Pediatric Emergency Conference R3 吳孟桓

General Data Name: 簡小弟 Name: 簡小弟 Chart No.: Chart No.: Birth Date: (2) Birth Date: (2) 就診日期 : :16 就診日期 : :16 到院方式 : 自家車 到院方式 : 自家車 檢傷級數 : 3 級 檢傷級數 : 3 級 檢傷主訴 : 家屬主訴因 腹痛 檢傷主訴 : 家屬主訴因 腹痛 Vital sign BT 36.5 ℃ HR 112/min RR 20/min BP -/- mmHg GCS: E4V5M6 BW 14 kg

Chief Complain Intermittent abdominal pain since yesterday Intermittent abdominal pain since yesterday

Present Illness No vomiting or diarrhea No vomiting or diarrhea Stool passage: normal Stool passage: normal s/p Fleet enema in LMD last night s/p Fleet enema in LMD last night No bloody or pus stool No bloody or pus stool Mild rhinorrhea for several days; no cough Mild rhinorrhea for several days; no cough Activity: fair; appetite: slightly decreased Activity: fair; appetite: slightly decreased No recent travel history No recent travel history Past history: denied congenital disease Past history: denied congenital disease No known allergy No known allergy Vaccination: as scheduled Vaccination: as scheduled

Physical Examination General appearance General appearance Not in distress Not in distress Breath: smooth Breath: smooth Circulation: stable Circulation: stable Consciousness Consciousness Clear, E4V5M6 Clear, E4V5M6 HEENT HEENT Conjunctiva: not pale Conjunctiva: not pale Sclera: anicteric Sclera: anicteric Neck: supple Neck: supple Oral mucosa: moist Oral mucosa: moist Chest Chest BS: clear BS: clear HS : RHB, no murmur HS : RHB, no murmur Abdomen Soft and flat No tenderness No rebounding pain Bowel sound: normoactive No McBurney point tenderness No Murphy sign Extremity No pitting edema Free movable Skin No rash, purpura or petechiae

Questions How to approach children with abdominal pain? How to approach children with abdominal pain? What differential diagnosis should be considered in children with abdominal pain? What differential diagnosis should be considered in children with abdominal pain?

History of Abdominal Pain in Children Age of onset Age of onset Pain history Pain history Location? Timing of onset? Character? Severity? Duration? Radiation of pain? Location? Timing of onset? Character? Severity? Duration? Radiation of pain? Recent trauma Recent trauma Precipitating or relieving factors Precipitating or relieving factors Associated symptoms Associated symptoms Pain or vomiting, which first? Bilious vomiting? Bloody diarrhea or currant-jelly stool? Failure to pass flatus or feces? Dysuria? Vaginal discharge? Polyria/polydipsia? Joint pain? Skin rash? Pain or vomiting, which first? Bilious vomiting? Bloody diarrhea or currant-jelly stool? Failure to pass flatus or feces? Dysuria? Vaginal discharge? Polyria/polydipsia? Joint pain? Skin rash? Gynecologic history Gynecologic history Past health Past health Drug use Drug use Family history Family history Leung AK., et al. Acute abdominal pain in children. American Family Physician. 67(11):2321-6, 2003 Jun 1.

Differential Diagnosis by Age Leung AK., et al. Acute abdominal pain in children. American Family Physician. 67(11):2321-6, 2003 Jun 1.

Tips about Physical Examination General apperance General apperance Visceral pain: tend to writhe; peritonitis: quite and resist movement Visceral pain: tend to writhe; peritonitis: quite and resist movement Vital sign Vital sign Abdominal examination Abdominal examination Breathing pattern Breathing pattern Distend and flatten abdomen Distend and flatten abdomen Gently palpate then moving toward to maximum pain area Gently palpate then moving toward to maximum pain area Assess muscle rigidity Assess muscle rigidity Gentle percussion best elicits rebound tenderness Gentle percussion best elicits rebound tenderness Deeper palpation Deeper palpation Rectal and pelvic examination Rectal and pelvic examination Associated sign Associated sign Leung AK., et al. Acute abdominal pain in children. American Family Physician. 67(11):2321-6, 2003 Jun 1.

Negative finding of the abdomen

:47 Echo: no target lesion, no bowel dilatation, no hydronephrosis Echo: no target lesion, no bowel dilatation, no hydronephrosis KUB: no ileus, no stool impaction KUB: no ileus, no stool impaction No obvious tender area or mass lesion No obvious tender area or mass lesion MBD MBD Dx: Abdominal pain, r/o early AGE Dx: Abdominal pain, r/o early AGE Lactobacillus 1# tid Lactobacillus 1# tid Primperan 1.5 ml tid Primperan 1.5 ml tid

2 nd Visit :41 ( 距離上次 14 小時 25 分 ) :41 ( 距離上次 14 小時 25 分 ) Vital sign Vital sign BT 37.7 ℃ BT 37.7 ℃ HR 142/min HR 142/min RR 18/min RR 18/min BP 130/78 mmHg BP 130/78 mmHg GCS: E4V5M6 GCS: E4V5M6

2 nd Visit C.C.: Abdominal pain for 2 days C.C.: Abdominal pain for 2 days P.I.: P.I.: 腹痛位置：臍周圍 腹痛位置：臍周圍 腹痛性質：絞痛 腹痛性質：絞痛 持續時間：間歇性陣痛 持續時間：間歇性陣痛 沒有轉移性腹痛、嘔吐、拉肚子、便秘 沒有轉移性腹痛、嘔吐、拉肚子、便秘 有發燒 (37.7 ℃ noted tonight) 有發燒 (37.7 ℃ noted tonight) 沒有旅遊史或集體食物中毒 沒有旅遊史或集體食物中毒 沒有解尿疼痛或頻尿 沒有解尿疼痛或頻尿 沒有頭痛或喉嚨痛 沒有頭痛或喉嚨痛 食慾正常、活動力正常 食慾正常、活動力正常

Physical Examination General appearance General appearance 外觀正常無痛苦 外觀正常無痛苦 Abdomen Abdomen 平坦 平坦 有壓痛： low abdomen 有壓痛： low abdomen 沒有反彈痛 (can’t determined) 沒有反彈痛 (can’t determined) 腹鳴：正常 腹鳴：正常 Flank knocking pain(-) Flank knocking pain(-) 肛門指診： no currant-jelly stool 肛門指診： no currant-jelly stool

Order (3/26 4:49, 0:08) CBC/DC, CRP CBC/DC, CRP U/A U/A IVF with D5 1/4S run 60 ml/hr IVF with D5 1/4S run 60 ml/hr NPO NPO KUB (supine) KUB (supine)

Negative finding of the abdomen. Fecal retention in colon

WBC9800Urine RBC4.66ColorYellow Hb12.6TurbidityClear Hct35.5 Sp. gravity MCV76.2pH6.0 MCH27.0LeukocyteNegative MCHC35.5NitriteNegative RDW12.0ProteinNegative Platelet273000GlucoseNegative Atypical-Lym1.0KetoneNegative Segment50.0UBG0.1 Lymphocyte37.0BiliruminNegative Monocyte9.0BloodNegative Eosinophil3.0RBC/WBC0/0-1 CRP30.65Squamus0

入觀 (3/26 6:12, 1:31) 觀察理由：做檢查 觀察理由：做檢查 診斷： Suspect acute aqppendicitis 診斷： Suspect acute aqppendicitis 診斷： Gastritis 診斷： Gastritis Vital sign: q8h Vital sign: q8h Diet as tolerable Diet as tolerable IVF as above IVF as above Arrange abdominal echo Arrange abdominal echo

Abdominal Echo Abdominal Echo Liver: Homogeneous, no enlarged or space taking lesion Liver: Homogeneous, no enlarged or space taking lesion Spleen, pancrease, gall bladder, billiary tree, bilateral kidneys, aorta & IVC of upper abdomen and urinary bladder and perivesicle area: negative Spleen, pancrease, gall bladder, billiary tree, bilateral kidneys, aorta & IVC of upper abdomen and urinary bladder and perivesicle area: negative Imp: Bowel edema, no target lesion Imp: Bowel edema, no target lesion

After Echo… MBD MBD Lactobacillus 1# po bid x 3 days Lactobacillus 1# po bid x 3 days

Question If abdominal echo is negative, can intussusception be ruled out? If abdominal echo is negative, can intussusception be ruled out?

Negative Echo=r/o Intussusception?(1) 83 clinical suspect Sensitivity: 100% (34/34) Specificity: 88% (43/49) NPV: 100% No diagnostic disagreements between the residents and the reviewing radiologist (65%) Verschelden P., et at. Intussusception in children: reliability of US in diagnosis--a prospective study. Radiology. 184(3):741-4, 1992 Sep.

Negative Echo=r/o Intussusception?(2) Clinically significant positive predictors for intussusception Clinically significant positive predictors for intussusception RUQ mass (PPV 94%, p = ) RUQ mass (PPV 94%, p = ) Gross blood in stool (PPV 80%, p = 0.014) Gross blood in stool (PPV 80%, p = 0.014) Gross blood on rectal examination (PPV 78%, p = 0.01) Gross blood on rectal examination (PPV 78%, p = 0.01) Triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p < ) Triad of intermittent abdominal pain, vomiting, and right upper quadrant abdominal mass (PPV 93%, p < ) Presence of gross or occult blood on rectal examination in addition to the triad increased the positive predictive value to 100% (p = not significant) Presence of gross or occult blood on rectal examination in addition to the triad increased the positive predictive value to 100% (p = not significant) Harrington L., et al. Ultrasonographic and clinical predictors of intussusception. Journal of Pediatrics. 132(5):836-9, 1998 May.

Negative Echo=r/o Intussusception?(3) No strong negative predictors for intussusception Presence of ≥3 of 10 features was a statistically significant negative predictor (negative predictive value 77%, p = Harrington L., et al. Ultrasonographic and clinical predictors of intussusception. Journal of Pediatrics. 132(5):836-9, 1998 May.

Negative Echo=r/o Intussusception?(4) Abdominal echo has an excellent correlation with air enema for diagnosis of intussusception Triad of intermittent abdominal pain, vomiting, RUQ mass, plus occult or gross blood on rectal examination constitutes an excellent positive predictor Harrington L., et al. Ultrasonographic and clinical predictors of intussusception. Journal of Pediatrics. 132(5):836-9, 1998 May.

3 rd Visit :44 ( 距離上次 39 小時 03 分，第一次 53 小時 28 分 ) :44 ( 距離上次 39 小時 03 分，第一次 53 小時 28 分 ) Vital sign Vital sign BT 37.2 ℃ BT 37.2 ℃ HR 142/min HR 142/min RR 20/min RR 20/min BP 122/64 mmHg BP 122/64 mmHg GCS: E4V5M6 GCS: E4V5M6

ED Chart 2 y/o boy, RTC to our hospital many times 2 y/o boy, RTC to our hospital many times KUB: negative finding; echo: no target lesion KUB: negative finding; echo: no target lesion No vomiting No vomiting Abdominal pain for 3-4 days Abdominal pain for 3-4 days LMD abdominal echo: target lesion LMD abdominal echo: target lesion Suspect ileo-colic intussusception Suspect ileo-colic intussusception

Physical Examination PAT PAT Apperance: fair Apperance: fair Breath: smooth Breath: smooth Circulation: stable Circulation: stable Abdomen Abdomen Soft and flat Soft and flat No tenderness No tenderness No rebound pain No rebound pain Bowel sound: normoactive Bowel sound: normoactive McBurney point: no tenderness McBurney point: no tenderness

Order (3/27 20:06, 0:22) Fluoroscopic reduction of intussusception Fluoroscopic reduction of intussusception CBC/DC, CRP, BUN/Cr, Na/K/Cl CBC/DC, CRP, BUN/Cr, Na/K/Cl IVF with D5 1/4S run 60 ml/hr IVF with D5 1/4S run 60 ml/hr NPO NPO

血液生化 WBC10300 BUN12 RBC4.51Cr0.4 Hb11.8Na136.9 Hct34.3K3.88 MCV76.1 Cl104.4 MCH26.2CRP45.89 MCHC34.4 RDW11.7 Platelet Segment45.0 Lymphocyte44.0 Monocyte11.0

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

Question What’s the contraindication of Air-reduction? What’s the contraindication of Air-reduction?

Contraindication of Air-reduction Prolonged intussusception with Prolonged intussusception with Sign of shock Sign of shock Peritoneal irritation Peritoneal irritation Intestinal obstruction Intestinal obstruction Pneumatosis intestinalis Pneumatosis intestinalis Lack of availble surgeon at the institution Lack of availble surgeon at the institution Kliegman: Nelson Textbook of Pediatrics, 18th edition. Saunders, 2007 MDConsult

However… High fever with exudative tonsil since admission High fever with exudative tonsil since admission Abdominal pain re-attack in the early morning on 3/29 Abdominal pain re-attack in the early morning on 3/29 Bending postural Bending postural No vomiting or stool passage No vomiting or stool passage Abdomen Abdomen Muscle guarding due to crying Muscle guarding due to crying Normoactive bowel sound Normoactive bowel sound No mass palpable No mass palpable

Mild infiltration in bil. lower lungs Gaseous dilatation of bowel loops

Abdominal Echo(1) Abdominal Echo(1) No target lesion at initial exam No target lesion at initial exam Few RLQ LAP(+) Few RLQ LAP(+) However, the target lesion was found suddenly after patient crying However, the target lesion was found suddenly after patient crying Imp Imp Intussusception (r/o intermittent) Intussusception (r/o intermittent) RLQ LAP(+) RLQ LAP(+) Air reduction immediatly Air reduction immediatly

Abdominal Echo(2) A loose target lesion with proximal bowel pull through into the distal bowel A loose target lesion with proximal bowel pull through into the distal bowel Liver: Homogeneous, no enlarged or space taking lesion Liver: Homogeneous, no enlarged or space taking lesion Spleen, pancrease, gall bladder, billiary tree, bilateral kidneys, aorta & IVC of upper abdomen and urinary bladder and perivesicle area: negative Spleen, pancrease, gall bladder, billiary tree, bilateral kidneys, aorta & IVC of upper abdomen and urinary bladder and perivesicle area: negative Imp: Intussusception, recurrence. Imp: Intussusception, recurrence.

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

Recurrent of Intussusception(1) Recurrent rate≈10% Recurrent rate≈10% Surgical reduction: lower recurrent rate 2-5% Surgical reduction: lower recurrent rate 2-5% Older age: leading point Older age: leading point Usually within 24 hrs Usually within 24 hrs

Recurrent of Intussusception(2) Clinical symptoms have no predictive value for recurrent Symptoms and signs of RI occur less frequent than first attack Yang CM., et al. Recurrence of intussusception in childhood. Acta Paediatrica Taiwanica. 42(3):158-61, 2001 May-Jun.

Hospital Course Abdominal pain improved gradually Abdominal pain improved gradually Fever subsided since night on 3/30 Fever subsided since night on 3/30 Abdominal echo on 3/31: no intussusception Abdominal echo on 3/31: no intussusception Try diet on 3/31 Try diet on 3/31 Adenovirus Ag(+) Adenovirus Ag(+) Discharged on 4/2 Discharged on 4/2

Discharge Diagnosis Recurrent intussusception with ileocolic type s/p twice successful air reduction (3/27, 3/29) Recurrent intussusception with ileocolic type s/p twice successful air reduction (3/27, 3/29) Acute exudative tonsillitis with Adenovirus infection Acute exudative tonsillitis with Adenovirus infection Dehydration, mild to moderate Dehydration, mild to moderate

Take Home Message Children with abdominal pain should take history carefully and examine thoroughly Children with abdominal pain should take history carefully and examine thoroughly Abdominal echo is useful for rule in or rule out intususception Abdominal echo is useful for rule in or rule out intususception Remember the contraindication of air reduction Remember the contraindication of air reduction

VS Commet Echo 是急診臨床 practice 的重要工具，也可 以作為懷疑 intussusception 的診斷工具 Echo 是急診臨床 practice 的重要工具，也可 以作為懷疑 intussusception 的診斷工具 牢記 intussusception 在 echo 上的影像，最常見 的是 ileo-colic type ，可先由患者的右上腹做 起 牢記 intussusception 在 echo 上的影像，最常見 的是 ileo-colic type ，可先由患者的右上腹做 起 如果 echo 的影像或結果有疑問，應與施行檢 查醫師討論溝通 如果 echo 的影像或結果有疑問，應與施行檢 查醫師討論溝通

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