1. ED morbidity and mortality conference
Date: 2006/09/26
R3 黃傑廷
Guided by VS 吳孟書

2. Initial triage and general data 2006-09-11 00:47 (0hr 0mins)
T:36, P:109, R:26, SaO2: 99%
E4V5M6
檢傷分類: 3級
病患主訴因腹痛,臉色蒼白,外院轉診
Name: 江X皓
Chart No:
Age: 4 y/o 3 m/o

3. Chief compliant
Severe abdominal pain with irritable crying tonight

4. Present illness
Abdominal pain with irritable crying since last night (9/10 10:pm)
Non-bilious vomiting x 4 times
Mild fever around 38 degree at home
No diarrhea
No URI recently
一開始去LMD,告之可能為腸套疊

5. Personal History
G1P1, twin B, BBW:2000gm, GA:38wks, C/S due to twin pregnancy
Newborn screen: negative finding
Allergy: no schedule
Vaccine: as schedule
Development: no delay
No admission or operation history

6. Physical Examination Appearance: weakness, awake Breathing: OK
Circulation: pink, no cyanosis
HEENT: throat no injection, ear-drum: ok
Chest: bil. Clear, RHB without murmur
Abdomen: soft, mild distended, diffuse tenderness, no muscle guarding
Extremity: free, no skin rash, CRT < 1 sec

7. What clinical histories and physical examinations should we approach about abdominal pain in a 4 y/o child?

8. Clinical history Presence and character of abdominal pain
History and character of emesis
Bowel history
Systemic symptoms
Associated symptoms attributable to the lower respiratory tract or urinary system
Past medical history

9. Physical examination
Gaining the child's confidence will often allow a better exam!
Observing the patient's ability to move
Repeat exams, especially if the child falls asleep, might prove invaluable
Inspection and observation
Abdominal palpation
Auscultation
Examination of nonabdominal areas
Rectal examination

10. Summary this patient
Sudden onset cramping pain, diffuse, intermittent or persistent ?
Vomit (+), several times, non-bilious
Bowel history: no diarrhea
Systemic symptoms: crying, mild fever
Associated symptoms: no cough, no dysuria
Past medical history: denied
Trauma history ?
Digital examination ?

11. 4 y/o boy with abdomen pain, what’s your D/D?

12. The etiology of abdominal pain
Under 2 years
Appendicitis
Colics (first 4 months)
Congenital anomalies
Gastroenteritis
Incarcerated hernia
Intussusception
Malrotation
Metabolic acidosis
Obstruction
Sickle cell crisis
Toxins
Urinary tract infection
Volvulus
2-5 years
Appendicitis
DKA
Gastroenteritis
Hemolytic-uremic syndrome
Henoch-Schonlein purpura
Incarcerated hernia
Intussuscetion
Metabolic acidosis
Obstruction
Pneumonia
Sickle cell crisis
Toxins
Trauma
Urinary tract infection
Volvulus
Tinitinalli p.184 table 127-1

13. The etiology of abdominal pain
6-11 years
Appendicitis
DKA
Functional
Gastroenteritis
Henoch-Schonlein purpura
Incarcerated hernia
Inflammatory bowel disease
Obstruction
Peptic ulcer disease
Pneumonia
Sickle cell syndrome
Streptococcal pharyngitis
Torsion of ovary or testicle
Toxins
Trauma
Urinary tract infection
Over 11 years
Appendicitis
Cholecystitis
DKA
Dysmenorrhea
Ectopic pregnancy
Functional
Gastroenteritis
Incarcerated hernia
Inflammatory bowel disease
Obstruction
Pancreatitis
Peptic ulcer disease
Pneumonia
Pregnancy
Sickle cell syndrome
Torsion of ovary or testicle
Toxins
Trauma
Urinary tract infection
Tinitinalli p.184 table 127-1

14. Which is possible cause ?
2-5 years
Surgical condition:
Intussuscetion: intermittent pain(-), echo?
Ruptured appendicitis
Bowel obstruction: with fever? Gangrene?
Incarcerated hernia: palpable mass? Complete PE needed
Trauma: history?
Volvulus: age?
Medical condition:
Gastroenteritis: no diarrhea, but still possible
Pneumonia: no cough, CXR is needed
DKA: F/S might be checked
Urinary tract infection: U/A might be checked
Hemolytic-uremic syndrome: CBC/DC, BUN/Cr ?
Toxins: history ?
Sickle cell crisis: no history
Henoch-Schonlein purpura: no purpura, no skin rash X
2-5 years
Surgical condition:
Intussuscetion
Ruptured appendicitis
Bowel obstruction
Incarcerated hernia
Trauma
Volvulus
Medical condition:
Gastroenteritis
Pneumonia
DKA
Urinary tract infection
Hemolytic-uremic syndrome
Toxins
Sickle cell crisis
Henoch-Schonlein purpura

15. Initial oder 95-9-11 00:57am (0hr 10mins) CBC/DC CRP Blood culture NaK
AST
ALT
Sugar
D5S1/4 run 50ml/hr

16. Lab data WBC 10900 Seg 82% Lym 16% Mono 1.0% RBC 6.02 Hb 16.7 Hct 49.2
Plt
323k
Sugar
278
AST 37
ALT 17 K
3.4 Na
142
CRP
12.7

17. LMD KUB 9/10 23:47

18. 95-09-11 02:53am (2hrs 06mins) U/A Ketone body ABG stat
Arrange air reduction
admission
Is it OK?

19. Consider order CXR (standing) Renal function (BUN/Cr)
air reduction after abdomen echo or more clear about diagnosis

20. U/A ABG Ketone body: negative Nitrite: negative PH: 7.400
Protein: negative
Ketone: negative
Glucose: 0.300
RBC:3
WBC:3
Ketone body: negative
ABG
PH: 7.400
PaCO2: 35.7
PaO2: 75
HCO3: 21.6
SBE: -3.2
SAT: 98.3

21. Air reduction 9/11 5:37am

23. Air reduction

25. Report:
No evidence of colonic obstruction, so the intussusception is not likely

26. Still abdominal pain… 95-9-11 09:37am (08hrs 50mins)
BT:39 HR:148 RR:24 BP:113/67
Diclofenac supp
:26am (10hrs 39mins)
BT: 39.4
Vomit x 1
:00 (12hrs 13mins)
Admission to ward

27. Do you agree? What happened to this patient?
If you were duty Dr, what would you do?

28. Peritoneal sign + fever -> surgical abdomen is highly suspected
More clear history and physical examination should be obtained!
Consider further image study
Abdominal echo
Abdominal CT

29. 95-9-11 afternoon Admission to ward…
:50 (13hrs 03mins)
Admission
:40 (13hrs 53mins)
Abdomen echo
Ascites, bowel dilation in proximal GI tract, rectum collapsed, gaseous abdomen r/o pneumoperitoneum
:50 (14hrs 03mins)
BT:40 P:180 RR:31 BP:110/80 oximeter:94%
F/S: 145mg/dl
Transfer to PICU
F/U plain abdomen

30. Small bowel dilatation
9/11 4:36pm
Small bowel dilatation

31. Impression r/o ischemic bowel r/o ileus with bowel obstruction
Consult 小兒外科

32. OP note
Congenital mensenteric defect about 7*7 cm at 140cm distal to Treitz ligment with entrapped small bowel, volvulus and bowel gangrene
300cc turbid ascites
Resection of the gangrene small bowel about 30cm ( cm distal to Treitz ligment), the residual ileum about 50cm
End ileostomy was performed at 140cm distal to Treitz ligment, and the distal ileum was closed by 2 layers closure

33. Admission course 09-11: operation and admit to PICU
09-16: extubation and transfer to oridnary ward
09-19: condition stable, MBD and OPD F/U

34. Key point Adequate history and PE before your diagnosis and management
The cause of the acute abdomen varies depending on the age of the child, and we should always keep surgical condition in mind