Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale)

1. Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof(not the classic tale) John Misdary PGY 6 Pediatric Emergency Medicine Emory University / CHOA

3. I have no conflict of interests to disclose.

4. QUALITY OF A PRESENTATION • 1. Novel but not Interesting • 2. Interesting but not Novel • 3. Both • 4. Neither

5. 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

6. Case 1 cont’d • Presents again next day, same symptoms • exam: no change • no bloods drawn • seen by Gen Surg. • D/C with Gastroenteritis

7. Case 1 cont’d • Presents 3rd time, abd pain increased • rebound • OR:perforated appendix

8. 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

9. Case 2 cont’d • Presents next day lethargic • pale, not responding, tachypneic • protuberant abd • 7.10/30/5 • OR:intussusception

10. Which of 2 diagnosis are found on emergency discharge records most frequently for missed pediatric abdominal catastrophies in court cases? Gastroenteritis Constipation

11. 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?

12. EPIDEMIOLOGY • #1.Minor Trauma 20-40% • #2.UTI 8-20% • #3. Non-traumatic abdominal pain 2-5%

13. KIDS: VERBAL vs. NON-VERBAL • Differences? • Similarities?

14. PRESENTATION:THE SPECTRUM • stoic denies pain fear of further medical attention • histrionic exaggerates pain

15. WHAT ’S IN COMMON? • fever nyd • irritability nyd • lethargy nyd • vomiting/diarrhea nyd

16. 1/3 of kids presenting with Abdominal Pain get no specific diagnosis!!! (not good)

17. DICTUM • All kids of non-verbal age presenting with DIAGNOSIS NYD should be considered to have abdominal pathology.until proven otherwise.

18. BENIGN CAUSES OF A/P (how long is this lecture again?) • Everything that’s not part of the next slide

19. SINISTER CAUSES OF A/P • Obstruction • Perforation • Inflammation • (Metabolic)

20. TAKE HOME MESSAGE • rely on history • very few physical findings (50% normal abd. exam)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Further Work-up • CBC and differential • Urinalysis • X-rays (KUB, CXR) • US • Abdominal CT • Stool cultures • Liver, pancreatic function tests • (Rehydrate, ?antibiotics, ?analgesiscs)

28. 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

29. Operate NOW • Vascular compromise • malrotation and volvulus • incarcerated hernia • nonreduced intussusception • ischemic bowel obstruction • torsed gonads • Perforated viscus • Uncontrolled intra-abdominal bleeding

30. Operate SOON • Intestinal obstruction • Non-perforated appendicitis • Refractory IBD • Tumors

31. 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)

32. 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

33. The “Medical Bellyache” • Pneumonia • Mesenteric adenitis • Henoch-Schonlein Purpura • Gastroenteritis/colitis • Hepatitis • Swallowed FB • Porphyria • Functional ileus • UTI • Constipation • IBD “flare” • rectus hematoma

34. 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

35. 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

36. 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

37. OBSTRUCTION: SYMPTOMS • persistent (bilious,feculent) vomiting • no stool/gas per rectum (not an absolute!) • po (P.S.!!) • poorly localized A/P

38. OBSTRUCTION:SIGNS • ALWAYS START WITH THE VITAL SIGNS!!!!

39. OBSTRUCTION: SIGNS • Inconsolable?/lethargic?/absolutely well? • hernias? • check out the rectum?

40. DIFFERENTIAL DIAGNOSIS • Infants: #1.ing. hernia, #2 intussusception

41. OBSTRUCTION:INVESTIGATION • +/-abd series (prior rectal exam?) • upper gi/lower gi study • CT?

42. PERFORATION:SYMPTOMS • irritability?/lethargy?/not well • sudden onset severe abd……….

43. PERFORATION:SIGNS • Vital signs!!!!!!!!!!!!

44. PERFORATION:SIGNS • not moving/legs drawn up • rebound (what is it?)

45. PERFORATION:INVESTIGATIONS • abd. series • CT

46. INFLAMMATION:SYMPTOMS • Irritable?/lethargic?/not bad(Perforation rate <2 82-92%) • limping/”PID shuffle”?

47. 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%)

48. 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

49. INVESTIGATION • abd. Series • U/S vs. CT

50. ANALGESIA • not a license to snow them • titration is the key