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Acute Abdomen

Acute Abdomen. Ashna Khurana, MD. Case 1. 4 yo male with abdominal pain, n/v , poor appetite, and fevers to 102 x 2-3 days. Vitals: T102, HR 140s, BP 90/50, RR 22, sats 97% RA, 18kg

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Acute Abdomen

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  1. Acute Abdomen Ashna Khurana, MD

  2. Case 1 • 4 yo male with abdominal pain, n/v, poor appetite, and fevers to 102 x 2-3 days. • Vitals: T102, HR 140s, BP 90/50, RR 22, sats 97% RA, 18kg • Exam: ill appearing child, anxious, dry MM, tachycardic, distal pulses 2/2, cap refill 3 sec, fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +guarding, GU exam normal. • Limited U/S did not visualize appendix, some free fluid noted. • WBC 13 with left shift, CPR 5.2, UA negative; running a NS bolus 20cc/kg • ED calls for a consult. Wants to know if they should get a CT.

  3. What concerns you about this case?

  4. Case 1 • 4 yomale with abdominal pain, n/v, poor appetite, and fevers to 102 x 2-3 days. • Vitals: T102, HR 140s, BP 90/50, RR 24, sats 97% RA, 18kg • Exam: ill appearing child, anxious, dry MM, tachycardic, distal pulses 2/2, cap refill 3 sec, fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +guarding, GU exam normal. • Limited U/S did not visualize appendix, some free fluid noted. • WBC13 with left shift, CRP 5.2, UA negative; running a NS bolus 20cc/kg • ED calls for a consult. Wants to know if they should get a CT.

  5. What do you think?

  6. Acute Appendicitis • 2nd most common admission dx on the Peds Ward at Valley • 3 most predictive clinical features: • Pain in RLQ • Abdominal wall rigidity • Migration of periumbical pain to RLQ • These signs are often absent in younger children • 30-45% have atypical presentation • Up to 60% perforation rate in children • Other clinical signs to look for: • Fever, Vomiting, Anorexia, +Rovsing/Obturator/Iliopsoas signs, difficulty ambulating

  7. Work up to Evaluate for Acute Appendicitis • History and Physical Exam • Labs to consider: CBC w diff, CRP, UA/U.cx, possibly an electrolyte panel • Diagnostic Imaging: • Start with Ultrasound: • Limited U/S to look specifically at appendix vs. Complete Abdominal U/S • CT Scan of Abd/Pelvis • Consider Admission for Serial Abdominal Exams • Consult Pediatric Surgery

  8. Pediatric Appendicitis Score (PAS) • Uses Hx, PE, and lab results to categorize risk in children with abd pain on 10 point scale • Anorexia 1 • Nausea or Vomiting 1 • Migration of Pain 1 • Fever > 38C 1 • Pain w/cough, hopping or percussion 2 • RLQ tenderness 2 • WBC > 10K 1 • Neutrophils/Bands >7.5K 1 (Discuss score for Case 1)

  9. PAS continued • PAS < 2 Low risk • Discharge home with return precautions • PAS 3-6 Indeterminate • Consider pediatric surgery consult, diagnostic imaging, and/or serial abd exams in the hospital • PAS > 7 High Risk • Consult Pediatric Surgery • If U/S and dx inconclusive, strongly consider CT scan

  10. Management and Treatment • Admit to Pediatrics • Consult Pediatric/General Surgery • NPO, IVFs • Pain control • Antibiotics • Discuss Cefoxitin vs Zosyn • Anticipate hospital course (non-ruptured vs. ruptured)

  11. Case 2 • 17 month old male infant brought to ED with inconsolable crying x 6 hours. Per mom, toddler has been well for past few days but no BM x 3 days. No fevers, no vomiting. • Vitals: T 99, HR 130s, BP 80/50, RR 28, sats 97% RA, 11kg • Exam: anxious toddler, crying in mom’s arms. Fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +guarding; GU exam normal • Limited Ultrasound did not visualize appendix. • WBC 13, CRP 5.2, UA negative; Running a NS bolus 20cc/kg. • ED calls for a consult. Wants to know if they should get a CT.

  12. What Concerns you about this case?

  13. Case 2 • 17 month old male infant brought to ED with inconsolable crying x 6 hours. Per mom, toddler has been well for past few days but no BM x 3 days. No fevers, no vomiting. • Vitals: T 99, HR 130s, BP 80/50, RR 28, sats 97% RA, 11kg • Exam: anxious toddler, crying in mom’s arms. Fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +guarding; GU exam normal • Limited Ultrasound did not visualize appendix. • WBC 13 with left shift, CRP 5.2, UA negative; Running a NS bolus 20cc/kg. • ED calls for a consult. Wants to know if they should get a CT.

  14. What do you think?

  15. Intussusception • Invagination of a part of the intestine into itself, causing obstruciton • Most common is ileocolic • Typical Age – 2 months to 2 years old • Characteristic pain that develops suddenly, is intermittent, severe, and classically accompained by inconsolable crying with drawing up of the legs toward the abdomen • As obstruction progresses, may have bilious emesis • Initial symptoms often confused with gastroenteritis • Primary symptom may be lethargy or altered level of consciousness • May have blood in stool or “currant jelly stools”

  16. Intussusception cont • Almost 75% in children under 5 yo are considered idiopathic • Up to 25% may have an underlying pathological lead point. • Ex – Meckel diverticulum, polyp, small bowel lymphoma, duplication cyst, vascular malformation, inverted appendiceal stump, HSP…

  17. Diagnosis • High index of suspicion • On exam, may feel sausage shaped abdominal mass on right side of abd • Labs? • Not really helpful with diagnosis but often get CBC w/diff, CRP, Chem 7, UA/UCx during the work up • Diagnostic Imaging: • KUB – may show signs of intestinal obstruction (dilated loops of bowel w/absence of colonic gas) or other signs • Ultrasound – method of choice • Classic image is target sign – layers of the intestine within the intestine • CT Scan may be helpful to identify a lead point

  18. Management • Notify Radiology and Pediatric Surgery as soon as the diagnosis is made • NPO • Place a PIV and start IVFs. Assess severity of dehydration and bolus if needed. • Enema reduction by Radiology. If unsuccessful, may need surgical reduction. • Recurrence can occur in up to 10% of patients after successful non-operative reduction, so should be observed for 12-24 hours afterwards.

  19. Back to Case 2 • Should you order a CT? • Recall the ultrasound done was limited to the appendix/RLQ area only, so start with repeating the ultrasound to evaluate for intussusception.

  20. Case 3 • 4 year old male brought to ED with severe abdominal pain x 1 day. No n/v/d, no fevers, +poor appetite. Mom unsure of last BM. • Vitals: T 99, HR 120, BP 90/50, RR 24, sats 97% RA, 18kg • Exam: anxious appearing child, MMM, +tachycardic, cap refill 2 sec, fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +voluntary guarding, GU exam normal. • Limited Ultrasound did not visualize appendix. • WBC 9, normal diff, CRP 1.2, UA negative; running a NS bolus 20cc/kg • ED calls for a consult. Wants to know if they should get a CT.

  21. What concerns you about this case?

  22. Case 3 • 4 year old male brought to ED with severe abdominal pain x 1 day. No n/v/d, no fevers, +poor appetite. Mom unsure of last BM. • Vitals: T 99, HR 120, BP 90/50, RR 24, sats 97% RA, 18kg • Exam: anxious appearing child, MMM, +tachycardic, cap refill 2 sec, fearful of abd exam but +bs, soft, ND, ?TTP in all quadrants, +voluntary guarding, GU exam normal. • Limited Ultrasound did not visualize appendix. • WBC 9, normal diff, CRP 1.2, UA negative; running a NS bolus 20cc/kg • ED calls for a consult. Wants to know if they should get a CT.

  23. What do you think?

  24. Constipation Discuss…

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