesterday that the daycare had another child with rotavirus," he offered.

The past medical history showed he had two ear infections and several viral infections including a documented influenza infection. Record review noted he was vaccinated for some diseases but not rotavirus.

The pertinent physical exam showed a very tired appearing male who was curled up in his father’s lap. He was alert and could cry appropriately but without tears. His vital signs showed heart rate of 106 beats/minute, blood pressure of 86/52, temperature of 100.5°F, and weight of 11.25 kg which was down from 12.36 kg in a visit the week before in his physician’s office. His mucous membranes were tacky and his capillary refill was > 3 seconds. His abdomen seemed overall slightly diffusely tender but without guarding, masses or organomegaly.

The diagnosis of acute gastroenteritis with dehydration was made. Two emergency room professionals felt that the smell of the diarrhea was consistent with rotavirus based on their past clinical experience. The work-up included starting an IV and drawing blood that was consistent with pre-renal dehydration. He started to appear somewhat better after his second IV fluid bolus, and after the third one, he started to drink some. His abdominal pain also seemed to improve. He was monitored in the emergency room overnight, and while he had more diarrhea, he started to have more free urine output and was drinking well before discharge.

Discussion
Rotaviruses (RV) are a leading cause of severe, acute, dehydrating diarrhea for children particularly those under age 5 years globally. As RVs are highly contagious and in the pre-RV era they caused an estimated 30-50% of hospitalizations for gastroenteritis yearly or about 111 million cases yearly. They also caused an estimated 500,000/year pediatric deaths.

RV are double-stranded RNA viruses of the genus Rotavirus. There are 11 species with type A being the most common cause of acute gastroenteritis. RV is transmitted mainly through the oral-fecal and hand-to-hand routes with the gastrointestinal system being the primary site of infection. Incubation is only 16-18 hours. RV is excreted in the feces in massive amounts for 5-7 days, but only a few particles (10-100) can cause infection. RV is also “…highly resistant to environmental factors, including temperature and pH, which enhances their infectious potential.”

Clinical symptoms include non-bloody (usually) diarrhea, and can also include nausea, emesis, and abdominal pain. Electrolyte imbalance and dehydration can easily occur because of multiple loose or liquid stools that can be smaller or voluminous. Dehydration itself obviously can have its own severe consequences which as noted above can cause significant morbidity and mortality. Systemic symptoms such as fever, and fatigue are common. The diarrhea occurs through osmotic, secretory and neurogenic pathways. Laboratory testing is consistent with a limited inflammatory response. Other systemic problems can occur through viremia and antigenemia including seizures and other central nervous system disease, biliary atresia, lower respiratory tract infections, and there appears to be a role in autoimmunity including Celiac disease, and Diabetes mellitus type 1. Disease does protect against subsequent infections, but remember there are more than 1 species. While the majority of infections occur in those under age 5, it can still occur in older ages.

Learning Point
RV vaccine introduction has been an extraordinary global public health achievement. RV vaccination is recommended for young children globally since 2006. The timing and number of doses depends on the particular vaccine, with most starting after 6 weeks of age. These are live-attenuated vaccines which are highly effective in reducing the proportion of RV associated acute gastroenteritis by 50% overall globally, with also a concurrent significant reduction in mortality. Estimates of effectiveness are around 90%, 80% and 40-50% for high, middle and low-mortality countries depending on the specific vaccine. This heterogeneity of effectiveness is based on country with more occurring in lower to mid- mortality countries and is likely multifactorial including nutritional status, co-infections, microbiome, maternal antibiotics and co-administration of polio vaccine.

Potential common vaccine adverse effects include appetite loss, fussiness, diarrhea, abdominal pain, emesis, fever and weakness. Overall safety is excellent with current vaccines. In 1999, the first RV vaccine RotaShield was withdrawn because of increased risk of intussception which has not been seen with subsequent RV vaccines.

Questions for Further Discussion
1. How is Norovirus similar to Rotavirus? A review can be found here
2. What is the physiology of vomiting? A review can be found here
3. What causes abdominal pain? A review can be found here

Related Cases

Disease: Rotavirus Infections | Childhood Immunization

Symptom/Presentation: Diarrhea | Dehydration |
Fever and Fever of Unknown Origin

Specialty: Emergency Medicine | Gastroenterology | Infectious Diseases

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Rotavirus Infections and Diarrhea.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Caddy S, Papa G, Borodavka A, Desselberger U. Rotavirus research: 2014-2020. Virus Res. 2021;304:198499. doi:10.1016/j.virusres.2021.198499

Cates JE, Tate JE, Parashar U. Rotavirus vaccines: progress and new developments. Expert Opin Biol Ther. 2022;22(3):423-432. doi:10.1080/14712598.2021.1977279

Karolina Pawluszkiewicz, Ryglowski PJ, Idzik N, et al. Rotavirus Infections: Pathophysiology, Symptoms, and Vaccination. Pathogens. 2025;14(5):480. doi:10.3390/pathogens14050480

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa