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

Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale). Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC. QUALITY OF A PRESENTATION. 1. Novel but not Interesting 2. Interesting but not Novel

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

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  1. Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof(not the classic tale) Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC

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

  3. 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: Gastro?enteritis

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

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

  6. 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

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

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

  9. GOoooooooooooooaL • Brazil 2 Germany 0 (my prediction)

  10. 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?

  11. EPIDEMIOLOGY • #1.Minor Trauma 20-40% • #2.URTI 8-20% • etc • #5. Non-traumatic abdominal pain 2-5%

  12. WHAT’S IN COMMON? • Patient 1: 1/52, lethagic • Patient 2: 8/12 m, irritable, po, bilious vomiting, red current jelly stools • Patient 3: 4/52 f, crying episodes x hours x 2 weeks, legs drawn up, “passing ++gas”, otherwise well baby

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

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

  22. OBSTRUCTION: SIGNS • Inconsolable?/lethargic?/absolutely well? • hernias? • check out the asshole?

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

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

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

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

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

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

  29. PERFORATION:INVESTIGATIONS • abd. series • CT

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

  31. 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%)

  32. 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

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

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

  35. 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”

  36. TAKE HOME ANDBRING TO WORK MESSAGE • HISTORY!!!! • IF IN DOUBT RE-EXAMINE • IF STILL UNSURE RE-EXAMINE LATER • GASTROENTERITIS (Dg of exclusion)

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