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Abdominal pain

Abdominal pain. Case Presentation Kriska Shalin Lara Joaquin. To present the history and physical examination of a pediatric patient presenting with abdominal pain To discuss the approach and management to a pediatric patient presenting with abdominal pain

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Abdominal pain

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  1. Abdominal pain • Case Presentation • Kriska Shalin Lara Joaquin

  2. To present the history and physical examination of a pediatric patient presenting with abdominal pain • To discuss the approach and management to a pediatric patient presenting with abdominal pain • To highlight differences in approach and management in pediatric and adult patients • To review basic anatomy and pathophysiology relevant for this case Objectives

  3. Patient data • CV • 16/M • Single • Filipino • Roman Catholic • College student • 4/12/1995 • Makati City

  4. Chief complaint Abdominal pain, 17 hours

  5. History of Present Illness 17 hours PTC • (+) epigastric pain 6/10 • Diffuse • (-) fever • (+) loss of appetite • Last meal: >20h PTC

  6. History of Present Illness 7 hours PTC (+) migration of pain to RLQ 10/10, sharp, localized (-) fever (+) vomiting Consult at ER

  7. PastMedicalhistory • No prior surgeries • Past hospitalization. 2010- Dengue fever (-) Asthma, (-) congenital diseases • Born FT via NSD in a hospital, developmentally at par with age • Patient claims to have complete immunizations from health center • No known allergies to food and drug

  8. Familyhistory • (+) asthma • (+) HTN • (+) DM • (-) allergies

  9. Personal& Social history • Denies smoking and illicit drug use • Occasional alcohol use • Lives in a well-ventilated house in Makati City • Potable water source • Garbage collected regularly • 1st year college student

  10. HEADSSS • Comfortable at home • 1st year college • Involved in sports, watches TV, computer games • Denies use of any drugs • Denies involvement in sexual activities, heterosexual, does not have a girlfriend • Safety – no high risk activities, does not drive • Attends mass every now and then

  11. Review of Systems • No weight loss • No rash • No cough/colds • No difficulty of breathing • No palpitations • No diarrhea, no constipation • No frequency, no dysuria, no penile discharge

  12. Physical examination

  13. Vital signs • BP 120/70 • HR 92 • RR 16 • T 38 C • VAS 9/10 • BMI 22.5

  14. General • Ambulatory, walking limited by pain • Refused to jump • Awake, coherent, not in cardiorespiratory distress

  15. Skin • Not flushed • Warm to touch • No active lesions or discolorations

  16. Head and neck • Normocephalic head • Anicteric sclerae, pink palpebral conjunctiva • Ears symmetric, no discharge • No nasal discharge • No tonsillopharyngeal congestion • No nasal discharge • No CLAD

  17. Chest and Lungs • Equal chest expansion • Resonant on all lung fields • Clear breath sounds • No rales/wheezes

  18. Heart • Adynamic precordium • PMI at 5th ICS along MCL • Good S1 and S2 • Normal rate, Regular rhythm • No murmurs

  19. Abdomen • Flabby, no visible lesions • normoactive bowel sounds, tympanitic on all quadrants • Soft, (+) direct and indirect tenderness with guarding at RLQ (-) Obturator sign (-) Psoas sign (-) Rovsing's sign

  20. Extremities • MMT: 5/5 upper and lower left and right • Sensory: 100% bilaterally • Full ROM, active and passive

  21. Acute appendicitis Primary Impression

  22. Discussion

  23. Anatomy • Landmarks • Size of Appendix: >1 cm - 30 cm, Ave: 6-9 cm • Appendiceal artery

  24. Appendix • Immunologic organ • Retrocecal (15%) • pelvic • subcecal • preileal • right pericolic position

  25. Uncomplicated Appendicitis the acutely inflamed, phlegmonous, suppurative, or mildly inflamed appendix with or without peritonitis Complicated Appendicitis gangrenous appendicitis, perforated appendicitis, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess Definitions EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF ACUTE APPENDICITIS Philippine College of Surgeons 2002

  26. Equivocal Appendicitis • a patient with right lower quadrant abdominal pain who presents with an atypical history and physical examination and the surgeon cannot decide whether to discharge or to operate on the patient Definitions EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF ACUTE APPENDICITIS Philippine College of Surgeons 2002

  27. Incidence • In pedia: more common 4-15 yo • Lifetime risk 7% (Irvin, 1989) • Lifetime rate of appendectomy: • 12% men • 25% women • 20s-40s, mean 31, median 22 yo • Misdiagnosis and negative appendectomy is higher in females

  28. Organisms • Escherichia coli • Bacteroides fragilis

  29. Schwartz 8th ed

  30. Manifestation RLQ pain Obstuction of lumen Secretions Dull diffuse pain Distention Bacteria Marked distention Reflex nausea/vomiting Exceeds venous pressure Occluded cap/veins Inflammation: Serosa and parietal Peritoneum Pathophysiology

  31. In more than 95% of patients with acute appendicitis: anorexia, abdominal pain, vomiting anorexia – almost always abdominal pain – most common complaint vomiting – 75%

  32. REVIEW • McBurney's point • Rovsing's sign • Psoas sign • Obturator sign

  33. TRUE or FALSE • Most common site of rupture is at the tip

  34. Rupture • Distal to the point of luminal obstruction along the antimesentericborder of the appendix • overall rate of perforated appendicitis is 25.8% (Schwartz) 17-48% (JAMAevidence 2010) • Happens 36-48 h after onset of symptoms • Children <5 and > 65 years have the highest rate of perforation (45 and 51%, respectively) • in elderly as high as 60-70% (JAMAevidence) • Suspect in: • > 39 deg • > 18000 WBC

  35. Misdiagnosis • Higher in females (45%) • accounting for more than 75% of misdiagnosis are: • acute mesenteric lymphadenitis • no organic pathologic conditions • acute pelvic inflammatory disease • twisted ovarian cyst or ruptured graafian follicle • acute gastroenteritis.

  36. Alvarado scoring Pre-test probabilities Diagnostic modalities Diagnostics

  37. Alvaradoscoring:MANTRELS

  38. Pre-testprobabilities • Evidence-based Rational Clinical Examination. JAMAEvidence 2010

  39. Atypical features in children absence of pyrexia (83%) absence of Rovsing's sign (68%) normal or increased bowel sounds (64%) absence of rebound pain (52%) lack of migration of pain (50%) lack of guarding (47%), abrupt onset of pain (45%), lack of anorexia (40%) absence of maximal pain in the right lower quadrant (32%) absence of percussive tenderness (31%) • Atypical features of pediatric appedicitis. Acad Emerg Med. 2007 Feb;14(2):124-9. Epub 2006 Dec 27.

  40. TRUE or FALSE • CT scan is preferred because it is more superior to Ultrasound Ultrasound should be requested for all pediatric patients

  41. Diagnostics • CBC • Leukocytosis: 10,000 to 18,000/mm3 • Urinalysis • Graded compression sonography • Non-compressible 6 mm and apendicolith • presence of thickening of the appendiceal wall and periappendiceal fluid - highly suggestive

  42. Diagnostics • CT scan • 5 mm or greater, Thickened wall • Fecaliths - not pathognomonic • Target sign/ Arrowhead sign - thickening of the cecum, which funnels contrast toward the orifice of the inflamed appendix

  43. Ultrasound preferred in pedia • CT scan preferred over ultrasonography in clinically equivocal appendicitis in adults because of its superior accuracy (PCS 2002) • Laparoscopy - both diagnostic and therapeutic, more beneficial in women

  44. Therapeutics • Appendectomy is the appropriate treatment for acute appendicitis. • Open vs Lap: equally effective but... • Incisions: • Mc Burney • Rocky davis

  45. ​Alternative agents:​ • Ampicillin-sulbactam​1.5-3 grams IV single dose (Adults)​75 mg/kg IV single dose (Children) • Amoxicillin-clavulanate 1.2 –2.4 grams IV single dose (Adults) ​    45 mg/kg IV single dose (Children) UNCOMPLICATED: • Cefoxitin2 grams IV single dose  (Adults)40 mg/kg IV single dose  (Children)​ EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF ACUTE APPENDICITIS Philippine College of Surgeons 2002

  46. COMPLICATED (PEDIA) • ​Ticarcillin-clavulanic acid 75 mg/kg IV every 6 hours • Alternative:​Imipenem-Cilastatin 15-25 mg/kg IV every 6 hours For children with beta-lactam allergy ​Gentamicin 5 mg/kg IV every 24 hours plus ​Clindamycin 7.5 –10 mg/kg IV every 6 hours

  47. COMPLICATED: • Cefotetan • Triple: Ampicillin, Gentamicin, Clindamycin or Metronidazole Principles of Pediatric Surgery. O’Neill JJr et. al 2003

  48. COMPLICATED (ADULTS) • ​Ertapenem 1 gram IV every 24 hours ​ • Tazobactam-piperacillin 3.375 grams IV every 6 hours or​  4.5 grams IV every 8 hours For adults with beta-lactam allergy:​ Ciprofloxacin 400 mg IV every 12

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