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This 4-year-old boy came after vomiting everything he ate for a month. In the previous week he had not even been able to keep down any water. He finished treatment for malaria and typhoid without improvement. He had a huge scar on his abdomen from an umbilical hernia repair in the capitol a year before so I suspected an adhesive bowel obstruction. Strangely he was not very distended or in much pain. He simply threw up every single ounce of what he put in his mouth. Ultrasound showed nothing notable. We offered the family an operation. We explained we may not find something we can fix with surgery.  

Our super smart nurse assistant predicted it would be a negative laparotomy. When we opened the abdomen there were no adhesions or small bowel dilation. There was nothing abnormal about the intestines. I told our nurse he won. Nothing we could help with. Disappointing!

I kept looking and praying we could find something. The stomach seemed really big. The anesthetic we often start with for children is ketamine alone. This kid was requiring some gentle bag masking with anesthesia. They tried, but couldn’t pass a tube in the nose to decompress the stomach. I kept examining the stomach. The pylorus, where the stomach meets the beginning of the small bowel, was hard. It seemed extremely narrow. We could not seem to force any air from the now giant stomach past this point into the small bowel. This was hard and fibrotic, unlike the common pyloric stenosis seen in babies. 

I decided to open the connection that seemed blocked with scar tissue (Heineke-Mikulicz Pyloroplasty). This is a delicate procedure in a 4 year-old. I was sweating not only because it was 80 degrees F. If what I was doing to him did not heal adequately, within a couple days the stomach juices would leak outside the intestine. If that happened in our circumstances here in Chad, the child would die. 

We watched pensively over the next several days. He was doing well and we let him drink liquids. He would cry whenever he saw me, but enjoyed drinking with no vomiting. He’s eating liquid cereal now without vomiting for the first time in over a month. He’s going home a week after his operation. I’m ecstatic. 

He and his family allowed us to take photos. Then his family talked to him and he did something I have never seen someone do here. Picture below.