Transcript Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof

Pediatric Abdominal Pain: Making
Sense of Crap or Lack Thereof
(not the classic tale)
John Misdary
PGY 6
Pediatric Emergency Medicine
Emory University / CHOA
 I have no conflict of interests to disclose.
QUALITY OF A PRESENTATION
 1. Novel but not Interesting
 2. Interesting but not Novel
 3. Both
 4. Neither
Case 1 (You are the attending)
 7 male, diarrhea, fever x 2 days
 vs:wnl, looks well
 abd: soft, +/-diffuse tenderness, no
peritoneal sign
 Bloods, urine: non contributory
 Dg: Gastroenteritis
Case 1 cont’d
 Presents again next day, same symptoms
 exam: no change
 no bloods drawn
 seen by Gen Surg.
 D/C with Gastroenteritis
Case 1 cont’d
 Presents 3rd time, abd pain increased
 rebound
 OR:perforated appendix
Case 2 (You are the attending)
 24 months, male, crying, “bloated”
 no v/d, last bm 2 days ago
 vs: wnl, happy, looks well
 abd:no mass, nontender, +BS
 Abd. Series: stool+++
 Dg: Constipation
Case 2 cont’d
 Presents next day lethargic
 pale, not responding, tachypneic
 protuberant abd
 7.10/30/5
 OR:intussusception
Which of 2 diagnosis are found on emergency
discharge records most frequently for missed pediatric
abdominal catastrophies in court cases?
Gastroenteritis
Constipation
GOALS
 Distinguish between benign and sinister
causes of non-traumatic A/P
 Which labs to order/not to order?
 Which imaging modalities to order/not to
order?
 How to dispose of the patient…..I mean
disposition of the patient?
EPIDEMIOLOGY
 #1.Minor Trauma 20-40%
 #2.UTI 8-20%
 #3. Non-traumatic abdominal pain 2-5%
KIDS: VERBAL vs. NON-VERBAL
 Differences?
 Similarities?
PRESENTATION:THE SPECTRUM
 stoic
denies pain
medical attention
 histrionic
fear of further
exaggerates pain
WHAT ’S IN COMMON?
 fever nyd
 irritability nyd
 lethargy nyd
 vomiting/diarrhea nyd
1/3 of kids presenting with
Abdominal Pain get no specific
diagnosis!!!
(not good)
DICTUM
 All kids of non-verbal age presenting
with DIAGNOSIS NYD should be
considered to have abdominal
pathology.until proven otherwise.
BENIGN CAUSES OF A/P (how long
is this lecture again?)
 Everything that’s not part of the next
slide
SINISTER CAUSES OF A/P
 Obstruction
 Perforation
 Inflammation
 (Metabolic)
TAKE HOME MESSAGE
 rely on history
 very few physical findings (50% normal
abd. exam)
In General
 Common problems occur commonly
– intussusception in the infant
– appendicitis in the child
 The differential diagnosis is age-specific
 In pediatrics most belly pain is non-surgical
– “Most things get better by themselves. Most things, in fact, are
better by morning.”
 Bilous emesis in the infant is malrotation
until proven otherwise
 A high rate of negative tests is OK
The History
 Pain (location, pattern, severity, timing)
– pain as the first sx suggests a surgical problem
 Vomiting (bile, blood, projectile, timing)
 Bowel habits (diarrhea, constipation, blood,
flatus)
 Genitourinary complaints
 Menstrual history
 Travel, diet, contact history
The Physical Examination
 Warm hands and exam room
 Try to distract the child (talk about pets)
 A quiet, unhurried, thorough exam
 Plan to do serial exams
 Do a rectal exam
Relevant Physical Findings
 Tachycardia
 Alert and active/still and silent
 Abdominal rigidity/softness
 Bowel sounds
 Peritoneal signs (tap, jump)
 Signs of other infection (otitis, pharyngitis,
pneumonia)
 Check for hernias
Blood in the Stool
 Newborn
– ingested maternal blood, formula intolerance, NEC, volvulus,
Hirschsprung’s
 Toddler
– anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile
polyps, HUS, IBD
 2 to 6 years
– infectious colitis, juvenile polyps, anal fissures, intussusception,
Meckel’s, IBD, HSP
 6 years and older
– IBD, colitis, polyps, hemorrhoids
Blood in the Vomitus
 Newborn
– ingested maternal blood, drug induced, gastritis
 Toddler
– ulcers, gastritis, esophagitis, HPS
 2 to 6 years
– ulcers, gastritis, esophagitis, varices, FB
 6 years and older
– ulcers, gastritis, esophagitis, varices
Further Work-up
 CBC and differential
 Urinalysis
 X-rays (KUB, CXR)
 US
 Abdominal CT
 Stool cultures
 Liver, pancreatic function tests
 (Rehydrate, ?antibiotics, ?analgesiscs)
Relevant X-ray Findings
 Signs of obstruction
– air/fluid levels
– dilated loops
– air in the rectum?
 Fecalith
 Paucity of air in the right side
 Constipation
Operate NOW
 Vascular compromise
–
–
–
–
–
malrotation and volvulus
incarcerated hernia
nonreduced intussusception
ischemic bowel obstruction
torsed gonads
 Perforated viscus
 Uncontrolled intra-abdominal bleeding
Operate SOON
 Intestinal obstruction
 Non-perforated appendicitis
 Refractory IBD
 Tumors
Appendicitis
 Common in children; rare in infants
 Symptoms tend to get worse
 Perforation rarely occurs in the first 24
hours
 The physical exam is the mainstay of
diagnosis
 Classify as simple (acute, supparative) or
complex (gangrenous, perforated)
Intussusception
 Typically in the 8-24 month age group
 Diagnosis is historical
– intermittent severe colic episodes
– unexplained lethargy in a previously healthy infant
 Contrast enema is diagnostic and often
therapeutic
 Post-op small bowel intussusception
The “Medical Bellyache”
 Pneumonia
 Mesenteric adenitis
 Henoch-Schonlein Purpura
 Gastroenteritis/colitis
 Hepatitis
 Swallowed FB
 Porphyria
 Functional ileus
 UTI
 Constipation
 IBD “flare”
 rectus hematoma
The Neurologically Impaired Patient
 The physical exam is important for non-
verbal patients
 The history is important for the spinal cord
dysfunction patient
 Close observation and complementary
imaging studies are necessary
The Immunologically Impaired
Patient
 A high index of suspicion for surgical
conditions and signs of peritonitis may
necessitate operation
– perforation
– uncontrolled bleeding
– clinical deterioration
 Blood product replacement is essential
 Typhlitis should be considered; diagnosis is
best established by CT
The Teenage Female
 Menstrual history
– regularity, last period, character, dysmenorrhea
 Pelvic/bimanual exam with cultures
 Pregnancy test/urinalysis
 US
 Laparoscopy
 Differential diagnosis
– mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic
pregnancy, UTI, pyelonephritis
OBSTRUCTION: SYMPTOMS
 persistent (bilious,feculent) vomiting
 no stool/gas per rectum (not an
absolute!)
 po (P.S.!!)
 poorly localized A/P
OBSTRUCTION:SIGNS
 ALWAYS START WITH THE VITAL
SIGNS!!!!
OBSTRUCTION: SIGNS
 Inconsolable?/lethargic?/absolutely well?
 hernias?
 check out the rectum?
DIFFERENTIAL DIAGNOSIS
 Infants: #1.ing. hernia, #2 intussusception
OBSTRUCTION:INVESTIGATION
 +/-abd series (prior rectal exam?)
 upper gi/lower gi study
 CT?
PERFORATION:SYMPTOMS
 irritability?/lethargy?/not well
 sudden onset severe abd……….
PERFORATION:SIGNS
 Vital signs!!!!!!!!!!!!
PERFORATION:SIGNS
 not moving/legs drawn up
 rebound (what is it?)
PERFORATION:INVESTIGATIONS
 abd. series
 CT
INFLAMMATION:SYMPTOMS
 Irritable?/lethargic?/not bad (Perforation rate <2
 limping/”PID shuffle”?
82-92%)
APPENDICITIS
 Classical presentation 50-60%
 RLQ pain 90-95%
 n/v/anorexia 65%
 mean temp @ presentation 37.6C
 WBC < 10000, no left shift <10%
 WBC normal in first 24hrs 80%
 Serial WBC or CRP measurementsuseless
 ? triple test for NPV (WBC<9000, CRP<0.6mg%, nph
<75%)
APPENDICITIS SCORE
 RLQ 2/10
anorexia 1/10 fever 1/10
good story 1/10
 WBC 2/10
n/v 1/10
left shift 1/10
rebound 1/10
 9-10/10OR
 7-8/10imaging
 <6/10consider other Dg
INVESTIGATION
 abd. Series
 U/S vs. CT
ANALGESIA
 not a license to snow them
 titration is the key
AT SIGN OVER….(ANYTHING MISSING?)
 11 girl
 A/P x 2 days, periumbilical
 vomitted once, no “poop”
 exam unremarkable
 u/a NEG, cbc unremarkable
 waited long enough, “wants to go home”
TAKE HOME AND BRING TO
WORK MESSAGE
 HISTORY!!!!
 IF IN DOUBT RE-EXAMINE
 IF STILL UNSURE RE-EXAMINE
LATER
 GASTROENTERITIS (Dg of exclusion)