DIOS in a toddler

Question

Hello,
the bowel of my one-year-old son has been purged 2 months ago. DIOS (distal intestinal obstruction syndrome) has been suspected. The physicians said that it would not occur at that age and that is was very unusual. He has had projectile voimting of his meals for several weeks and in the end refused to eat at all. After purging all the symptoms disappeared and he felt well.
We were told to give macrogol in the mornings and the afternoon. Then he had again a phase of about 3 weeks in which he did not gain weight and his stools were more frequent and also not shaped. (We told it to the doctors of our CF center, but they rejected it to be irrelevant as he did not vomit). For some time he does not like to eat and for 5 days he is vomiting from time to time. Is it really so unusual or a very unusual course? Which possiblity do I still have to treat him?
Thank you for your efforts,
M.

Answer

Hello,
you report that in your son, who is one year old, increasing vomiting has been observed and that in the end the diagnosis of DIOS had been made. After purging of the bowel the vomiting stopped. Then a prophylactic therapy with macrogol had been prescribed by the physicians of your center. With that, the stools of your son had been partly unshaped and he developed a decreased appetite and in the meantime he started vomiting again. You ask about other therapeutic options and ask, if it is indeed so unusual that a CF child develops a DIOS at the age of 12 months.
It is indeed very unusual that already at that age a DIOS can be diagnosed, however not impossible. There are several reasons for the diagnosis of a DIOS. Here, at first a false dosage of the therapy with pancreatic enzymes has to be mentioned. Often a too low dosage, seldom an overdosage, is the cause behind. In order to clarify the correct adjustment of the therapy, an analysis of the stool fat out of 3 samples of 24-hours collected stool should be done. Further reasons for a DIOS are too low fluid intake and too few physical activity.
In general, however, it should be questioned, if not another organic reason might come into question for the vomiting. If the vomiting is accompanied with increasing pauses of having stool, it should also be considered, that stenosis of the bowel can occur in CF children in single cases (inherited stenosis of the bowel). Also, there can be an invagination of parts of the bowel that accompany a DIOS. Therefore it should be clarified by x-ray with a passage of the bowel if such stenosis can be excluded. At the same time, a false localization of the bowel (malrotation) can be excluded with this investigation.
As another reason for increasing vomining, there is the reflux disease to be mentioned. In this case there is a decreased apetite, however not cessation of the stools.
In case the DIOS should be confirmed as the sole reason, a preventive therapy with macrogol is sensible. This therapy should however be done in intervals when pauses of the stool start to begin. Also it has to be questioned, if indeed 2 sacs of movicol are necessary per day, or if not 2 half sacs will suffice. A supportive therapy with N-acetlycysteine together with macrogol could be helpful.
However, the correct adjustment of the therapy with pancreatic enzymes is most important. The nutrition should contain fibres, however should not be too rich in fibres.
Best regards,
Dr. H.-G. Posselt

26.10.2015