Leybie Ang
PEM Fellow
Aug 6 2009
Objectives
 Approach to GI Bleed
 DDx
 Common Causes
 Life threatening Causes
 Approach to Abdominal Pain
 Case Presentations
Approach to GI Bleed
ABC
 Severity of the bleeding
 Site of the bleed
 Common cause of UGI in neonatal period?
 Common cause of UGI in preschool age?
 Common cause of LGI during neonatal period?
 Common cause of LGI during infancy?
Approach to Abdominal Pain
Causes of Acute Abdomen Pain
Causes of Acute Abdomen Pain
Life-Threatening Cause
Life Threatening Cause
Case Presentation #1
 2 week old male presented with abdominal distension
 At triage, noted to have bilious vomiting
 Former 37 weeker SVD
 SCN stay x 48hr for ?TTN
 No sick contact
 Afebrile HR 200 RR 65 O2 sat 98% RA
 Fussy but consolable
 GI exam revealed distended abdomen
Case Presentation #1 (con’t)
 Management priorities?
 Likely diagnosis?
Malrotation With Midgut Volvulus
 Congenital malrotation of the midgut
 During 5th-8th embryonic week, intestine projects out
of cavity, rotates 270 degree and then returns
 If incomplete rotation, intestine does not anchor at the
mesentry
 Volvulus is twisting of a loop of bowel about the
mesentric attachment
Malrotation with Volvulus
 Incidence 1 in 500
 Male-to-female ratio 2:1
 Usually presents in the first year of life
 Bilious vomiting
 Abdominal distension
 Hematochezia
Imaging
 Abdominal films – Classic double bubble sign
 Upper GI (GOLD STD) – “cork-screwing”, spiraling of
SB around SMA
 US – distended, fluid filled duodenum, with dilated
loops of bowel to the right of the spinal column
Treatment
 SURGICAL CONSULT!!!
 IV hydration
 Correction of electrolytes
 NG tube
Case Presentation 2
 1 yo female presents with vomiting, and intermittent
abdominal cramping
 Noted to be lethargic
 PE revealed palpable mass in RUQ
 Heme positive stools
 Most likely diagnosis???
 Management???
Intussusception
 Telescoping of a segment of bowel into an adjacent
segment
 Mesentery and venous supply obstruct  mucosal
edema and increased pressure  arterial flow
obstruction
 Incidence: 6mo to 2 yo
Intussusception
 Most common location ???
 Most common reported symptoms ???
Intussuception
 Idiopathic
 Meckel’s Diverticulum
 HSP
 Polyps
 Tumors
 Lymphoma
Intussusception
 Intermittent, colickly abdominal pain
 Currant jelly stools => late finding
 +/- RUQ mass
 Emesis -> bilious
 Heme positive stools
Intussusception - Dx
 AXR – may normal initially, but then may see signs of
obstruction, paucity of air and dilated loops of bowel
 US – “target” or “donut” sign = single hypoechoic ring
with hyperechoic center
 “pseudokidney” sign = superimposed hypo- and
hyperechoic rings of edematous bowel and
compressed mucosal layers
 What is crescent sign?
 Please show it in the imaging below….
Air Enema vs Contrast Enema
 PROS
 Inert
 Rapid
 Less radiation
 Air perforation better than contrast perforation
 Easier to administer
 CONS
 May miss the lead point
 Poorer visualisation
 Absolute contraindication???
Case Presentation 3
 6 yo male presents with diffuse abdo pain, decreased
appetite, fever, vomiting, increased pain with motion
 T38 HR 120 bp 108/58 RR22
 In moderate discomfort
 Abdo exam revealed tenderness over periumbilical
pain with rebound tenderness
 Differential diagnosis?
Appendicitis
 Most common etiology for surgical abdomen in
children
 Third leading cause of pediatric hospitalisation
 Incidence 4 cases per 1000 children
 Male to female ratio 2:1
Appendicitis
 Mortality in children 0.1-1%
 False positive rate 15-20%
 Perforation rate 15-40% in younger children due to
delayed in diagnosis
 In younger children <5 yo, ,perforation rate 50-85%
 Morbidity in children treated with appendicitis results
either from late diagnosis or negative appendectomy
Pathophysiology
 Blockage of lumen with stool, barium, food or
parasites
 Swollen lymph glands
 Hyperplastic lymphoid tissue
 Edematous appendical mucosa
 Increase intraluminal pressure
 Persistence inflammation
 Exudate drainage
Pathophysiology (con’t)
 Exudate touches parietal peritoneum
 Pain (diffuse)
 Fecal bacteria grown within the obstructing material
 Worsening inflammation response
 Further increase intraluminal pressure
 perforation
Pathophysiology (con’t)
 Peritonitis develops
 In adult, the omentum can wall off inflamed or
perforated appendix
 In child, less well developed omentum, hence decrease
the ability to wall off perforation
 More likely to have peritonitis
 Severe blunt abdo trauma
History
 Classic history
 Anorexia, pain migrated from periumbilical to RLQ and
vomiting
 Less than 60% patients
 Pain precedes vomiting
 Afebrile or low grade fever
 High grade – after perforation
Appendicitis – Signs & Symptoms
Am Emerg Med, 1986; 15:557-561
 M – Migration of pain
 A – Anorexia
 N – Nausea/Vomiting
 T – Tenderness
 R – Rebound
 E – Elevated temperature
 L – Leukocytosis
 S – Shift (Bandemia)
Pain Meds???
Green R et al. Pediatrics 2005
 5 – 16 yo with acute abdominal pain requiring surgical
consult
 52 – IV morphine
 56 – IV placebo
 Standardised form used to document clinical data and
physician confidence in dx and 15 min after meds
 Surgeon see pt w/i 1 hr and same data collected
 Pt monitored for 2 weeks after enrollment
Conclusion
Green R et al. Pediatrics 2005
 No difference in MD confidence – ED or surgeon’s after
morphine
 No difference in significant decrease in pain
 No difference in diagnosis
Management
 Emergency appendectomy (operation within 6hr) in
children has no advantages over urgent appendectomy
(operation with 12 h) wrt gangrene and perforation
rates, readmissions, postoperative complications,
hospital stay, or hospital charges.
Objectives
 Approach to hematuria
 DDx for testicular mass
Approach To Hematuria
 Determine if the pigment in urine is from blood or
other source. Are red blood cells present?
 Determine the source of bleeding, i.e., kidney, bladder,
urethra.
 Select those who will require referral versus those who
simply require follow-up.
Case Presentation #5
 10 yo male presented with 24 hour of scrotal pain.
 Mom noted that patient was walking “funny”
 Afebrile HR 120 bp 120/75 RR 18 O2 sat 97% RA
 PE exam revealed patient in moderate discomfort
 GI revealed benign exam
 GU revealed erythema, swollen right testes. High
riding testes with absent cremasteric reflex on the
right
Differential diagnosis
PAINFUL SCROTAL PAIN
 Torsion of spermatic cord
 Torsion of testicular appendage
 Epididymitis
 Orchitis
 Incarcerated hernia
 Hematocele
Differential diagnosis
PAINLESS SCROTAL SWELLING
 Hydrocele
 Variocele
 Testicular cancer
 Nonincarcerated inguinal hernia
 Spermatocele
 Localised edema from insect bites
 Nephrotic syndrome
Testicular Torsion
 Most dramatic and potentially serious acute
process affecting the scrotum
 Associated with anatomic anomaly of the tunica
vaginalis
 Normally the tunica vaginalis inserts at the lower
pole of testis (gubernaculum testes)
 Testes lack of the normal attachment to tunica
vaginalis and rest transverse w/i scrotum
Bell Clapper Deformity
Testicular Torsion
 Deformity permits xs mobility of testis, increasing
likelihood of torsion on its spermatic cord and
compromise blood flow
 If bell clapper deformity, usually bilateral
 Twisting of spermatic cord w/i tunica vaginalis
causes venous compression and subsequent edema
of testicle and cord -> arterial occulsion 
ischemia
Testicular Torsion
 Can occur at any age
 Two peak incidence: neonatal period and puberty
 1:4000 in males <25yo
 65% cases in boys 12-18yo
 Increased incidence during adolescent - secondary to
increase of weight of testes during puberty
Clinical Presentation
 Abrupt onset of severe scrotal pain
 Typical presentation:
 awaken from sleep with scrotal pain in the middle of
night
 +/- radiation to lower abdomen
 Nausea/vomiting
Physical Exam
 Tender and firm
 +/- edematous
 Abn transverse lie
 Absence of cremasteric reflex
 Unilat elevation of testis
 Retracted upward in hemiscrotum
 Usually negative Prehn sign
 Positive Prehn sign where elevation of scrotal contents
relieves pain
 Usually true in epididymitis
 Unreliable distinguishing feature
Intermittent Testicular Torsion
 Acute and intermittent sharp testicular pain and
scrotal swelling
 Rapid resolution (w/i secs to mins)
 Long period symptom-free
 Hence clinical and radiographic eval (US) maybe
normal
 Intermittent pain with nml evaluation – f/u w/i 7D
and sooner if pain recurs
 If high suspicious, referral to urology
Testicular Torsion
Doppler US or nuclear scan
 Decreased testicular perfusion
 Can be positive in pt with large hydrocele, abscess,
hematoma or scrotal hernia
 Can be negative in intermittent torsion or spontaneous
detorsion
 Sensitivity and specificity of US in detecting
testicular torsion 69-100% and 77-100%
respectively
 Limited usefulness in doppler US in prepubertal pt
due to lower blood flow
 Nuclear scan sensitivity and specificity 100 and 97%
respectively
Management of Testicular Torsion
 SURGICAL EMERGENCY!!!
 Increased time in a state of torsion is inversely
proportional to testis survival rates
 Urology/surgery consult
 Surgical detorsion of affected testes
 Orchiopexy of both testes
 Bell clapper deformity bilateral
 If nonviable  orchiectomy
 What is the viability if detorsion happens after 12hr???
Viability & Fertility
 Studies have shown:
 Detorsion w/i 4-6 hr  100% viability
 Detorsion after 12 hr  20% viability
 Detorsion after 24 hr  0% viability
 Fertility  controversial issues
 Decreased fertility after unilat torsion (immune-mediated damage)
 No evidence of decreased fertility or anti-sperm antibodies
 Heindel et al The effect of unilateral spermatic cord torsion
on fertility in the rat JUrol 1990 Aug;144:366-9
 If torsion >720 degree or more causes a significant reduction of
subsequent fertility
Manual Detorsion
 Manual detorsion if experienced clinician available,
definitive care hours away and appropriate sedation and
analgesics
 Textbook teaching: Testes rotates medially normally
 To detorse, rotate outward towards the thigh.
 Retrospective study showed pt with surgical detorsion, 1/3 has lateral
rotation
 Successful detorsion if pain relief, lower position of testes
and return of normal arterial pulsations (US)
 Still need to have orchiopexy
Torsion of Appendix Testes
 Sudden onset pain
 Less severe pain
 Usually tender
 localised palpable mass at superior/inferior pole
 Tiny, localised swelling
 pain localised to upper portion of testis
 Blue dot sign
 gangrenous/black appendix through scortal skin (esp in
lightly pigmented skin pt)
Torsion of Appendix Testes
 Nearly always able to elicit cremasteric reflex
 +/- Reactive hydrocele
 US showed nml or increased blood flow to affected testis
(2nd to inflammation)
 Lesion of low echogenicity with central hypoechogenic
area
 Unable to visible involved appendage
 In prepubertal, US unreliable (low baseline testicular
perfusion)
Management
 Supportive management
 Analgesics
 Bed rest
 Pain resolve in 5-10D
 If persistent pain -> surgery to remove testicular
appendix
 Contralateral hemiscrotum need not to be
explored
Epididymitis
 Inflammation of epididymis
 Common among adolescents
 Often caused by infections
 Sexually active – Chlamydia, N. gonorrhea and viruses
 Less commonly - Ureaplasma, Mycobacterium,
CMV/Cryptococcus in pt with HIV
Normal Scrotal Anatomy
Epididymitis
 Occur in younger boys who deny sexual activity
 Other causes: heavy physical exertion,
bicycle/motorcycle riding, structural anomalies of
UT
 Noninfectious – chemical inflammation 
swelling  ductal obstruction reflux of sterile
urine through ejaculatory ducts and vas into
epididymis
Multiple etiologies of epididymitis
Clinical Features
 Acute/subacute pain and swelling
 Urinary frequency, dysuria, urethral discharge,
fever
 Nml vertical lie of testes
 +/- erythema scrotum and parchment-like scrotal
edema
 +/- inflammatory nodule is felt with soft, NT
epididymis
 Nml cremastric reflex
Epididymitis
 Pain relief with elevation of testes (Prehn sign) –
unreliable marker for epididymitis
 +/- leukocytosis and pyuria
 +/- UA nml with urine culture (still need to get
UA/UCx)
 US – increased blood flow
 If suspect STD induced epididymitis -> GS smear
and culture of urethral/intraurethral, NAA test for
NG and CT, syphilis and HIV testing
Management of Epididymitis
 Antibiotics if ST epididymitis
 CTX 250mg IM x1 and doxycycline 100mg PO bid x10D
 If allergic to cephalosporins, ofloxacin 300mg PO bid
x10D or levofloxacin 500 mg PO daily x10D
 Analgesics
 Scrotal support
 Elevation
 Bed rest
Orchitis
 Acute inflammation reaction of the testes
 Mostly associated with viral infection
Bacterial Orchitis
 rare
 usually associated with a concurrent epididymitis
(epididymo-orchitis)
 occur in sexually active males > 15yo
 Unilateral testicular edema occurs in 90% of cases
 Bugs in immunocompromised pt?
Clinical features
 Testicular pain and swelling
 course variable and ranges from mild discomfort to severe pain.
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Fatigue
Malaise
Myalgias
Fever and chills
Nausea
Headache
Mumps orchitis follows the development of parotitis by 4-7
days.
 complicated by a reactive hydrocele or pyocele
Physical exam
 Testicular enlargement and tenderness
 Induration of the testis
 Erythematous scrotal skin
 Edematous scrotal skin
 Enlarged epididymis
 If associated with epididymo-orchitis
 Rectal examination
 Soft boggy prostate (prostatitis) often associated with
epididymo-orchitis
 Parotitis
Diagnosis
 based on history and physical examination
 if concerns for epididymo-orchitis
 UA and culture
 urethral cultures
 serum immunofluorescence antibody testing
 Color Doppler ultrasound
 to rule out testicular torsion.
 inflammation of the testis or the epididymis
Management
 Rule out testicular torsion
 Supportive treatment (viral)
 Analgesics
 Bed rest
 Hot or cold packs
 If highly suspicious for epididymo-orchitis, treat
appropriately.
 If a significant hydrocele or pyocele is detected or
suspected  surgical tapping
 Bacterial orchitis or epididymo-orchitis requires
appropriate antibiotic coverage
Complications
 ~60% with orchitis  Unilateral testicular atrophy
 Sterility is rarely a consequence of unilateral orchitis.
 little evidence supports an increased likelihood of
developing a testicular tumor after an episode of
orchitis.
Hydrocele
 Collection of peritoneal fluid between the parietal
and visceral layers of tunica vaginalis
 Communicating vs noncommunicating
Communicating
 result of failure of the processus vaginalis to close
during development
 fluid around testes is peritoneal fluid
Hydrocele
Noncommunicating
 no connection to the peritoneum; the fluid comes
from the mesothelial lining of tunica vaginalis
 Common in newborns and majority spontaneously
resolve
 In older children and adolescents
 Idiopathic
 secondary to epididymitis, orchitis, testicular torsion,
torsion of the appendix testes/epididymis, trauma or
tumor (reactive hydrocele)
 Communicating
 usually cystic scrotal mass
 Reducible
 increase mass in size during the day or with valsalva
maneuver
 Non communicating
 not reducible
 no change in size or shape with crying/straining
 Transillumination of scrotum
 cystic fluid collection
 US of testes
 to r/o primary causes
 In newborns – spontaneously resolution by 1 year
of age
 If communicating, rarely resolve and risk of
incarcerated inguinal hernia
 If tense scrotum – concerns for reduce circulation
to testes
 surgical repair at time of diagnosis
 If secondary causes, treat underlying condition
Varicocele
 Collection of dilated and tortuous veins in the
pampiniform plexus surrounding the spermatic cord in
scrotum
 Result from increased venous pressure and incompetent
valves
 Commonly on left side (85-95%)
 Left spermatic vein entering left renal vein to a 90 degree angle
 Right spermatic vein drains more obtuse angle directly in IVC –
more continuous flow
 10-15% varicoceles - infertility
Varicocele
 Asymptomatic
 c/o dull ache in scrotum upon standing
 Gr I (small) – palpable only with valsalva
maneuver
 Gr II (mod) – nonvisivible on inspection, but
palpable upon standing
 Gr III (large) - Visible distention around spermatic
cord
 Palpable varicocele – texture of “a bag of worms”
Varicocele
 Examined in both supine and standing position
 If idiopathic – prominent when upright and
disappears in supine
 If secondary – no change in size with change of
position
 US
 r/o IVC thrombus, right renal vein thrombosis with clot
propagation down IVC and abdo mass
Varicocele
 Conservative management
 Observation
 Surgical ligation / Testicular vein embolization
 Affected testicular vol < unaffected testicle (diff in size
of >10-15% or >2mL by US)
 Presence of bilat varicoceles
 Large varicoceles (Gr III)
 Presence of scrotal pain
Paraphimosis
 SURGICAL EMERGENCY
 occurs when a phimotic ring of foreskin is retracted,
becoming trapped proximal to the coronal sulcus
 Significant edema of the glans penis
 Ischemic injury to the glans
Paraphimosis - Management
 Reduction of the foreskin
 Manually after applying gentle constant pressure to the
edematous foreskin with or without local anesthesia
 Surgically by division of the phimotic ring.
 Circumcision is advisable at some point after the
occurrence
Hair Tourniquet Syndrome
 SURGICAL EMERGENCY
 Circumferential strangulation of an appendages or
genitalia by human hairs or fibers
 Ischemic injury to the glans may occur if not relieved
promptly by division and removal of the hair strand
Hair-Thread Tourniquet Syndrome in an
Infant with Bony Erosion- a Case Report, Lit
Review, and Meta-analysis
Saad et al. Ann Plast Surg 2006; 57: 447–452
 210 reported cases
 Penile - 44.2%
 Toes - 40.4%
 Fingers - 8.57%
 Others (female external genitalia, uvula, and neck) -
6.83%
 Penile tourniquet is more common in patients around
2 years old.
 What product would you use to remove hair torniquet
on finger/toe non-operatively???
Post-Circumcision Bleed
 Bleeding remains the commonest complication
encountered during and after circumcision
 Reported incidence ranges from 0·1 to 35 per cent
 Majority is minor bleed
 Required to achieve haemostasis is gentle pressure
Post-Circumcision Bleed
 Excessive bleeding
 Anomalous vessels
 Bleeding disorder
 13 000 circumcisions reported in two large series, no
patient required blood transfusion for bleeding
 In the event of a bleeding disorder, appropriate
clotting factors may have to be administered.
 Circumferential bandage may be used to aid
haemostasis
 May cause a degree of urethral obstruction which in
severe cases, leads to urinary retention and may
dispose thus dispose to urinary tract infection