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Stuart A Bradin, DO, FAAP, FACEPAssociate Professor of Pediatrics and Emergency Medicine
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Introduce common causes for abdominal pain in the pediatric population
Recognition of typical presentation for these illnesses Identify surgical abdominal emergencies Discuss diagnostic and management strategies
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Frequent, nonspecific symptom typically associated with self-limited minor conditions Represents 5% ER visits yearly Less then 10% of those visits require surgery
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Abdominal pain is common complaint in ED Most common discharge diagnoses:
Abdominal pain Gastroenteritis Viral syndrome Constipation Strep pharyngitis
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Adapted from: Scholer SJ, Pituch K, Orr DP, et al. Clinical outcomes ofchildren with acute abdominal pain. Pediatrics 1996;98(4):680-685.
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To identify uncommon diagnoses that require further intervention
Appendicitis SBO Intussusception Incarcerated hernia Pancreatitis Malrotation with volvulus Foreign body ingestion
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Way, L. Doherty, G. Current Surgical Diagnosis and Treatment, 11th ed.
Mediated by ONLY afferent C fibers Visceral pain slow in onset, dull, poorly localized Signaled by distention, inflammation or ischemia, or indirect stimulation of sensory nerves Visceral pain is usually midline because sensation is provided to both sides of spinal cord
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What the ED physician wants to know Is this a surgical emergency?
▪ Peritonitis▪ Obstruction
Is this an urgent medical problem?
What the surgeon wants to know Does this patient need an operation now? Will this patient need an operation later?
(i.e. what testing and follow up do I need to figure that out?)
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Onset Pain precedes other symptoms Sudden: perforation or ischemia Gradual: inflammatory
Location Point with one finger? Diffuse hard to localize: obstruction Well localized: peritonitis
Anorexia the rule for urgent/emergent abdominal pathology
Vomiting before pain or after pain, bilious, bloody, feculent
Diarrhea bloody*, black or tarry, currant jelly, mucusy, watery
Constipation hard stools, no stools
Abdominal Distention Suggests obstruction
Fever, Chills Suggests infection
Jaundice Biliary/Liver dysfunction
Urinary changes Renal pathology
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EPIGASTRIUM
Stomach, Duodenum, Pancreas, Liver, Biliary tree
PERIUMBILICAL
Small intestine; ureters, colon, bladder uterus, testes, ovaries, early appendicitis.
SUPRAPUBIC
Bladder, ureter, uterus, ovaries, retrosigmoid colon
LUQ
Pancreas, spleen, transverse colon, splenic flexure, diaphragm
LLQ
Pelvic and retrosigmoidcolon, descending colon, Left adnexa, psoas abscess
RUQ
Liver,
Gallbladder, biliary tree, hepatic flexure
Pancreas, diaphragm
RLQ
Appendix, terminal ileum, ceacum, right adnexa, Meckelsdiverticulum
FLANK: U
reters and kidney
FLANK: U
reters and kidney
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Acute (hours) and Subacute (days) Often presentation of serious medical illness
Recurrent and Chronic Often presentation of functional abdominal pain
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Involuntary weight loss Decreased linear growth velocity GI bleeding RUQ or RLQ pain Significant vomiting Persistent diarrhea Unexplained fevers Family history of Inflammatory Bowel Disease
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Mild, moderate, severe (FACES or 1-10) Crampy (colic) Dull/aching (visceral) Sharp/stabbing (somatic) Associated symptoms-
anorexiavomitingbloody stoolpallor
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Alleviating/ aggravating Worse with movement, cough, sneezing: peritonitis Better with changes in position: obstruction
Radiation To right shoulder = cholecystitis To back = pancreatitis Flank to groin = Ureter
Treatment Anything help? Anything hurt?
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Observation Vital signs Abdomen Inspect, auscultate then palpate Light percussion; Light palp; Deep palp Note guarding and rebound
Rectal: only if diagnosis unclear, h/o bleeding, h/o Intussusception GU: eval for hernias
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Many diverse causes
Could this be trauma? How old is the patient?
▪ Infant -2 y/o▪ 2y/o – 5 y/o▪ School-aged (5y/o -12 y/o) ▪ Adolescent (menstruating or > 12 y/o)
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A common cause of fatal injuries in childhood Constellation of injuries: severe and indolent Splenic injury (most common) Liver injury Kidney injury Duodenal and pancreatic injury (handle bars) Bowel and mesenteric injury (lap belts) Non accidental trauma
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Common Colic (age
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A 3-day-old infant presents to the ED for bilious vomiting and abdominal distention. He has been feeding poorly and has been difficult to console.
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Incidence: 1: 500 births 75% present within the 1st year
Etiology: Twisting of bowel along it’s own axis resulting in vasulcular compromise
Presentation: Bilious emesis, dehydration, Abd. Distention, Abd Pain; Shock
Diagnosis: abdominal Xray: no air, dilated loops Upper GI with SBF: malpositon of c loop of duodenum
Treatment: Fluid support, NG tube, Surgical correction with Ladds procedure.
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Occurs in 1 in 500 live births Male predominance by at least 2 75% present in the 1st month of life Presentation – acute onset bilious emesis
abdominal distentionill appearing
Diagnostic procedure of choice – Upper GIabnormal position of duodenojejunal flexure"corkscrew" appearance of distal duodenum and proximal jejunum
Place of ultrasound is still being determined
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Volvulus
Non rotation
Malrotation
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An 18-month-old male infant presents to the emergency department with a 2-hour history of intermittent abdominal pain and vomiting. His mother reports that he is difficult to arouse between these episodes.
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Incidence: Most common intestinal obstruction in infant 3-6 m/o 80% present before 2 y/o
Etiology Loop of bowel invaginates caudally Most common ileocecal 10% have lead point (Meckels, Lymphoid tissue, HSP, Tumor)
Presentation Paroxysmal colicky abdominal pain with pain free periods Emesis bilious Increasing lethargy eventually shock Bloody stools (12 hr -2 days later) Palpable mass in RLQ/epigastrum
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Most common cause of intestinal obstruction in children younger then 2 Estimated incidence 1 per 2000 children younger then 15 years of age Male predominance Presentation – abdominal pain, vomiting, and bloody stools
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Lower GI contrast study Obstruction to flow of barium with coiled spring appearance
X-ray Multiple air fluid levels Soft tissue shadow Paucity of large bowel gas
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US Target sign Free/interloop fluid
Sensitivity 88.2 % Specificity 100% Positive predictive value 100% Negative predictive value 94.5%
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1st time parents of a 1 m/o bring him in to the ED for inconsolable crying for the past 4 ½ hours…it has been 5 hours since his last diaper change
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Incidence: 10-20% of pediatric hernias become incarcerated 50% in infants younger than 6 months
Etiology: Indirect Hernia (most common) bowel enters inguinal canal Bowel becomes trapped (incarcerated) leading to obstruction If not reduced:
blood supply cut off (strangulated) bowel death, necrosis, shock
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Extra abdominal cause of abdominal pain Most common cause of intestinal obstruction between 1-16 weeks of
life Presentation :
abdominal painscrotal edemanauseavomitinglow-grade fever
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Presentation Incarcerated: Nausea, vomiting, abdominal distention, painful enlargement of hernia that cannot be reduced Strangulated: Fever and toxic appearance or pain persist after reduction
Diagnosis Will be noted on PE X-rays: may help visualize SBO Ultrasound and CT can be used as needed
Treatment Attempt manual reduction Surgical correction for failed reduction or suspected strangulation
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5 week old, benign birth hx, “pukes all the time” birth wt 4 kg Meeting milestonesSeems like the “excorcist”- projectile , non bilious. Seems hungry after vomiting. Afebrile. Triage wt 4.8 kg
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Most common cause of infantile GI obstruction after 1st month of life Occurs 1 in every 250 life births Boys >>>> Girls Whites > African Americans > Asian Americans Presentation – gradually progressive emesis that becomes projectile and remains nonbilious Hungry after feeds- ultimately poor wt gain Hyponatremic, hypokalemic, hypochloremic metabolic alkalosis Must correct dehydration, electrolyte anomalies before OR
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Exam with palpation of olive then no further workup required Ultrasound diagnostic modality of choice Both US and upper GI have accuracies >95%
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positive UGI = narrowed pyloric channel the “string sign.” positive US =
pyloric muscle thickness > 4 mm length pyloric canal > 14 mm.
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Common Acute Gastro UTI Trauma Appendicitis Pneumonia HbSS “Viral syndromes” Constipation
Uncommon Meckel's diverticulum Henoch-Schönlein purpura Toxin Intussusception
Rare Incarcerated hernia Neoplasm HUS Hepatitis IBD Diabetes mellitus
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A 3-year-old girl presents with irritability and abdominal pain following several days of bloody diarrhea. Patient is hypertensive and pale with petechiae and purpura.
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Incidence 0.3-10/100,000 children Age: 7 months to 6 years. Increase in summer and early fall; outbreaks
Etiology Bacteria (e.g. E Coli 0157:H7) releases toxins absorbed by gut Toxins cause endothelial damage: primarily in kidney Endothelium swells, triggers fibrin deposition, and microthrombi Consumes platelets and sheers RBCs
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Presentation Diarrhea (80% bloody), vomiting and crampy abdominal pain 3-12 days later:
Irritability, restlessness, oliguria, edema, hypertension, pallor, petechiae, hematuria
Diagnosis CBC: Leukocytosis with Left shift
ThrombocytopeniaAnemia (shistocytes and helmet cells on smear)
Elevated BUN/Cr, Uric acid and K increased, Bicarb decreased Stool cx or serum antibodies for E Coli 0157:H7
Treatment Supportive care:
▪ ARF: Careful fluid and electrolyte management, Dialysis as needed▪ Anemia: Keep Hbg > 7 with PRBC transfusion▪ Thrombocytopenia: Plts only if bleeding
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A 4 year-old boy complains of migratory pain and swelling of his joints. He is noted to have a purple, papular rash on his buttocks and lower extremities and was experiencing severe abdominal pain and swelling of his left elbow
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Incidence 14-15:100,000 children Peaks: age 5 y/o Increase in cases Nov – Jan
Etiology IgA related vasculitis usually following a URI
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Presentation: HSP Tetrad
RASH: (100%)▪ Symmetric Mac-pap rash on lower extremities▪ Rash becomes purpuric and spreads to legs, perineum and arms▪ May coalesce and look like bruises
ARTHRITIS (~ 80%) ▪ Arthralgias effect knees & ankles>>wrists & fingers
ABDOMINAL PAIN (~ 60%) ▪ Colicky abdominal pain & bloody/guiac + stools
RENAL INVOLVEMENT (~40%)▪ Proteinuria and hematuria w/ RBC casts▪ Renal involvement rarely leads to renal failure
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Diagnosis CBC: Leukocytosis with Eosinophila
Thrombocytosis UA: proteinuria and hematuria Stool Guiac + (50%) IgA increased in 50% of pts
Treatment Supportive care ~90% resolve spontaneously Steroids?: severe abdominal pain
GI bleedingrenal involvementscrotal edema
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Common Acute gastroenteritis Trauma Appendicitis UTI Functional abdominal pain HbSS Constipation “Viral syndromes”
Uncommon Pneumonia, asthma IBD Peptic ulcer disease Cholecystitis Pancreatic disease Diabetes mellitus Collagen vascular disease
Rare Toxin Renal calculi Testicular Torsion Ovarian torsion CF Intussusception
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10 y/o male awoke from sleep writhing in pain and later began to vomit. He is taken to the ED laying in backseat of the car and remembers every bump. He cannot walk back to Room 3 because it hurts so much . He denies scrotal pain. Temp 38.7 at triage
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Most common surgical problem in pediatrics Most common non-traumatic surgical emergency in children Peak incidence between 9-12 yrs of age Up to 8% of abdominal pain visits to pediatric ED Initial diagnosis missed in up to 57% Lifetime risk ~7% Uncommon in children less then 5 years of age- hard to diagnose Presentation – abdominal pain
nausea/vomitingfeveranorexia
Negative operative exploration rates: 10-15%
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Incidence 4/1000 children 2x more common in males
Etiology Obstruction of appendix; usually by fecolith Mucosal edema, bacterial overgrowth Inflammation, ischemia, gangrene Children develop peritonitis Adolescents develop abcess.
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Presentation Initial: intermittent periumbilical pain (visceral) Later: pain migrates to RLQ (somatic) Pain with percussion, hopping or coughing Inability to walk/ limping Nausea, anorexia Afebrile or low grade fever “Classic” Presentation (Appendicitis with perforation until proven otherwise!
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Diagnosis Labs:
▪ CBC: WBC elevated (> 8850 but less than 18,000)ANC elevated (> 6750)CRP
▪ UA: r/o renal disease mild pyuria/ hematuria with pelvic appendicitis▪ HcG
Imaging▪ Plain films: low yield, may see paucity of gas RLQ, Fecolith (5%)▪ US: operator dependent (sens: 85%; spec: 94%) ▪ CT: ideally Rectal contrast and IV contrast ▪ Focused MR ( > 7 yrs age)
Treatment Surgery Observation and Antibiotics
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Of the following, which is the most sensitive PE finding in appendicitis?
1. Obturator sign 2. Psoas sign3. Rovsing sign 4. Pain with hopping
Guarding: voluntary contraction of abdominal musclesRigidity: involuntary reflex spasm of muscles of abdominal wall Rebound Tenderness: press over point of pain and leave hand there for 30-60 seconds, then remove
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You are evaluating an 8 y.o. female with suspected appendicitis. After informing the parents, they inquire about serum lab work for diagnosis. Your response regarding laboratory diagnosis of appendicitis is:
1. Elevated C-reactive protein (CRP) is very sensitive for acute appendicitis 2. High white blood cell count (WBC) is highly sensitive3. Elevated C-reactive protein (CRP) is very specific4. Diagnostic radiology is a better option than lab tests
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Operator dependentSensitivity 80-90% Specificity 85-98%
LimitationsAtypical position of appendix Abdominal wall rigidity Obesity
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Sensitivity 89-98% Specificity 90-99% IV = IV contrast + po contrast +/- rectal contrast
LimitationsPaucity of fat in RLQ Radiation Cost
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RCT of children 5-16 year old Suspected acute surgical abdomen by attending PEM physician
Morphine group: Reduction in pain No delay in diagnosis or procedure No increase in perforated appendicitis
Green K et al, Pediatrics, 2005
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Children with missed appendicitis (Rothrock, 1991)28% previously evaluated by physician Young children and adolescent females No abdominal pain at initial evaluation in 50% !
Most common misdiagnosis: gastroenteritis (42%) 2nd most common PEM malpractice claim IF Discharge :
NEVER say you are 100 % sure Provide specific instructions to when to return
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9 Y/O male complains of abdominal pain. Abdomen has been increasing in size for the past few days. +anorexia, feels nauseated but has not vomited, tactile temp for 24 hours. Has hx constipation, uses miralax daily
Abdomen is very distended with quiet bowel sounds and tender throughout
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Constipation Obstruction Abdominal Mass Appendicitis
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Enterocolitis causing toxic megacolon Fever Bilious vomiting Abdominal distention Diarrhea Shock
Hirschsprungs Disease
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50‐90% of patients present in neonatal period Classic Presentation:
Failure to pass meconium within the first 8‐24 hours of lifeBilious emesisAbdominal distensionFTT
Rectal exam - no stool in rectal vault— “gloved finger”can cause patient to have explosive diarrhea
If stool passes ribbon‐like Chronic constipation diagnosed later in life Gold standard= rectal biopsy
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Uncommon Ectopic pregnancy Testicular torsion Ovarian torsion Renal calculi Peptic ulcer disease Hepatitis Cholecystitis Pancreatic disease CF Collagen vascular disease IBD Toxin
Rare Rheumatic fever Tumor Abdominal abscess
Common Acute gastroenteritis Gastritis GERD Trauma Constipation Appendicitis PID UTI Pneumonia, asthma “Viral syndromes” Dysmenorrhea Epididymitis Lactose intolerance Sickling syndromes
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Rare in children younger then 10 Incidence of 1 in 50,000 children Presentation – epigastric pain that radiates to the back,
nausea, and vomiting Complications – abscess, pseudocyst, and fistulae
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Gastritis/Peptic Ulcer disease: Loss of mucosal protection from HCL caused by NSAIDs, alcohol, stress, H. pylori Vague, dull periumbilical or epigastric
vomitingGuiac + stoolHematemesis
Pancreatitis Inflammation /auto digestion of pancreas Severe epigastric pain radiating to back with nausea and vomiting
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Hepatitis Inflammation of Liver Causes diverse: Infectious, toxins, autoimmune Tenderness in RUQ, hepatomegaly, scleral icterus, dark urine, nausea, anorexia, +/- fever
Cholecystitis/ Cholelithiasis Inflammation of gallbladder Caused by Bile stasis, gallstones, congenital anomalies, hemoglobinopathies Tenderness in RUQ with pain radiating to back jaundice Nausea/ vomiting following meals +/- fevers
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UTI 2nd most common infection in children Caused by Ascending infection; E coli Abdominal or flank tenderness dysuria +/- fever vomiting and diarrhea
Urolithiasis Commonly Calcium stones Rising rate w/ rising obesity Abdominal or flank colicky pain with radiation to groin gross or microscopic hematuria
UPJ obstruction
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Most common cause of Hydronephrosis Epidemiology 1: 500 Live births Boys> girls Left > right 10-20% bilateral
Pathophysiology: Usually a partial obstruction Intrinsic: anatomic or functional Extrinsic: Compression by artery
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Clinical presentation: Commonly diagnosed on asymptomatic prenatal US. Infants: Palpable mass
UTIFailure to ThriveRenal failure
Older children: Intermittent flank/abdominal painPain worse with diuresisPain lasts from minutes to hourshematuria following minimal traumahypertension
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Ovulatory pain PID Spontaneous abortion / Ectopic pregnancy Torsion of the ovary In all ages, mostly adolescents Sudden onset sharp pain on one side of the abdomen that radiates to back and down to
thigh. +/-Vomiting, >50% tender mass Pelvic US with Doppler if suspected
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Sort Acute from Chronic Exclude trauma Think about your age-based differential Focus the evaluation to exclude peritonitis and obstructive causes Take a thorough History and Physical When in doubt, evaluate and reevaluate
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Abdominal complaints are common in children Maintain healthy skepticism of “constipation” diagnosis The cardinal presenting symptom in Hirschsprung’s disease is delayed passage of meconium. Surgically correctable causes of abdominal pain in children are relatively uncommon (about 1% of cases of abdominal pain presenting to the ED). Of surgically correctable causes of abdominal pain in children, appendicitis is by far the most common. Lethargy is a common presentation of intussusception- can present as altered mentation A small minority have the “classic” presentation of intermittent abdominal pain, vomiting, and bloody stool with or without a palpable right upper-quadrant mass. A neonate with bilious vomiting has malrotation with midgut volvulus until proven otherwise. This is a surgical emergency. Appendicitis may present with white cells in the urine. Suspect ectopic pregnancy in any post-menarchal girl with abdominal pain. Utilize observation time in the ED to help sort out ambiguous abdomens. Consider pneumonia as a cause of abdominal pain, particularly if cough or tachypnea is present. Drop the diaper to search for testicular torsion and incarcerated inguinal hernias. Don’t use the diagnoses “gastroenteritis” or “constipation” when the diagnosis is unclear Consider non-accidental trauma in cases where the history is confusing, changes over time, or doesn’t make sense
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Which of the following is true of Hirschsprung’s disease?
A. Incidence of the disease is 1 in every 5,000 live births.B. The disease is four times more prevalent in boys.C. Child may present with poor feeding.D. Plain x-rays may show massive distention of the colon with gas and feces present.E. All of the above
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Which of the following is NOT true regarding hypertrophic pyloricstenosis?
A. Pathognomonic feature is gastric outlet obstructionB. Incidence higher in first born maleC. Infants between ages 3-12 weeks of life make up 95% of casesD. Current mortality rate is about 30%
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The likely component(s) of the clinical presentation of midgut volvulusis/are:
A. Poor feedingB. IrritabilityC. Bloody stoolD. Bilious vomitingE. All of the above
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The findings of “cockscrew sign” on upper GI series is indicative of:
A. Incarcerated herniaB. Midgut volvulusC. Pyloric stenosisD. Aganglionic colon
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The estimated perforation rate in infant with acute appendicitis is:
A. 10%–20%B. 25%–40%C. 45%–50%D. 60%–70%
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What is the most common misdiagnosis of appendicitis?a. Mesenteric adenitisb. Pneumoniac. Diabetic ketoacidosisd. Gastroenteritis
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An important consideration in the differentialdiagnosis of a menstruating female patient is:
a. Pelvic inflammatory diseaseb. Ovarian torsionc. Early pregnancyd. All of the above
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What are the interventions that should be donein a patient with a diagnosis of appendicitis?
a. Pain controlb. IV fluid hydration with NPO statusc. Surgical consultationd. All of the above
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All are true about intussusception except:
a. The leading cause of intestinal obstruction in children 5 months to 3 years of ageb. One of the most common causes of acute abdominal emergency in young childrenc. Is common over the age of 5 yrsd. Can be associated with recent viral illnessd. None of the above