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Acute Abdomen Ashna Khurana, MD

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 - PowerPoint PPT Presentation

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Page 1: Acute Abdomen

Acute AbdomenAshna Khurana, MD

Page 2: Acute Abdomen

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.

Page 3: Acute Abdomen

What concerns you about this case?

Page 4: Acute Abdomen

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.

Page 5: Acute Abdomen

What do you think?

Page 6: Acute Abdomen

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

Page 7: Acute Abdomen

Work up to Evaluate for Acute AppendicitisHistory and Physical ExamLabs to consider: CBC w diff, CRP, UA/U.cx, possibly

an electrolyte panelDiagnostic 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 ExamsConsult Pediatric Surgery

Page 8: Acute Abdomen

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)

Page 9: Acute Abdomen

PAS continuedPAS < 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

Page 10: Acute Abdomen

Management and TreatmentAdmit to PediatricsConsult Pediatric/General SurgeryNPO, IVFsPain controlAntibiotics

Discuss Cefoxitin vs Zosyn

Anticipate hospital course (non-ruptured vs. ruptured)

Page 11: Acute Abdomen

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.

Page 12: Acute Abdomen

What Concerns you about this case?

Page 13: Acute Abdomen

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.

Page 14: Acute Abdomen

What do you think?

Page 15: Acute Abdomen

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”

Page 16: Acute Abdomen

Intussusception contAlmost 75% in children under 5 yo are considered

idiopathicUp to 25% may have an underlying pathological

lead point.Ex – Meckel diverticulum, polyp, small bowel

lymphoma, duplication cyst, vascular malformation, inverted appendiceal stump, HSP…

Page 17: Acute Abdomen

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

Page 18: Acute Abdomen

ManagementNotify Radiology and Pediatric Surgery as soon as the

diagnosis is madeNPOPlace 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.

Page 19: Acute Abdomen

Back to Case 2Should 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.

Page 20: Acute Abdomen

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.

Page 21: Acute Abdomen

What concerns you about this case?

Page 22: Acute Abdomen

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.

Page 23: Acute Abdomen

What do you think?

Page 24: Acute Abdomen

ConstipationDiscuss…