Acute Abdomen

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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
 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.
What concerns you about
this case?
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 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.
 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.
What do you think?
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
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
Pediatric Appendicitis Score (PAS)
 Uses Hx, PE, and lab results to categorize risk in children with
abd pain on 10 point scale








Anorexia
Nausea or Vomiting
Migration of Pain
Fever > 38C
Pain w/cough, hopping or percussion
RLQ tenderness
WBC > 10K
Neutrophils/Bands >7.5K
(Discuss score for Case 1)
1
1
1
1
2
2
1
1
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
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)
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.
What Concerns you about
this case?
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.
What do you think?
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”
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…
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
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.
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.
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.
What concerns you about
this case?
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.
What do you think?
Constipation
Discuss…
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