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Case 2: What is that in your bowel?

A previously healthy nine-month-old Mexican girl presented to the emergency room with three days of vomiting, diarrhea and fever. The emesis was nonbloody and nonbilious, and the diarrhea was watery without blood or mucous. The parents were concerned about the persistent emesis and the potential for dehydration. They reported no sick contacts. The child was up to date for all her immunizations. There was no recent travel or dietary changes. 
 
A physical examination revealed a fussy, well-nourished, Hispanic infant, lying in her mother’s arms. She was afebrile. Her mucous membranes and lips seemed dry. She was mildly tachycardic, but the remainder of her examination was unremarkable. 
 
Initial laboratory findings included a white blood cell count of 9.3 × 109/L (normal 5 × 109/L to 15 × 109/L), hemoglobin concentration of 143 g/L (normal 100 g/L to 140 g/L), platelet count of 430 × 109/L (normal 150 × 109/L to 400 × 109/L), sodium level of 148 mmol/L (normal 133 mmol/L to 142 mmol/L), potassium level of 3.9 mmol/L (normal 3.5 mmol/L to 6 mmol/L) and bicarbonate level of 14 mmol/L (normal 18 mmol/L to 29 mmol/L). The remainder of her blood chemistry was within normal limits. A chest x-ray revealed no evidence of acute cardiopulmonary disease, but some radiopaque material within the right lower quadrant of the abdomen was seen (Figure 1). This high-density material was described as small and granular in appearance. The state toxicologists were contacted, and the child was transferred to a tertiary care centre for further evaluation and management. 
 
 
 
Figure 1 
 
High-density radiopaque material is present within the abdomen. This material is small and granular in appearance. Air fluid levels are also noted