Pediatric Case Presentation 2007. 1. 30 Supervisor: 吳孟書醫師

李X珍 4326659 Age: 8y/o, Gender: female 基隆急診, 就診時間:2007/1/2 04:25 Vital signs: TPR:36.1C/ 125/ 20, BP: 115/53mmHg GCS: E4V5M6, SaO2:99% 檢傷主訴: 腹痛

Chief complaint Abdomimal pain since tonight (1/1 night)

Present illness 12/28.29: fever, watery diarrhea for 2-3 times/day, abd pain    visited LMD: Rx: antipyretics, antidiarrhea (drug unknown)  no improve  diarrhea 7-8 times/day x 2 days 1/1: LMD Rx: antidiarrhea (different drug, 2-3 pills in one package, unknown)        took one package in the morning  no diarrhea or abd pain     at the night: abd distension, abd pain with cold sweating, fever, N/V

Past history no known drug allergies no other systemic diseases

Physical examination: Appearance: ill-looking HEENT: neck supple Chest: coarse breathing sound Heart: RHB Abdomen: muscle guarding, diffuse tenderness McBurney tender(+) Extremities: freely movable Initial impression: Peritonitis, r/o appendicitis ruptured

Initial order (04:31) CBC/DC CRP SUGAR B/C U/A KUB NPO, IV D5.225S keep 80ML/HR

K.U.B. shows :    Negative finding of the abdomen.

Lab Glucose: 136 CRP: 112.23 WBC: 12500 Seg: 77.4% Lym: 17.4 Hb: 12.5 PLT: 287K

Further 05:51: CT OF ABDOMEN C+/- GENTA 80MG STAT METRONIDAZOLE 400MG STAT

CT report MSCT study for the abdomen and pelvic cavity, mainly for the  ,   without and with IV contrast study shows:   1.Evidence of normal size of the apendix, However,its wall is   thickened, compatible with early changes of acute appendicitis. No   strandings to be noted in the ileocecal region   2.The liver, spleen, pancreas, kidneys and adrenal glands are normal.   No definite intraabdominal lymphadenopathy.    3.The stomach, duodenum, small intestine and the colon are seen to be   unremarkable except feces in the colon.   4.There is no abnormal lesion in the pelvic cavity. The uterus and   ovaries are normal in size.   5.There are no enlargement of the paraaortic, pelvic and inguinal   nodes.    6.No ascites in the abdomen and pelvic cavity.     Imp.:Compatible with acute appendicitis.        Others are unremarkable in the abdomen.

Further 06:37: Consult GS -- peritonitis, suggest operation

OP record Post OP Dx: cecum perforation, peritonitis OP method: right hemicolecotmy with end to side anastomsis

Toxic megacolon Def: total or segmental nonobstructive colonic dilatation plus systemic toxicity Up to date~ Toxic megacolon

Up to date~ Toxic megacolon

Toxic megacolon Precipitating factors: Hypokalemia antimotility agents Opiates Anticholinergics barium enema colonoscopy Up to date~ Toxic megacolon

Radiographic evidence of colonic distension (frequently > 6cm) The most widely used criteria for the clinical diagnosis of toxic megacolon are : Radiographic evidence of colonic distension (frequently > 6cm) PLUS at least three of the following: Fever >38ºC Heart rate >120 beats/min Neutrophilic leukocytosis >10,500/mm3 Anemia PLUS at least one of the following: Dehydration Altered sensorium Electrolyte disturbances Hypotension Up to date~ Toxic megacolon

Up to date~ Toxic megacolon

Inadequate early hydration: urine <2ml/kg/h in the first 8 hrs on admission Factors associated with intestinal perforation in children's non-typhi Salmonella toxic megacolon. Pediatric Infectious Disease Journal. 19(12):1158-1162, December 2000.

Gender, high frequency of defecation, peripheral leukocytosis, electrolyte imbalance and positive results of stool analysis including OB, mucus and pus  no statistically significant correlation with intestinal perforation. proper and effective antibiotic therapy  still risk of intestinal perforation. Factors associated with intestinal perforation in children's non-typhi Salmonella toxic megacolon. Pediatric Infectious Disease Journal. 19(12):1158-1162, December 2000.

aggressive intravenous hydration and close monitoring of the effect of fluid resuscitation  may reduce the risk for intestinal perforation appropriate rectal tube placement is very effective for the prevention of bowel perforation in children with non-typhi Salmonella toxic megacolon. Factors associated with intestinal perforation in children's non-typhi Salmonella toxic megacolon. Pediatric Infectious Disease Journal. 19(12):1158-1162, December 2000.

Adequate rehydration as a means of prevention of bowel perforation Predilection for 3 areas: T colon near splenic flexure, lower sigmoid, ileocecal region (anatomically watershed areas) Ischemic injuries may result from vascular shunting in response to dehydration Adequate rehydration as a means of prevention of bowel perforation Spontaneous Bowel Perforation in Infants and Young Children: A Clinicopathologic Analysis of Pathogenesis. Journal of Pediatric Gastroenterology & Nutrition. 30(4):432-435, April 2000.

Key points AGE treatment: Hydration is the most important! Not antidiarrhea! Antimotility agents are not suitable in children. D/D of viral gastroenteritis and bacterial gastroenteritis

Ref Up to date “Toxic megacolon” Chen, Jeng-Chang; Chen, Chiu-Chiang +; Liang, Jin-Tung +; Huang, Shiu-Feng * Spontaneous Bowel Perforation in Infants and Young Children: A Clinicopathologic Analysis of Pathogenesis. Journal of Pediatric Gastroenterology & Nutrition. 30(4):432-435, April 2000. CHAO, HSUN-CHIN MD; CHIU, CHENG-HSUN MD; KONG, MAN-SHAN MD, MD; CHANG, LUAN-YIN MD; HUANG, YHU-CHERING MD; LIN, TZOU-YIEN MD; LOU, CHIH-CHEN MD Factors associated with intestinal perforation in children's non-typhi Salmonella toxic megacolon. Pediatric Infectious Disease Journal. 19(12):1158-1162, December 2000. Sheth, S G. LaMont, J T. Toxic megacolon. [Review] [17 refs] Lancet. 351(9101):509-13, 1998 Feb 14.

Thank your for your attention!!!