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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.
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.
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 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)
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
AntibioticsDiscuss 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.
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.
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.
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.