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Abdominal pain in children

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Abdominal pain in children Madesa Espana, MD Pediatric EM Section St. Joseph s Regional Medical Center Abdominal pain: evidence-based data Incidence 5 % of patients ... – PowerPoint PPT presentation

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Title: Abdominal pain in children


1
Abdominal pain in children
  • Madesa Espana, MD
  • Pediatric EM Section
  • St. Josephs Regional Medical Center

2
Abdominal pain evidence-based data
  • Incidence
  • 5 of patients presenting to the pediatric
    clinic and ED (2 12 years old, lt72 hours
    duration)
  • 1 of patients with abdominal pain had surgical
    intervention
  • 84 of patients were diagnosed to have
  • URI and/or Otitis Media
  • Pharyngitis
  • Viral syndrome
  • Abdominal pain or uncertain etiology
  • Gastroenteritis
  • Acute febrile illness

3
Abdominal pain evidence-based data
  • Incidence
  • 7.4 had return visits
  • 1 had treatable medical conditions
  • 0.3 needed surgical intervention on subsequent
    visits

4
Abdominal pain evidence-based data
  • Incidence
  • 1.7 were hospitalized
  • Diagnoses when abdominal pain was first complaint
  • Appendicitis
  • Abdominal pain of uncertain etiology
  • Intussusception
  • Abdominal adhesions
  • Gastroenteritis
  • Acute Febrile Illness
  • Pyelonephritis
  • Sickle cell painful crisis
  • Henoch-Schonlein purpura

5
Abdominal pain evidence-based data
  • Incidence
  • 1.3 were hospitalized
  • Diagnoses when abdominal pain was second
    complaint
  • Gastroenteritis/Dehydration
  • Abdominal abscess after appendectomy
  • Pneumonia
  • Viral syndrome
  • Pyelonephritis
  • Sickle cell pain crisis and fever
  • Hematochezia
  • Hematemesis
  • URI and seizure
  • Reactive airway disease

6
Abdominal pain evidence-based data
  • Associated symptoms
  • Fever
  • Vomiting
  • Decreased appetite
  • Cough
  • Headache
  • Sorethroat

7
Historical Data
  • Duration of the pain
  • Location of the pain
  • Radiation of the pain
  • General appearance of the patient
  • Associated symptoms
  • Sick contacts
  • Recent travel

8
Historical data
  • Associated symptoms
  • Vomiting
  • Duration
  • Type of emesis bile, blood
  • Diarrhea
  • bloody
  • Fever
  • Rash
  • Genitourinary symptoms

9
Physical Examination
  • General appearance
  • Ill-appearing or toxic
  • Dehydrated
  • Shock
  • Vital signs
  • Febrile
  • Tachycardic
  • Tachypneic
  • Hypotensive

10
Physical Examination
  • Head/Face
  • Fontanels
  • Sunken
  • Bulging
  • Signs of inflicted injury
  • Bruising/swelling

11
Physical Examination
  • Eyes
  • Icteric sclera
  • Abnormal eye movements
  • Sunken appearance
  • Periorbital swelling

12
Physical Examination
  • ENT
  • Mucus membranes
  • Moist vs dry
  • Lesions/ulcerations
  • Teeth and Gums
  • Swelling
  • Bleeding

13
Physical Examination
  • ENT
  • Nose
  • Rhinorrhea
  • Nose bleed
  • Throat
  • Erythema
  • Exudates

14
Physical Examination
  • Chest/Axilla
  • Appearance
  • Tenderness
  • Swelling/Masses

15
Physical Examination
  • Cardiovascular
  • Heart sounds
  • Rhythm
  • Pulses
  • Edema

16
Physical Examination
  • Abdomen
  • Appearance
  • Distension
  • Scars
  • Bruises

17
Physical Examination
  • Abdomen
  • Palpation
  • Tenderness
  • Organomegaly
  • Masses

18
Physical Examination
  • Abdomen
  • Tenderness
  • Localized
  • Diffuse
  • Rebound
  • Rovsings sign
  • Guarding
  • Voluntary
  • Non-voluntary

19
Physical Examination
  • Abdomen
  • Rectal exam
  • Stool Guaic
  • Other findings
  • Psoas sign
  • Obturators sign
  • Murphys sign

20
Physical Examination
  • Pelvis/inguinal area
  • Males
  • Scrotum and testicles
  • Urethral discharge
  • Phymosis/paraphymosis
  • Females
  • Vaginal bleeding
  • Speculum exam

21
Physical Examination
  • Skin
  • Color
  • Pale
  • jaundice
  • Rashes
  • Signs of injury/abnormal bleeding
  • Turgor
  • Peripheral circulation

22
Physical Examination
  • Neurologic examination
  • Mental status
  • Cranial nerves
  • Motor
  • Sensorory
  • Cerebellar

23
Physical examination
  • Psychiatric evaluation
  • Mental status
  • Depression
  • Anxiety
  • Suicidal ideation/attempt
  • Homicidal ideation/attempt
  • Hallucinations/delusions

24
Differential diagnosis
  • Infants
  • Gastroenteritis
  • Constipation
  • Malrotation /- Volvulos
  • GERD
  • Infantile Colic
  • Intussuception
  • Urinary tract infection
  • Testicular torsion

25
Differential diagnosis
  • Children
  • Gastroenteritis
  • Constipation
  • Intussuception
  • Torsion
  • UTI
  • Kidney stones
  • Sickle cell crisis
  • DKA
  • Testicular torsion
  • Incarcerated Hernia
  • Pneumonia
  • Strep throat
  • Henoch-Schonlein Purpura
  • Meningococcemia
  • Toxic ingestions

26
Diferrential Diagnosis
  • Adolescent Males
  • Testicular torsion
  • Varicocele
  • Pyelonephritis
  • Kidney stones
  • Gallstones
  • Pancreatitis
  • Hepatitis
  • Incarcerated Hernia
  • Constipation
  • DKA
  • IBD
  • STD
  • GERD
  • Toxic ingestions

27
Differential diagnosis
  • Adolescent females
  • Ovarian torsion
  • Ruptured ovarian cyst
  • PID
  • UTI
  • Gallstones
  • Cholecystitis
  • Kidney stones
  • DKA
  • Toxic ingestions
  • Pre-/menstrual cramps
  • Complications of pregnancy
  • Ectopic
  • Threatened AB
  • Missed AB

28
Abdominal pain evidence-based data
  • Abdominal pain appendicitis or not?

29
Abdominal pain evidence-based data
  • Appendicitis
  • Incidence
  • 11/10,000 population per year
  • Highest in males 10-14 years (27/10,000)
  • Highest in females 15-19 years (20/10,000)
  • Malefemale ratio 1.41
  • Life time risk
  • Males 8.6 Females 6.7
  • Perforation 18 highest in lt 5 and gt65 y.o.

30
Appendicitis evidence-based data
  • Signs and symptoms
  • Neonates
  • Abdominal distension
  • Vomiting
  • Fever
  • Hypothermia
  • Respiratory distress

31
Appendicitis evidence-based data
  • Signs and symptoms
  • 3 years and under
  • Diffuse abdominal pain
  • Fever
  • Vomiting
  • Diarrhea
  • Abdominal distension
  • Diffuse abdominal tenderness

32
Appendicitis evidence-based data
  • Signs and symptoms
  • Older children
  • Abdominal pain
  • Vomiting
  • Fever
  • Anorexia
  • Pain with movement or cough
  • Localized RLQ tenderness
  • Diffuse/rebound tenderness

33
Abdominal pain evidence-based data
  • Laboratory studies
  • CBC, differential
  • ESR
  • C-reactive protein
  • Urinalysis
  • Poor sensitivity and specificity

34
Abdominal pain evidence-based data
  • Radiologic studies
  • Plain films
  • Small bowel obstruction
  • Fecalith
  • Pneumoperitoneum
  • Poor sensitivity and specificity

35
Abdominal pain evidence-based data
  • Radiologic studies
  • Ultrasound
  • Appendiceal diameter or gt6 mm
  • Target sign with 5 concentric layers
  • Distension or obstruction of the lumen
  • High echogenicity around the appendix
  • Pericecal or perivesical fluid
  • Appendix wall gt 2 mm
  • Absence of appendiceal peristalsis
  • Can confirm but not exclude appendicitis

36
Abdominal Pain Evidence-based Data
  • Radiologic studies
  • CT scan
  • Enlarged appendiceal diameter (gt 6 mm)
  • Appendiceal wall thickening (gt 1 mm)
  • Periappendiceal inflammatory changes including
    fat streaks, phlegmon, fluid collection, and/or
    extraluminal gas
  • Other findings appendicalith, abscess, arrowhead
    sign, or cecal bar
  • Sensitivity 87 100 , Specificity 89 98

37
Abdominal pain evidence-based data
  • Radiologic studies
  • CT scan
  • Advantages
  • Establish alternative diagnoses
  • Differentiates between perforated and
    non-perforated appendicitis
  • Reduces length of stay and cost of care
  • Reduces perforation rate
  • Useful in obese, uncooperative patients

38
Abdominal pain evidence-based data
  • Radiologic studies
  • CT scan
  • Disadvantages
  • Higher cost compared to ultrasonography
  • Risks associated with contrast administration
  • Potential need for sedation
  • Exposure to ionizing radiation
  • False negative rate 10

39
Diagnostic work-up
  • History and physical examination
  • Serial abdominal exams
  • Surgical consultation
  • Laboratory data
  • Radiologic evaluation
  • Ultrasound
  • CT scan

40
Treatment of appendicitis
  • Surgery
  • Laparoscopic
  • Open
  • Conservative management
  • Antibiotics
  • IV hydration

41
Treatment of appendicitis
  • Conservative management
  • IV and oral antibiotics
  • Cefotaxime (ofloxacin tinidazole)
  • Ciprofloxacin and metronidazole (ciprofloxacin
    tinidazole)

42
Treatment of appendicitis
  • Conservative management
  • Advantages
  • Less pain
  • Shorter recovery time
  • Avoid complications of surgery
  • and anesthesia

43
Treatment of appendicitis
  • Conservative management
  • Disadvantages
  • High recurrence rate

44
Abdominal pain evidence-based data
  • Use of analgesics in patients with abdominal pain
  • Will analgesics mask the signs of acute
  • abdomen and cause a delay making the
  • diagnosis?
  • What medications are effective and safe?

45
Abdominal pain evidence-based data
  • Use of analgesics in patients with abdominal pain
  • 56 of patients with abdominal pain were not
    given pain medication
  • Studies in adults show that opioids are effective
    in reducing pain without significant adverse
    effects or delay in diagnosis of acute abdomen

46
Abdominal pain evidence-based data
  • Use of analgesics in pediatric patients with
    abdominal pain
  • Morphine 0.1 mg/kg vs. normal saline
  • Reduction of pain score by 2 points (1 10)
  • No change in the area(s) of tenderness
  • Tenderness persisted in patients with surgical
    conditions
  • No change in the diagnostic accuracy
  • No significant complications

47
Abdominal pain evidence-based data
  • Follow up care of discharged patients
  • Return or follow up visit in 8 12 hours
  • Will identify serious medical conditions
    presenting as abdominal pain and detect surgical
    conditions that may have presented early in the
    disease process.

48
  • Thank you!
  • Have a great day.
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