Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale) John Misdary PGY 6 Pediatric Emergency Medicine Emory University / CHOA

4 I have no conflict of interests to disclose.

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: Gastroenteritis

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

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.UTI 8-20% 4 #3. Non-traumatic abdominal pain 2-5%

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)

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

In General 4 Common problems occur commonly –intussusception in the infant –appendicitis in the child 4 The differential diagnosis is age-specific 4 In pediatrics most belly pain is non-surgical –“ Most things get better by themselves. Most things, in fact, are better by morning.” 4 Bilous emesis in the infant is malrotation until proven otherwise 4 A high rate of negative tests is OK

The History 4 Pain (location, pattern, severity, timing) –pain as the first sx suggests a surgical problem 4 Vomiting (bile, blood, projectile, timing) 4 Bowel habits (diarrhea, constipation, blood, flatus) 4 Genitourinary complaints 4 Menstrual history 4 Travel, diet, contact history

The Physical Examination 4 Warm hands and exam room 4 Try to distract the child (talk about pets) 4 A quiet, unhurried, thorough exam 4 Plan to do serial exams 4 Do a rectal exam

Relevant Physical Findings 4 Tachycardia 4 Alert and active/still and silent 4 Abdominal rigidity/softness 4 Bowel sounds 4 Peritoneal signs (tap, jump) 4 Signs of other infection (otitis, pharyngitis, pneumonia) 4 Check for hernias

Blood in the Stool 4 Newborn –ingested maternal blood, formula intolerance, NEC, volvulus, Hirschsprung’s 4 Toddler –anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile polyps, HUS, IBD 4 2 to 6 years –infectious colitis, juvenile polyps, anal fissures, intussusception, Meckel’s, IBD, HSP 4 6 years and older –IBD, colitis, polyps, hemorrhoids

Blood in the Vomitus 4 Newborn –ingested maternal blood, drug induced, gastritis 4 Toddler –ulcers, gastritis, esophagitis, HPS 4 2 to 6 years –ulcers, gastritis, esophagitis, varices, FB 4 6 years and older –ulcers, gastritis, esophagitis, varices

Further Work-up 4 CBC and differential 4 Urinalysis 4 X-rays (KUB, CXR) 4 US 4 Abdominal CT 4 Stool cultures 4 Liver, pancreatic function tests 4 (Rehydrate, ?antibiotics, ?analgesiscs)

Relevant X-ray Findings 4 Signs of obstruction –air/fluid levels –dilated loops –air in the rectum? 4 Fecalith 4 Paucity of air in the right side 4 Constipation

Operate NOW 4 Vascular compromise –malrotation and volvulus –incarcerated hernia –nonreduced intussusception –ischemic bowel obstruction –torsed gonads 4 Perforated viscus 4 Uncontrolled intra-abdominal bleeding

Operate SOON 4 Intestinal obstruction 4 Non-perforated appendicitis 4 Refractory IBD 4 Tumors

Appendicitis 4 Common in children; rare in infants 4 Symptoms tend to get worse 4 Perforation rarely occurs in the first 24 hours 4 The physical exam is the mainstay of diagnosis 4 Classify as simple (acute, supparative) or complex (gangrenous, perforated)

Intussusception 4 Typically in the 8-24 month age group 4 Diagnosis is historical –intermittent severe colic episodes –unexplained lethargy in a previously healthy infant 4 Contrast enema is diagnostic and often therapeutic 4 Post-op small bowel intussusception

The “Medical Bellyache” 4 Pneumonia 4 Mesenteric adenitis 4 Henoch-Schonlein Purpura 4 Gastroenteritis/colitis 4 Hepatitis 4 Swallowed FB 4 Porphyria 4 Functional ileus 4 UTI 4 Constipation 4 IBD “flare” 4 rectus hematoma

The Neurologically Impaired Patient 4 The physical exam is important for non- verbal patients 4 The history is important for the spinal cord dysfunction patient 4 Close observation and complementary imaging studies are necessary

The Immunologically Impaired Patient 4 A high index of suspicion for surgical conditions and signs of peritonitis may necessitate operation –perforation –uncontrolled bleeding –clinical deterioration 4 Blood product replacement is essential 4 Typhlitis should be considered; diagnosis is best established by CT

The Teenage Female 4 Menstrual history –regularity, last period, character, dysmenorrhea 4 Pelvic/bimanual exam with cultures 4 Pregnancy test/urinalysis 4 US 4 Laparoscopy 4 Differential diagnosis –mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis

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 rectum?

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)