More Fun with Abdominal Pain 02.15.2012

8/2/2019 More Fun with Abdominal Pain 02.15.2012

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More fun with abdominal pain

Kathy Garcia

AM ReportFebruary 15, 2012


2/14

HPI

2 year old previously healthy Somali girl

Chief Complaint: abdominal pain

HPI: 2-3 weeks of intermittent abdominal pain, poor appetite, andvomiting

Progressive limitation of diet from regular table foods to essentiallyonly milk

Drinks >5 glasses of whole milk daily, sometimes juice

Denies feeling hungry and if pushed to eat other foods will vomit

Vomiting only associated with eating

I

ntermittent episodic abdominal pain, sometimes associated witheating, but not always

Recently has been seen eating non-food items (dirt, paper, paintchips, wood)


3/14

HPI continued

ROS: + constipation

PMH: healthy, no hospitalizations/surgeries

Had 2yr WCC yesterdayImms: UTD

Meds: no medicines, herbal supplements

FamilyHx

: family members healthySocial Hx: lives in a house with parents, 2 brothers.

Family originally from Somalia but pt born in US.


4/14


5/14

DIFFERENTIAL DIAGNOSIS?


6/14

Work-Up

CBC: WBC 6.1, Hct 34, Plt 366

MCV 55, 4+ microcytosis

TIBC: 441 (NL), Iron 64 (NL), Retic count 0.4% ZPP: 388 (NL < 69)

Lead: 72.9

Vitamin D: 22 KUB: normal


7/14

LEAD

Has been used since 4000 BC

Lead poisoning has been recognized nearly

that long poudre de la succession Plumbism from use of lead (Pb) as

inexpensive pipe material


8/14

Lead Exposure

Can be inhaled or ingested

Used in paint in US until 1978

In gasoline until 1995 Common sources: water (pre-1988 plumbing),

food (soil along major roads), herbal

remedies, glazed pottery, imported jewelryand toys

Pica: paint, soil, buckshot, fishing weights


9/14

Lead Toxicity

Neurologic: irritability, decreased activity, hearing loss,peripheral neuropathy, developmental delay(particularly language), behavioral disturbance,seizures Lead encephalopathy: acute, persistent vomiting, AMS,

ataxia, seizures, coma, cerebral edema

Hematologic: decreased heme synthesis

Renal: lead nephropathy (chronic interstitial nephritis)

GI: lead colic sporadic vomiting, intermittentabdominal pain, constipation

Endocrine: decreased Vitamin D, delayed puberty,decreased growth


10/14

Diagnosis

Blood lead level >10mcg/dL on venous blood

sample

Physical E

xam: neurologic abnormalities,

Burton lines

Lab: basophilic

stippling, elevated ZPP


11/14

Evaluation Repeat venous lead level (takes 1-2 days) ZPP (only elevated if lead level >30)

CBC, retic count, iron studies

KUB if history of pica or ingestion of lead containing items


12/14


13/14

Management

Notify Health Department

Severe (BLL >70 or symptoms ofencephalopathy) -> IV chelation

Dimercaprol: aka BAL

Moderate (BLL 45-69) -> oral chelation

Succimer: aka DMSA

Mild (BLL


14/14

Dont Be Like These Guys

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More Fun with Abdominal Pain 02.15.2012