1. PER Case Present Present 施宏謀 Present 施宏謀 Supervisor 吳孟書醫師 2008/08/27

2. A boy visiting our ED due to abdominal pain……

3. Triage Age : 15 y/o Age : 15 y/o Gender ： male Gender ： male Time ： 2008/05/21 13:51 Time ： 2008/05/21 13:51 Triage : BT: 36.3'C P: 87 R: 20 Triage : BT: 36.3'C P: 87 R: 20 BP: 124/64 BP: 124/64 BW: 56 BW: 56 主訴 : 腹痛嘔吐 主訴 : 腹痛嘔吐

4. Present illness Intermittent upper abdominal pain since last afternoon Intermittent upper abdominal pain since last afternoon Vomiting for 4-5 times with non-digested food Vomiting for 4-5 times with non-digested food No radiating pain No radiating pain No fever No fever No constipation / no tarry stool / no diarrhea No constipation / no tarry stool / no diarrhea Decreased appetite Decreased appetite

5. Physical exam PAT: Easy looking / smooth breathing / stable PAT: Easy looking / smooth breathing / stable HEENT: negative recording HEENT: negative recording Chest : clear Chest : clear Abdomen: soft and flat, Abdomen: soft and flat, epigastric mild tender epigastric mild tender hyperactive bowel sound hyperactive bowel sound no McBurney point tenerness no McBurney point tenerness no rebounding no rebounding Extremities: free movable Extremities: free movable No skin rash No skin rash

6. Need more information about history and PE? Need more information about history and PE? What’s your impression? What’s your impression?

7. Acute abdomen in teenagers Acute appendicitis Acute appendicitis Cholecystitis Cholecystitis Incarcerated hernia Incarcerated hernia Pancreatitis Pancreatitis Obstruction Obstruction Peptic ulcer disease Peptic ulcer disease Function pain Function pain AGE AGE Inflammatory bowel disease Inflammatory bowel disease Pneumonia Pneumonia Trauma Trauma DKA DKA Henoch-Schönlein Purpura Sickle cell syndrome Sickle cell syndrome UTI UTI Renal stone Renal stone Pregnancy Pregnancy Torsion of ovarian or testicle Torsion of ovarian or testicle Dysmenorrhea Dysmenorrhea Ectopic pregnancy Ectopic pregnancy

8. What we concerning Is this surgical abdomen ? Is this surgical abdomen ? Peritonitis Peritonitis Obstruction Obstruction And is there Systemic illness that we should keep in mind? And is there Systemic illness that we should keep in mind?

9. Peritoneal Irritation Appendicitis Appendicitis Meckel’s Diverticulitis With and Without Perforation Meckel’s Diverticulitis With and Without Perforation Pancreatitis Pancreatitis Hollow organ perforation Hollow organ perforation Peritoneal sign, rebounding pain, muscle guarding, 可以走可以跳可以爬上爬下 很少會自己 relief 可能比較不像

10. Intestinal Obstruction Intussusception Intussusception Incarcerated Inguinal / umbilical hernia Incarcerated Inguinal / umbilical hernia Volvulus Volvulus Postoperative Adhesions Postoperative Adhesions Chronic Constipation Chronic Constipation Inflammatory Bowel Disease Inflammatory Bowel Disease Feeding / bowel habit / flatus passage  上下都有通 有吐 也許在多問點相關問題 等等讓他吃吃看

11. Other consideration Intraabdominal Masses Intraabdominal Masses Foreign Bodies of the Gastrointestinal Tract Foreign Bodies of the Gastrointestinal Tract Pneumonia Pneumonia Sepsis Sepsis DKA DKA Henoch-Schönlein Purpura Henoch-Schönlein Purpura Hemolytic uremic syndrome (hematuria) Hemolytic uremic syndrome (hematuria) ↖ By History / PE Hematochezia / hematuria / skin lesion / recent URI / other inflammatory process 事實上, 大多我們 都沒問, 沒想到

12. Otherwise….. Functional GI symptoms Functional GI symptoms Constipation Constipation AGE AGE

13. More History Location : Epigastric Location : Epigastric Quality : Quality : Quantity : Quantity : Onset : 1 day, intermittent Onset : 1 day, intermittent Precipitating factor : Precipitating factor : Exaggerating : Exaggerating : Relieving : Relieving : Associated : Associated :  Appetite : decreased  Bowel habit : stool / flatus passage?  Vomiting : 4-5 times  Fever: no  Trauma

14. Physical examination Appearance Appearance Respiration Respiration Circulation Circulation Inspection : including inguinal area, skin lesion Inspection : including inguinal area, skin lesion Auscultation Auscultation Percussion Percussion Palpation : tender / rebounding / guarding Palpation : tender / rebounding / guarding Walking / jumping / climbing table Walking / jumping / climbing table What about the inguinal / scrotum area ? What about the inguinal / scrotum area ?

15. Brief history 2008/5/21 13:55 buscopan 1amp IM stat 2008/5/21 13:55 buscopan 1amp IM stat 2008/5/21 15:34 improved abdominal pain, no more vomiting after intake 2008/5/21 15:34 improved abdominal pain, no more vomiting after intake no RLQ tenderness no RLQ tenderness  suspect acute gastritis  MBD 衛教 : Early appendicitis could not rule out

16. 2 nd visiting 2008/05/22 19:19 2008/05/22 19:19 Triage : T 39.4 P 98 R 18 Triage : T 39.4 P 98 R 18 Upper abdominal pain shifting to RLQ area Upper abdominal pain shifting to RLQ area Fever noted since 5/22 Fever noted since 5/22 Abdomen : RLQ tenderness, hypoactive bowel sound, rebounding pain ++ Abdomen : RLQ tenderness, hypoactive bowel sound, rebounding pain ++

17. Laboratory WBC 23200 / uL WBC 23200 / uL RBC 5.13 million/uL RBC 5.13 million/uL Hb 14.8 g/dL Hb 14.8 g/dL Hct 41.4 % Hct 41.4 % Platelet 276000/uL Platelet 276000/uL Seg 87.5% Seg 87.5% Lymphocyte 1.5 % Lymphocyte 1.5 % Monocyte 11.0% Monocyte 11.0% Creatinine 0.9 mg/dL Creatinine 0.9 mg/dL CRP 128.38 mg/L CRP 128.38 mg/L U/A: negative finding U/A: negative finding

18. Alvarado score >7 highly suspect >7 highly suspect 5-6  suggest CT or image study 5-6  suggest CT or image study ★ ★ ★ ★ ★ ★ ★ ★

19. The KUB

20. Appendicoliths

23. Abdominal echo A heterogenous mass lesion measured 3.5x1.6 cm near RLQ area A heterogenous mass lesion measured 3.5x1.6 cm near RLQ area Imp.: Imp.: Bowel edema. Bowel edema. Suspect intraabdominal abscess. Suspect intraabdominal abscess.

24. OP finding 1. ascites: 50 cc turbid ascites 1. ascites: 50 cc turbid ascites 2. appendix: subcecal in position downward to pelvic space, sized 7*1.2*1.2 cm, congestion,pus coating on the shaft,gangrenous change over the shaft with frank perforation and severe surrounding adhesion 2. appendix: subcecal in position downward to pelvic space, sized 7*1.2*1.2 cm, congestion,pus coating on the shaft,gangrenous change over the shaft with frank perforation and severe surrounding adhesion 3. fecalith: impacted in the mid-shaft of the lumen 3. fecalith: impacted in the mid-shaft of the lumen 4. omentum: shifting 4. omentum: shifting

25. Take home message 1. The differential diagnosis of Acute abdomen in teenagers … 2. We must rule out surgical abdomen! 3. Inguinal area!! Don’t forget it !! 4. Think more before we take it as a AGE!!! 5. Education, 事前一句勝過事後百句解釋 6. Look for appendicoliths in KUB

26. Reference Textbook of Pediatric Emergency Medicine, 5th Edition, Copyright (c) 2006 Lippincott Williams & Wilkins. Textbook of Pediatric Emergency Medicine, 5th Edition, Copyright (c) 2006 Lippincott Williams & Wilkins. Emergency Medicine: A Comprehensive Study Guide Editor: Tintinalli, Judith E.; Kelen, Gabor D.; Stapczynski, J. Stephan, 6th Edition Emergency Medicine: A Comprehensive Study Guide Editor: Tintinalli, Judith E.; Kelen, Gabor D.; Stapczynski, J. Stephan, 6th Edition