Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale) Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC

QUALITY OF A PRESENTATION 4 1. Novel but not Interesting 4 2. Interesting but not Novel 4 3. Both 4 4. Neither

You Case 1 (You are the attending) 4 7 male, diarrhea, fever x 2 days 4 vs:wnl, looks well 4 abd: soft, +/-diffuse tenderness, no peritoneal sign 4 Bloods, urine: non contributory 4 Dg: Gastro?enteritis

Case 1 cont’d 4 Presents again next day, same symptoms 4 exam: no change 4 no bloods drawn 4 seen by Gen Surg. 4 D/C with Gastroenteritis

Case 1 cont’d 4 Presents 3rd time, abd pain increased 4 rebound 4 OR:perforated appendix

You Case 2 (You are the attending) 4 24 months, male, crying, “bloated” 4 no v/d, last bm 2 days ago 4 vs: wnl, happy, looks well 4 abd:no mass, nontender, +BS 4 Abd. Series: stool+++ 4 Dg: Constipation

Case 2 cont’d 4 Presents next day lethargic 4 pale, not responding, tachypneic 4 protuberant abd /30/5 4 OR:intussusception

Which of 2 diagnosis are found on emergency discharge records most frequently for missed pediatric abdominal catastrophies in court cases? Gastroenteritis Constipation

GOoooooooooooooaL 4 Brazil 2 Germany 0 (my prediction)

GOALS 4 Distinguish between benign and sinister causes of non-traumatic A/P 4 Which labs to order/not to order? 4 Which imaging modalities to order/not to order? 4 How to dispose of the patient…..I mean disposition of the patient?

EPIDEMIOLOGY 4 #1.Minor Trauma 20-40% 4 #2.URTI 8-20% 4 etc 4 #5. Non-traumatic abdominal pain 2-5%

WHAT’S IN COMMON? 4 Patient 1: 1/52, lethagic 4 Patient 2: 8/12 m, irritable, po, bilious vomiting, red current jelly stools 4 Patient 3: 4/52 f, crying episodes x hours x 2 weeks, legs drawn up, “passing ++gas”, otherwise well baby

KIDS: VERBAL vs. NON-VERBAL 4 Differences? 4 Similarities?

PRESENTATION:THE SPECTRUM 4 stoic denies pain fear of further medical attention 4 histrionic exaggerates pain

WHAT ’S IN COMMON? 4 fever nyd 4 irritability nyd 4 lethargy nyd 4 vomiting/diarrhea nyd

1/3 of kids presenting with Abdominal Pain get no specific diagnosis!!! (not good )

DICTUM 4 All kids of non-verbal age presenting with DIAGNOSIS NYD should be considered to have abdominal pathology.until proven otherwise.

BENIGN CAUSES OF A/P (how long is this lecture again?) 4 Everything that’s not part of the next slide

SINISTER CAUSES OF A/P 4 Obstruction 4 Perforation 4 Inflammation 4 (Metabolic)

OBSTRUCTION: SYMPTOMS 4 persistent (bilious,feculent) vomiting 4 no stool/gas per rectum (not an absolute!) 4 po (P.S.!!) 4 poorly localized A/P

OBSTRUCTION:SIGNS 4 ALWAYS START WITH THE VITAL SIGNS!!!!

OBSTRUCTION: SIGNS 4 Inconsolable?/lethargic?/absolutely well? 4 hernias? 4 check out the asshole?

TAKE HOME MESSAGE 4 rely on history 4 very few physical findings (50% normal abd. exam)

DIFFERENTIAL DIAGNOSIS 4 Infants: #1.ing. hernia, #2 intussusception

OBSTRUCTION:INVESTIGATION 4 +/-abd series (prior rectal exam?) 4 upper gi/lower gi study 4 CT?

PERFORATION:SYMPTOMS not 4 irritability?/lethargy?/not well 4 sudden onset severe abd……….

PERFORATION:SIGNS 4 Vital signs!!!!!!!!!!!!

PERFORATION:SIGNS 4 not moving/legs drawn up 4 rebound (what is it?)

PERFORATION:INVESTIGATIONS 4 abd. series 4 CT

INFLAMMATION:SYMPTOMS 4 Irritable?/lethargic?/not bad (Perforation rate < %) 4 limping/”PID shuffle”?

APPENDICITIS 4 Classical presentation 50-60% 4 RLQ pain 90-95% 4 n/v/anorexia 65% 4 mean presentation 37.6C 4 WBC < 10000, no left shift <10% 4 WBC normal in first 24hrs 80% 4 Serial WBC or CRP measurements  useless 4 ? triple test for NPV (WBC<9000, CRP<0.6mg%, nph <75%)

APPENDICITIS SCORE 4 RLQ 2/10 anorexia 1/10 fever 1/10 good story 1/10 4 WBC 2/10 n/v 1/10 left shift 1/10 rebound 1/ /10  OR 4 7-8/10  imaging 4 <6/10  consider other Dg

INVESTIGATION 4 abd. Series 4 U/S vs. CT

ANALGESIA 4 not a license to snow them 4 titration is the key

AT SIGN OVER…. (ANYTHING MISSING?) 4 11 girl 4 A/P x 2 days, periumbilical 4 vomitted once, no “poop” 4 exam unremarkable 4 u/a NEG, cbc unremarkable 4 waited long enough, “wants to go home”

BRING TO WORK TAKE HOME AND BRING TO WORK MESSAGE 4 HISTORY!!!! 4 IF IN DOUBT RE-EXAMINE 4 IF STILL UNSURE RE-EXAMINE LATER 4 GASTROENTERITIS (Dg of exclusion)