Steven Teich, M.D. Daniel Cohen, M.D. Ann Dietrich, M.D. Osama El-Assal, M.D. John Shultz, M.D.

1. Steven Teich, M.D. Daniel Cohen, M.D. Ann Dietrich, M.D. Osama El-Assal, M.D. John Shultz, M.D. Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

2. Study Aims Aim 1: Describe the presentation of acute abdomen in medically fragile, high risk children and adults to expedite the recognition of a surgical emergency Aim 2: Develop a diagnostic algorithm for patients with special care needs with possible intra-abdominal emergency

3. Background • There are an estimated 9 million children and 23 million adults in the U.S. with special health care needs • Large subset of special health care needs patients at risk to develop acute surgical abdomen due to co-morbidities • Multiple abdominal surgeries • Indwelling abdominal devices • Chronic constipation • Nissen fundoplication

4. Background • Adhesive peritoneal bands occur in 93-100% of patients with prior abdominal surgery • Nissen fundoplication increases the risk of adhesive SBO up to 21% in children • Incidence of complications after VP shunt varies from 5-47% -CSF pseudocyst -Inguinal hernia -SBO -Intestinal perforation -CSF ascites -Intestinal entanglement -Shunt displacement

5. Background • Nonverbal children and adults with altered sensation often unable to communicate symptoms classically associated with acute abdomen and often present with subtle manifestations • Therefore, this patient population at greater risk for acute abdominal surgical emergencies and delayed or missed diagnoses with potentially catastrophic outcomes

6. Study Design • Study conducted at Nationwide Children’s Hospital, Columbus, OH (#IRB09-00151) • Retrospective case-controlled study with patients serving as their own control • Review of hospital discharge data including ICD9 codes and surgical case records • Inclusion criteria: patients with neuro-developmental delay with diagnosis of acute surgical abdomen within 48 hours of hospital admission from the Emergency Department between May 2005 and October 2009

7. Study Design • Acute surgical abdomen defined as an abdominal surgical procedure demonstrating a pathological process or an IR procedure for abdominal pathology (e.g. drainage of CSF cyst) • Each subject had to have an index ED visit during which an acute surgical abdomen was diagnosed and a control ED visit which proved to be negative for an acute surgical emergency • The control visit required to have occurred within two years of the acute surgical abdomen visit but at least two months distant to avoid repeat presentation for the same illness

8. Study Definitions • Feeding intolerance • Decreased oral intake or vomiting in orally fed patient • Abdominal distention, discomfort, or increased gastrostomy tube output after oral or gastrostomy feeds • Pain • Described by patients able to communicate • Interpreted by caregivers as changes in behavior consistent with feeling abdominal pain such as grimaces or moaning with abdominal touch • Constipation • New onset or worsening

9. Results • 169 patients with special needs had abdominal procedures over the study time period • 24 patients met the selection criteria after screening for elective surgical procedures and lack of a qualifying ED control visit

10. Demographic Data

11. ED Index Visit (Surgery)

12. ED Control Visit (No Surgery)

13. Symptoms at Presentation * p < 0.05

14. Physical Findings at Presentation * p < 0.05

15. Laboratory Results and Diagnosis of Acute Surgical Abdomen * p < 0.05

16. Early ED Management and Diagnosis of Acute Surgical Abdomen * p < 0.05

17. Radiology Testing

18. Patient #1

19. Patient #1

20. Patient #2

21. Patient #2

22. Predictive Variables For Surgical Abdomen

23. High Risk Patient with Clinical Suspicion or ≥ 2 of : Vomiting/Increased G tube output Abdominal pain, Tenderness, Dehydration, Absence of diarrhea, or Elevated WBC: Yes V-P shunt No Acute abdominal series Abdominal ultrasound Positive Negative Negative Positive Abdominal CT with contrast Definitive treatment Negative Positive Definitive treatment Observe and reassess every 2 hours

24. Conclusions • First study on high-risk patients with suspicion for acute surgical abdomen • Presence of abdominal pain, abdominal distention, increased gastrostomy tube output or vomiting, abdominal tenderness, and signs of dehydration are significant predictors of need for emergency surgery in high risk, medically fragile patients

25. Conclusions • We propose abdominal ultrasound as the initial modality for patients with VP shunts when presenting with a possible acute surgical abdomen • Positive AAS is reliable finding but negative AAS can be misleading and a further confirmatory test is indicated • Abdominal CT is most reliable imaging modality • Our pathway for atypical, medically fragile patients at high risk for an acute surgical abdomen needs to be validated bya prospective study with a larger cohort

26. Questions?