Pediatric Abdominal Pain- Making Sense of Crap

Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale) Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC QUALITY OF A PRESENTATION  1. Novel but not Interesting  2. Interesting but not Novel  3. Both  4. Neither Case 1 (You are the attending)  7 male, diarrhea, fever x 2 days  vs:wnl, looks well  abd: soft, +/-diffuse tenderness, no peritoneal sign  Bloods, urine: non contributory  Dg: Gastro?enteritis Case 1 cont’d  Presents again next day, same symptoms  exam: no change  no bloods drawn  seen by Gen Surg.  D/C with Gastroenteritis Case 1 cont’d  Presents 3rd time, abd pain increased  rebound  OR:perforated appendix Case 2 (You are the attending)  24 months, male, crying, “bloated”  no v/d, last bm 2 days ago  vs: wnl, happy, looks well  abd:no mass, nontender, +BS  Abd. Series: stool+++  Dg: Constipation Case 2 cont’d  Presents next day lethargic  pale, not responding, tachypneic  protuberant abd  7.10/30/5  OR:intussusception Which of 2 diagnosis are found on emergency discharge records most frequently for missed pediatric abdominal catastrophies in court cases? Gastroenteritis Constipation GOoooooooooooooaL  Brazil 2 Germany 0 (my prediction) 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? EPIDEMIOLOGY  #1.Minor Trauma 20-40%  #2.URTI 8-20%  etc  #5. Non-traumatic abdominal pain 2-5% WHAT’S 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 KIDS: VERBAL vs. NON-VERBAL  Differences?  Similarities? PRESENTATION:THE SPECTRUM  stoic denies pain medical attention fear of further  histrionic exaggerates pain WHAT ’S IN COMMON?  fever nyd  irritability nyd  lethargy nyd  vomiting/diarrhea nyd 1/3 of kids presenting with Abdominal Pain get no specific diagnosis!!! (not good) DICTUM  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?)  Everything that’s not part of the next slide SINISTER CAUSES OF A/P  Obstruction  Perforation  Inflammation  (Metabolic) OBSTRUCTION: SYMPTOMS  persistent (bilious,feculent) vomiting  no stool/gas per rectum (not an absolute!)  po (P.S.!!)  poorly localized A/P OBSTRUCTION:SIGNS  ALWAYS START WITH THE VITAL SIGNS!!!! OBSTRUCTION: SIGNS  Inconsolable?/lethargic?/absolutely well?  hernias?  check out the asshole? TAKE HOME MESSAGE  rely on history  very few physical findings (50% normal abd. exam) DIFFERENTIAL DIAGNOSIS  Infants: #1.ing. hernia, #2 intussusception OBSTRUCTION:INVESTIGATION  +/-abd series (prior rectal exam?)  upper gi/lower gi study  CT? PERFORATION:SYMPTOMS  irritability?/lethargy?/not well  sudden onset severe abd………. PERFORATION:SIGNS  Vital signs!!!!!!!!!!!! PERFORATION:SIGNS  not moving/legs drawn up  rebound (what is it?) PERFORATION:INVESTIGATIONS  abd. series  CT INFLAMMATION:SYMPTOMS  Irritable?/lethargic?/not bad (Perforation rate <2  limping/”PID shuffle”? 82-92%) APPENDICITIS  Classical presentation 50-60%  RLQ pain 90-95%  n/v/anorexia 65%  mean temp @ presentation 37.6C  WBC < 10000, no left shift <10%  WBC normal in first 24hrs 80%  Serial WBC or CRP measurementsuseless  ? triple test for NPV (WBC<9000, CRP<0.6mg%, nph <75%) 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  <6/10consider other Dg INVESTIGATION  abd. Series  U/S vs. CT ANALGESIA  not a license to snow them  titration is the key 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” TAKE HOME AND BRING TO WORK MESSAGE  HISTORY!!!!  IF IN DOUBT RE-EXAMINE  IF STILL UNSURE RE-EXAMINE LATER  GASTROENTERITIS (Dg of exclusion)