Pediatric Case Conference R2 施家祥 Supervisor: 吳孟書 醫師

Case 張 X 傑 張 X 傑 Age: 3y 9 m/o, Gender: male Age: 3y 9 m/o, Gender: male BW: 16 kg BW: 16 kg 台北急診, 就診時間 :2007/8/15 16:17 台北急診, 就診時間 :2007/8/15 16:17 Vital signs: TPR:36.5C/ 112/ 20, BP: ?/?mmHg Vital signs: TPR:36.5C/ 112/ 20, BP: ?/?mmHg GCS: E4V5M6, SaO 2 :98% GCS: E4V5M6, SaO 2 :98% 檢傷主訴 : 腹痛. 嘔吐 檢傷主訴 : 腹痛. 嘔吐

Chief complaint & present illness Chief complaint: Chief complaint: intermittent abdominal pain since this morning intermittent abdominal pain since this morning Present illness: Present illness: no fever, no cough, no RN no fever, no cough, no RN vomiting after eating or drinking since this morning vomiting after eating or drinking since this morning no stool passage for 2 days no stool passage for 2 days visited LMD this morning with enema  little stool visited LMD this morning with enema  little stool no food intake today, activity: mild decreased no food intake today, activity: mild decreased Past history: Past history: febrile convulsion febrile convulsion no known drug allergies, no travel Hx no known drug allergies, no travel Hx

Physical examination PAT: Appearance/breathing/circulation: good HEENT: neck supple HEENT: neck supple Throat: Not injected, No enlarged tonsil Throat: Not injected, No enlarged tonsil Eardrum: Not injected Eardrum: Not injected Chest: clear breathing sound Chest: clear breathing sound Heart: RHB, no murmur Heart: RHB, no murmur Abdomen: soft, no tenderness, normoactive bowel sound Abdomen: soft, no tenderness, normoactive bowel sound general tenderness, no palpable mass, no muscle guarding general tenderness, no palpable mass, no muscle guarding Extremities: freely movable Extremities: freely movable Initial impression: Initial impression: Abdominal pain, r/o AGE, r/o constipation Abdominal pain, r/o AGE, r/o constipation

Abdominal pain D/D

Differential diagnosis

Management Management Intermittent abdominal pain and vomiting with pain-free intervals) Intermittent abdominal pain and vomiting with pain-free intervals) ? ? Discharge or not? Discharge or not? More information? More information?

KUB No hepatosplenomegaly. No hepatosplenomegaly. No obvious radiopaque stone along bilateral utrotracts No obvious radiopaque stone along bilateral utrotracts Normal bowel gas pattern Normal bowel gas pattern Unremarkable T-L spine alignment, disc spaces, no degenerative spur formation. Unremarkable T-L spine alignment, disc spaces, no degenerative spur formation. Unremarkable other bony structures (including lower ribs, pelvic bones, bil SI joints, femoral head and necks). Unremarkable other bony structures (including lower ribs, pelvic bones, bil SI joints, femoral head and necks).

AbdominalNonabdominal AGE Stool impaction UTITraumaIntussusception Appendicitis Incarcerated hernia paralytic ileus Peritonitis Obstruction due to previous op Henoch-Sch ö nlein purpura Pneumonia Myocarditis, pericarditis Diabetic ketoacidosis

Bed side echo 8/15 16: 43 8/15 16: 43 bed side echo: bed side echo: Target sign! Target sign!  CBC/DC  CRP, BUN  Na/K, Sugar  NPO  D5 1/4S run 80ml/hr 80ml/hr  Refer to LER

WBC /cmm 6.7~11.8(>1Y-4Y ) WBC /cmm 6.7~11.8(>1Y-4Y ) RBC 6.48 milon/cmm 4.28~5.05(6M-6Y ) RBC 6.48 milon/cmm 4.28~5.05(6M-6Y ) HGB 12.3 g/dL 11.6~13.7(3M-6Y ) HGB 12.3 g/dL 11.6~13.7(3M-6Y ) HCT 39.7 % 34.2~39.8(6M-6Y ) HCT 39.7 % 34.2~39.8(6M-6Y ) MCV 61.3 umm 74.9~ 84.6(6M-6 Y) MCV 61.3 umm 74.9~ 84.6(6M-6 Y) MCH 19 pg/Cell 25.2~29.1(6M-6Y ) MCH 19 pg/Cell 25.2~29.1(6M-6Y ) MCHC 31 g/dL 32.6~35.1(6M-6Y ) MCHC 31 g/dL 32.6~35.1(6M-6Y ) RDW 14.1 % RDW 14.1 % PLATELET /cmm PLATELET /cmm SEGMENT 88.1 % 13.9~49.5(>1Y-4Y) SEGMENT 88.1 % 13.9~49.5(>1Y-4Y) LYMPHOCYTE 10.2 % 44.7~81.6(>1Y-4 Y) LYMPHOCYTE 10.2 % 44.7~81.6(>1Y-4 Y) MONOCYTE 1.6 % 1.3~ 7.2(>1Y-4Y ) MONOCYTE 1.6 % 1.3~ 7.2(>1Y-4Y ) EOSINOPHIL 0 % 0.0~ 4.3(>1Y-4Y ) EOSINOPHIL 0 % 0.0~ 4.3(>1Y-4Y ) CRP mg/L CRP mg/L BUN 13 BUN 13 Na/K 141/4 Na/K 141/4

Air reduction

Fluoroscopic reduction of intussusception 1. Preliminary radiograph shows soft tissue density at hepatic flexure of the colon compatible with intussusception. 1. Preliminary radiograph shows soft tissue density at hepatic flexure of the colon compatible with intussusception. 2. Under pressure-device monitoring, air reduction was attempted. 2. Under pressure-device monitoring, air reduction was attempted. 3. Free reflux of air into the terminal ileum was noted, indicating successful reduction. 3. Free reflux of air into the terminal ileum was noted, indicating successful reduction. 4. Post-procedural standing radiograph shows no free air in the peritoneum. 4. Post-procedural standing radiograph shows no free air in the peritoneum. Impression : Intussusception, ileocolic, successful reduction. Impression : Intussusception, ileocolic, successful reduction.

Intussusception The most common cause of intestinal obstruction in children between 3 months to 6 years old. 80% < 2 y The most common cause of intestinal obstruction in children between 3 months to 6 years old. 80% < 2 y A lead point can be identified in up to 25 % of children with ileo-colic intussusception The majority of cases in children are idiopathic. A lead point can be identified in up to 25 % of children with ileo-colic intussusception Etiology: Telescoping of one segment of intestine into another  Bowel edema and obstructs venous return  bowel wall ischemia  perforation may occure Etiology: Telescoping of one segment of intestine into another  Bowel edema and obstructs venous return  bowel wall ischemia  perforation may occure

Leading point < 5 years old: Enlarged peyer ’ s patches secondary to a recent viral infection < 5 years old: Enlarged peyer ’ s patches secondary to a recent viral infection > 5 years old: Underlying lesion is found in 75% of cases: Henoch-Schonlein purpura, Meckel ’ s diverticulum, Lymphoma, polyps, cystic fibrosis > 5 years old: Underlying lesion is found in 75% of cases: Henoch-Schonlein purpura, Meckel ’ s diverticulum, Lymphoma, polyps, cystic fibrosis

Intussusception symptoms and signs Clinical triad: pain, a palpable sausage shaped abdominal mass, and currant-jelly stool (<15%) Clinical triad: pain, a palpable sausage shaped abdominal mass, and currant-jelly stool (<15%) Sudden onset of intermittent, severe, crampy, progressive abdominal pain. Sudden onset of intermittent, severe, crampy, progressive abdominal pain. Usually occur at 15 to 20 minute intervals. Usually occur at 15 to 20 minute intervals. More frequent and more severe over time. More frequent and more severe over time. Accompanied by inconsolable crying and drawing up of the legs toward the abdomen. Accompanied by inconsolable crying and drawing up of the legs toward the abdomen. Vomiting may follow episodes of abdominal pain Vomiting may follow episodes of abdominal pain Between the painful episodes, the child may behave relatively normally and be free of pain. Between the painful episodes, the child may behave relatively normally and be free of pain. Initial emesis is non-bilious(6-12hrs), but it may become bilious as the obstruction progresses. Initial emesis is non-bilious(6-12hrs), but it may become bilious as the obstruction progresses. Up to date~ intussusception in children

Intussusception symptoms and signs Journal of gastroenterology and hepatology (2006) 21,

Abdominal pain evaluation Abdominal plain films: 1. Cresent sign. 2. RUQ radiopaque mass lesion. 3. No ascending colon gas and RLQ ileum gas Abdominal plain films: 1. Cresent sign. 2. RUQ radiopaque mass lesion. 3. No ascending colon gas and RLQ ileum gas Abdominal sonography: a sensitive diagnostic tool, target lesion, "bull's eye" or "coiled spring" lesion Abdominal sonography: a sensitive diagnostic tool, target lesion, "bull's eye" or "coiled spring" lesion CT: reserved for patients in whom the other imaging modalities are unrevealing CT: reserved for patients in whom the other imaging modalities are unrevealing

Evaluation and Management Fluoroscopic reduction The standard procedure for diagnosis and treatment of ileocolonic intussusception is a contrast (air favored) enema. The standard procedure for diagnosis and treatment of ileocolonic intussusception is a contrast (air favored) enema. Greatest risk of perforation in: (<1%) Greatest risk of perforation in: (<1%) 1. infants younger than six months of age who have had symptoms for three days or longer. 2. patients with evidence of small bowel obstruction Reduction should not be attempted in patients with prolonged symptoms or any signs of peritoneal irritation or free peritoneal air

Fluoroscopic reduction Observation policy differed between countries and settings, with a minimum observation period of hrs after conservative treatment. (The pediatric infectious disease journal. Vol.25, NO1, Jan review article) Observation policy differed between countries and settings, with a minimum observation period of hrs after conservative treatment. (The pediatric infectious disease journal. Vol.25, NO1, Jan review article) Recurrence after successful nonoperative reduction is approximately 10%. Recurrence after successful nonoperative reduction is approximately 10%. Recurrence is not necessarily an indication for surgery. Recurrence is not necessarily an indication for surgery.

Surgery Indications: Indications: 1. nonoperative reduction is incomplete 2. persistent filling defect 3. signs of peritoneal irritation or free peritoneal air Manual reduction (recurrence :1%)& resection with primary anastomosis Manual reduction (recurrence :1%)& resection with primary anastomosis

Key points Abdominal pain: child ’ s age, fever, ex/abdominal, obstructive, local or systemic Abdominal pain: child ’ s age, fever, ex/abdominal, obstructive, local or systemic Bilious vomiting is always indicative of a serious process. Diarrhea should be evaluated for blood. Bilious vomiting is always indicative of a serious process. Diarrhea should be evaluated for blood. Chest and abdominal radiographs can be useful for pneumonia and obstruction or ileus. Chest and abdominal radiographs can be useful for pneumonia and obstruction or ileus. Abdominal sonography can be helpful in ER for differential diagnosis. Abdominal sonography can be helpful in ER for differential diagnosis.