Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof not the classic tale

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Pediatric Abdominal Pain Making Sense of Crap or
Lack Thereof(not the classic tale)

• Joe Nemeth MD CCFP (EM)
• Department of Emergency Medicine
• Montreal Childrens Hospital
• Montreal General Hospital
• MUHC

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QUALITY OF A PRESENTATION

• 1. Novel but not Interesting
• 2. Interesting but not Novel
• 3. Both
• 4. Neither

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Case 1 (You are the attending)

• 7 male, diarrhea, fever x 2 days
• vswnl, looks well
• abd soft, /-diffuse tenderness, no peritoneal
  sign
• Bloods, urine non contributory
• Dg Gastro?enteritis

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Case 1 contd

• Presents again next day, same symptoms
• exam no change
• no bloods drawn
• seen by Gen Surg.
• D/C with Gastroenteritis

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Case 1 contd

• Presents 3rd time, abd pain increased
• rebound
• ORperforated appendix

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Case 2 (You are the attending)

• 24 months, male, crying, bloated
• no v/d, last bm 2 days ago
• vs wnl, happy, looks well
• abdno mass, nontender, BS
• Abd. Series stool
• Dg Constipation

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Case 2 contd

• Presents next day lethargic
• pale, not responding, tachypneic
• protuberant abd
• 7.10/30/5
• ORintussusception

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

• Gastroenteritis
• Constipation

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GOoooooooooooooaL

• Brazil 2 Germany 0 (my prediction)

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GOALS

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

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EPIDEMIOLOGY

• 1.Minor Trauma 20-40
• 2.URTI 8-20
• etc
• 5. Non-traumatic abdominal pain 2-5

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WHATS IN COMMON?

• Patient 1 1/52, lethagic
• Patient 2 8/12 m, irritable, po, bilious
  vomiting, red current jelly stools
• Patient 3 4/52 f, crying episodes x hours x 2
  weeks, legs drawn up, passing gas, otherwise
  well baby

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KIDS VERBAL vs. NON-VERBAL

• Differences?
• Similarities?

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PRESENTATIONTHE SPECTRUM

• stoic denies pain fear of further
  medical attention
• histrionic exaggerates pain

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WHAT S IN COMMON?

• fever nyd
• irritability nyd
• lethargy nyd
• vomiting/diarrhea nyd

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1/3 of kids presenting with Abdominal Pain get
no specific diagnosis!!!

• (not good)

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DICTUM

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

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BENIGN CAUSES OF A/P (how long is this lecture
again?)

• Everything thats not part of the next slide

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SINISTER CAUSES OF A/P

• Obstruction
• Perforation
• Inflammation
• (Metabolic)

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OBSTRUCTION SYMPTOMS

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

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OBSTRUCTIONSIGNS

• ALWAYS START WITH THE VITAL SIGNS!!!!

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OBSTRUCTION SIGNS

• Inconsolable?/lethargic?/absolutely well?
• hernias?
• check out the asshole?

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TAKE HOME MESSAGE

• rely on history
• very few physical findings (50 normal abd. exam)

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DIFFERENTIAL DIAGNOSIS

• Infants 1.ing. hernia, 2 intussusception

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OBSTRUCTIONINVESTIGATION

• /-abd series (prior rectal exam?)
• upper gi/lower gi study
• CT?

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PERFORATIONSYMPTOMS

• irritability?/lethargy?/not well
• sudden onset severe abd.

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PERFORATIONSIGNS

• Vital signs!!!!!!!!!!!!

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PERFORATIONSIGNS

• not moving/legs drawn up
• rebound (what is it?)

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PERFORATIONINVESTIGATIONS

• abd. series
• CT

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INFLAMMATIONSYMPTOMS

• Irritable?/lethargic?/not bad (Perforation rate
  lt2 82-92)
• limping/PID shuffle?

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APPENDICITIS

• Classical presentation 50-60
• RLQ pain 90-95
• n/v/anorexia 65
• mean temp _at_ presentation 37.6C
• WBC lt 10000, no left shift lt10
• WBC normal in first 24hrs 80
• Serial WBC or CRP measurements?useless
• ? triple test for NPV (WBClt9000, CRPlt0.6mg, nph
  lt75)

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APPENDICITIS SCORE

• RLQ 2/10 anorexia 1/10 fever 1/10
  good story 1/10
• WBC 2/10 n/v 1/10 left shift 1/10
  rebound 1/10
• 9-10/10?OR
• 7-8/10?imaging
• lt6/10?consider other Dg

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INVESTIGATION

• abd. Series
• U/S vs. CT

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ANALGESIA

• not a license to snow them
• titration is the key

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AT SIGN OVER.(ANYTHING MISSING?)

• 11 girl
• A/P x 2 days, periumbilical
• vomitted once, no poop
• exam unremarkable
• u/a NEG, cbc unremarkable
• waited long enough, wants to go home

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TAKE HOME AND BRING TO WORK MESSAGE

• HISTORY!!!!
• IF IN DOUBT RE-EXAMINE
• IF STILL UNSURE RE-EXAMINE LATER
• GASTROENTERITIS (Dg of exclusion)