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 (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 1 cont’d

Presents 3rd time, abd pain increased rebound OR:perforated appendix

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?

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 fear of further medical attention

histrionic 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?/notnot 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 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

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 BRING TO WORKWORK MESSAGE

HISTORY!!!! IF IN DOUBT RE-EXAMINE IF STILL UNSURE RE-EXAMINE

LATER GASTROENTERITIS (Dg of exclusion)