Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof
(not the classic tale)
John Misdary
PGY 6
Pediatric Emergency Medicine
Emory University / CHOA
QUALITY OF A PRESENTATION
1. Novel but not Interesting 2. Interesting but not Novel 3. Both 4. Neither
Case 1 (YouYou 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 2 (YouYou 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?
PRESENTATION:THE SPECTRUM
stoic denies pain fear of further medical attention
histrionic exaggerates pain
DICTUM
All kids of non-verbal age presenting with DIAGNOSIS NYD should be considered to have abdominal pathology.until proven otherwise.
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
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
INFLAMMATION:SYMPTOMS
Irritable?/lethargic?/not bad (Perforation rate <2 82-92%)
limping/”PID shuffle”?
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 measurementsuseless ? 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
9-10/10OR 7-8/10imaging <6/10consider other Dg
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”