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FALL15 N833 Adv Pedi Probs > Acute Abdominal Pain > Flashcards

Acute Abdominal Pain Flashcards

1
Q

Indications for prompt surgical evaluation of acute abdominal pain

A
  • Hx abdominal trauma
  • Worse w/ movement
  • Involuntary guarding
  • Rebound tenderness
  • Tenderness with percussion
  • Signs of bleeding? (may not require surgery, but need to be addressed)
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2
Q

Common causes of acute abdominal pain in neonates

A

Adhesions*, necrotizing enterocolitis*, volvulus*, colic, dietary protein allergy, testicular torsion

*life threatening

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3
Q

Common causes of acute abdominal pain: 2 months to 2 years

A

Adhesions*, foreign body ingestion*, hemolytic uremic syndrome*, hirschsprung disease*, incarcerated hernia*, intussusception*, trauma*, gastroenteritis, viral illness, dietary protein allergy, hepatitis, Meckel’s diverticulum, sickle cell syndrome vasoocclusive crisis, toxin, tumor, UTI

*life threatening

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4
Q

Common causes of acute abdominal pain: 2 to 5 years

A

Adhesions*, appendicitis*, foreign body ingestion*, hemolytic uremic syndrome*, intussusception*, primary bacterial peritonitis*, trauma*, gastroenteritis, viral illness, pharyngitis, constipation

Henoch Schönlein Purpura, hepatitis, intraabdominal abscess, Meckel’s diverticulum, UTI, ovarian torsion, pneumonia, sickle cell syndrome vasoocclusive crisis, toxin, tumor

*life threatening

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5
Q

Common causes of acute abdominal pain: >5years

A

Adhesions*, appendicitis*, diabetic ketoacidosis*, hemolytic uremic syndrome*, myocarditis*, pericarditis*, perforated ulcer*, primary bacterial peritonitis*, trauma*, gastroenteritis, viral illness, pharyngitis, constipation

Abdominal migraine, cholecystitis, familial Mediterraneal fever, Inflammatory Bowel Disease, Henoch Schönlein Purpura, hepatitis, intraabdominal abscess, Meckel’s diverticulum, pancreatitis, UTI, testicular torsion, ovarian torsion, ruptured ovarian cyst, pneumonia, sickle cell syndrome vasoocclusive crisis, urolithiasis

*life threatening

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6
Q

What to suspect with epigastric pain?

A

GER/D, esophagitis, gastritis, gastric ulcer, duodenal ulcer, pancreatitis, gastric volvulus, small bowel volvulus, erythromycin induced, NSAID induced

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7
Q

What to suspect with hypogastric pain?

A

Constipation, colon spasm, colitis, bladder disease, uterine conditions, PID

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8
Q

What to suspect with periumbilical pain?

A

Functional disease, constipation, gastroenteritis, early appendicitis, pancreatitis, small bowel volvulus, henoch schonlein Purpura, incarcerated umbilical hernia

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9
Q

What to suspect with RUQ pain?

A

Hepatitis, cholecystitis, cholelithiasis, biliary colic, cholangitis, RLL pneumonia, kidney disease, UTI

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10
Q

What to suspect with RLQ pain?

A

Constipation, mesenteric adenitis, crohn disease, acute obstruction, localized perforation, appendicitis, intussusception, ovarian torsion, ectopic pregnancy, testicular torsion, hernia

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11
Q

What to suspect with LUQ pain?

A

Splenomegaly, splenic infarction, tramatic spleen injury, LLL pneumonia, kidney disease, UTI

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12
Q

What to suspect with LLQ pain?

A

Constipation, colon spasm, colitis, ovarian torsion, ectopic pregnancy, testicular torsion, hernia, sigmoid volvulus

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13
Q

What to suspect with diffuse abdominal pain?

A

Gastroenteritis, perforation, constipation, functional disease, colic, strep pharyngitis, intussusception, IBD, Henoch-Schonlein Purpura, DKA, porphyria, SSC, volvulus, abdominal migraine, cyclic vomiting syndrome, lead poisoning, iron ingestion, familial Mediterranean fever, angioneurotic edema, venomous bite

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14
Q

Examples of abdominal pain that varies in location?

A

Trauma, infarction, gluten-sensitivity enteropathy

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15
Q

What is NEC?

A

Most common emergency for newborns

Ischemic necrosis of intestinal mucosa associated w/inflammation, invasion of enteric gas forming organisms, dissection of gas into muscularis and portal venous system

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16
Q

Causes NEC

A

Definitive cause unknown

Heterogeneous factors implicated:

  • Prematurity
  • Microbial bowel overgrowth
  • Milk feeding
  • Impaired mucosal defense
  • Circulatory instability of the intestinal tract
  • ·Medications that cause intestinal mucosal injury or enhance microbial overgrowth
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17
Q

S/S of NEC

A
  • Abdominal tenderness
  • Vomiting
  • Abdominal distension
  • Poor feeding
  • Respiratory distress
  • Irritability and later lethargy
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18
Q

PE findings of NEC

A
  • Tachypnea or apnea
  • Temp instability
  • Hypotension (late sign)
  • Abdominal distension/discoloration
  • Pallor
  • Emesis/residuals – bilious or non-bilious
  • Abdominal guarding
  • Bloody stools/rectal drainage
  • Decreased or absent bowel sounds
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19
Q

Diagnostics for NEC: Labs

A
  • *PE & VS can be best diagnostics
  • CBC w/manual diff:
    • Leukocytosis à neutropenia (low ANC)
    • Left shift
    • Thrombocytopenia
    • Anemia (if bloody stools)
  • Elevated CRP
  • Blood culture: + if NEC 2/2 sepsis OR if intestinal perf à sepsis
  • Coagulation studies for DIC
  • Electrolytes: dehydration if 3rd spacing
  • Blood gas: possible hypercarbia & metabolic acidosis
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20
Q

Diagnostics for NEC: radiographic

A
  • A/P and Left decubitis X-rays
    • Disorganized bowel gas pattern
    • Distended bowel loops
    • Gasless bowel loops
  • Hallmark signs: pneumotosis of bowel wall (tiny air bubbles) +/- pneumoperitoneum (free air w/in abdominal cavity) +/- portal venous air
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21
Q

Treatment for NEC

A

Medical mgmt: NPO, antibiotics, supportive therapy

Surgical MGMT (most often): Excision of necrotic bowel segments and creation of ostomies/fistulas, Cleaning out of peritoneal cavity

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22
Q

What is volvulus?

A
  • Small bowel twists around superior mesenteric artery –> vascular compromise in large portions of midgut.
  • Can lead to ischemia and necrosis if not corrected.
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23
Q

Causes of volvulus

A
  • Incomplete rotation of bowel during embryologic dvpt
  • Malrotation
  • Ladd’s Bands: peritoneal bands that cross over the duodenum and fixate the cecum to the peritoneal wall
    • with abnormal rotation/fixation may cause compression of duodenum (obstruction)
  • s/p surgery likely 2/2 adhesions
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24
Q

S/S of volvulus

A
  • Abdominal pain w/crying (constant or episodic)
  • Pulling up of legs toward chest
  • Vomiting (non-bilious or bilious –can indicate emergency!)
  • Blood in stool (late sign)
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25
Q

PE findings volvulus

A
  • Distended abdomen
  • Abdominal guarding
  • Decreased bowel sounds
  • s/s of shock (late)
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26
Q

Diagnostics for volvulus

A
  • Labs: dependent on condition
  • Stool: blood
  • A/P abdominal x-ray: not diagnostic: dilated stomach and proximal duodenum (double bubble)
  • GOLD STANDARD: upper GI study w/water soluble contrast (cork screw small bowel)
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27
Q

Tx for volvulus

A
  • Preop: stabilization
  • Surgical repair: laparoscopy untwists bowel: cut ladd bands, appendectomy, tube through duodenum to r/o obstruction
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28
Q

What is intussusception?

A
  • Intestine is telescoped into adjacent bowel. Most commonly at junction of ileum and colon.
  • May lead to lymphatic congestion w/resulting intestinal edema –> ischemia–> perforation –> peritonitis
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29
Q

Causes of intussusception

A
  • Unknown in infants.
  • Risk factors:
    • polyps, tumor, Meckel diverticulum, etc.
    • Some association w/viral illnesses
    • Crohn’s and surgery, esp in older
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30
Q

Symptoms intussusception

A
  • Abdominal pain w/colicky crying, >3h but episodic
  • Pulling of legs toward chest
  • Lethargy
  • Vomiting
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31
Q

PE findings of intussusception

A
  • Distended abdomen
  • Abdominal guarding
  • Pallor
  • Abdominal mass in rt abdomen (sausage like)
  • Classic sign: red currant jelly stool –sign vascular compromise
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32
Q

Diagnostics for intussusception

A
  • Stabilize preprocedure (antibiotics only if perf)
  • U/S or fluoroscopy guided non-operative reduction: tx of choice w/o perf
  • If non-op fails or if perf: surgical reduction
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33
Q

Two causes to testicular torsion?

A
  • Neonatal TT: rare. Extravaginal. Twisting of spermatic cord, compromising vasculature to testes
  • Intravaginal torsion: inadequate fixation of testis to tunica vaginalis –> testis may twist on spermatic cord w/in tunica vaginalis–> venous compression –> edema of testicle and cord –> ischemia of testicle.
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34
Q

Symptoms of testicular torsion

A

Scrotal pain radiating to abdomen (constant or episodic)

N/V

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35
Q

PE findings testicular torsion

A
  • Scrotal edema, induration and erythema or bluish coloring
  • Tenderness, swelling, slight elevation of affected testis
  • Testis may be horizontal
  • Reactive hydrocele possible
  • Cremasteric reflex absent >6mo old
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36
Q

Diagnostics for testicular torsion

A
  • Clinical w/ acute onset severe testicular pain, N/V, absent cremasteric reflex, testicular changes on PE
  • Dopper U/S: assess testicular blood flow and twisting of SC. Can be helpful but not necessary. In fact, may delay tx.
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37
Q

Tx for testicular torsion

A
  • Immediate: pediatric surgeon / urologist!
  • Surgical detorsion (w/in 4-6h preferred to preserve viability)
  • Nonviable testis: orchiectomy
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38
Q

What is gastroenteritis?

A
  • Infection or inflammation of digestive system
  • Clinical syndrome defined by 3+ loose or watery stools in 24h OR # of loose/watery BMs that exceeds usual BMs by 2+
  • W/or w/o vomiting or fever
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39
Q

Duration of gastroenteritis

A

Usually less than one week and not longer than 2

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40
Q

Common viral causes of gastroenteritis

A

Rotavirus (diarrhea), norovirus (vomiting), sapovirus, astrovirus, enteric adenovirus

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41
Q

S/S of viral gastroenteritis

A
  • N/V/D
  • Abdominal distension, tenderness, guarding
  • Indigestion
  • Decreased appetitie
  • Irritability
  • Lethargy
  • Muscle pain/HA
  • Pain: generalized or retroperitoneal
  • Throat or CP
  • Rhinorrhea, conjunctivitis
  • Cough: productive or dry
  • Respiratory distress, wheeze/apnea
  • Fever
42
Q

When to see NP for viral gastroenteritis

A
  • Age <6mo or weight <8kg (17lb 10oz)
  • Fever: >38C (100.4F) if <3mo; >39C (102.2F) >3mo
  • Visible blood in stool/melena (nonviral!)
  • Frequent substantial diarrhea
  • Diarrhea >7 days or persistent vomiting
  • Sx moderate to severe dehydration
  • Underlying immunodeficiency or complicating condition
43
Q

PE acute gastroenteritis

A
  • Weight for dehydration
  • Growth retardation for underlying condition
  • Vitals
  • Signs of dehydration (know these! Chart on slides 43-44)
  • Signs of other infections (ex. meningitis, pneumonia)
  • Abd pain, tenderness, distension
  • Hypoactive/absent bowel sounds
44
Q

Diagnostics gastroenteritis

A
  • Most kids don’t need testing
  • Severe FVD, atypical, or complicated presentation:
    • CMP w/glucose for underlying condition
    • CBC w/diff for anemia, hemolysis, infection
    • Stool culture
    • Urinalysis and urine culture
    • Chest x-ray, VBG or ABG if sxs severe
45
Q

Tx for viral gastroenteritis

A
  • Rest
  • Fluids (possible IVF)
  • Diet/nutrition – resume age-appropriate diet when rehydration complete
  • Can breastfeed during diarrhea
  • Oxygen as needed
  • Symptom management (antipyretics, NSAIDs, Magic mouthwash, antiemetics, probiotics PRN)
  • Immunizations – rotavirus
  • ·Return to school when vomiting and diarrhea cease for at least 24hrs
46
Q

Most common pathogens in UTI?

A
  • Most common bacterial cause of UTI is E. coli but other causes:
  • Gram neg: klebsiella, proteus, enterobacter, citrobacter
  • Gram pos: staph saprophyticus, enterococcus, staph aureus
47
Q

Red flags in UTI

A
  • Fever, chills, and flank pain → pyelonephritis
  • Though w/pyelo kids typically have a fever, can be difficult to distinguish w/cystitis in younger children <2yo
  • Should be evaluated promptly to avoid renal scarring!
48
Q

PMH and risk factors for UTI

A
  • Age: highest in boys <1yr and girls <4yrs
  • Uncircumsized males <1yr
  • Females
  • FHx UTI
  • Urinary obstruction
  • Bladder/bowel dysfunction, incl. behavioral
  • VUR – most common urologic anomaly
  • Bladder catherterization
49
Q

S/S of UTI in young children

A
  • fever
  • Hx UTI
  • Temp >40C
  • Suprapubic tenderness
  • Lack of circumcision
  • Fever >24hrs
50
Q

S/S of UTI in older children

A
  • fever
  • urinary sxs: dysuria, urgency, frequency, incontinence
  • macroscopic hematuria
  • abd pain
  • CVA tenderness
  • HTN
  • Poor wt gain, short stature
51
Q

PE for UTI

A
  • VS: T, BP, growth
  • And tenderness/suprapubic tenderness
  • Mass or palpable stool in colon
  • Enlarged bladder or kidney
  • CVA tenderness
  • Low back: myelomeningocele, tuft hair –> neurogenic bladder
52
Q

Diagnostics for UTI

A
  • UA, dipstick and/or microscopic eval and urine culture
  • Pyuria and bacteriuria on cx are necessary to make diagnosis
  • Findings:
    • Clean sample: >/= 100,000 bacteria
    • Catheter: >/= 50,000 uropathogenic bacteria or 10,000-50,000 in febrile children <24mo
    • Suprapubic sample – any uropathogenic bacteria
    • Pyuria – presence of WBC in urine not specific for UTI so repeat and send CX
  • Voidng cystourethrogram – presence and degree of VUR
  • Renal Bladder U/S – noninvasive. helps predict risk for renal scarring
53
Q

Methods to obtain urine catch on children

A
  • Infants/non-toilet trained: catheterization or suprapubic aspiration
  • Toilet trained: clean catch specimen
  • Quick point of care tests: dipstick analysis or microscopic exam
54
Q

When to hospitalize for UTI

A
  • Most infants >2mo w/UTI can be managed outpt w/close FU
  • Age <2mo
  • Clinical urosepsis (toxic appearance, hypotension, poor cap refill)
  • Immunocompromised pt
  • Vomiting/inability to tolerate PO meds
  • Lack of adequate FU (no phone, lives far from hospital)
  • Failure to respond to outpatient therapy
  • U/S: RBUS, VCUG
55
Q

Treatment for UTI

A
  • Empiric therapy: early and aggressive antibiotic therapy (w/in 72hrs) necessary to prevent renal damage
    • Initiate immediately after urine collection when suspected UTI and positive urinalysis
  • Cephalosporin is 1st line agent when no GU abnormalities: Cefixime, Cefdinir
  • Anti-inflammatory agents used in preventing renal scarring
56
Q

S/S of foreign body ingestion

A
  • often r/t the location of the foreign body
  • retrosternal pain, cyanosis, dysphagia
  • substernal chest pain more likely to have mucosal ulceration of esophagus
  • injury to esophageal mucosa, bleeding, stricture, obstruction
57
Q

foreign body ingestion on PE

A
  • Refusal of feeds or dysphagia
  • Drooling, vomiting
  • fever
  • Respiratory sxs incl expiratory wheezing, inspiratory stridor, choking
  • Long-standing esophageal foreign bodies may cause wt loss or recurrent aspiration pneumonias
  • Mucosal damage, strictures, erosion of esophagus à fistulas or perforation
  • Neck swelling
  • Crepitus
  • Pneumomediastinum
  • Erosion of the aorta has been reported à life-threatening bleeding
  • Bowel obstruction or perforation, Fecal retention mimicking appendicitis, GI bleed
58
Q

Dx of foreign body ingestion

A
  • Biplane radiographs (A/P and lateral) of neck/chest/abd
  • CT/ultrasonography
  • MRI
  • Handheld metal detector
  • Unnecessary if pt is asymptomatic and certain about type of foreign body (<2cm, not sharp or long, not magnet or battery)

*biplane view so will not miss!

59
Q

Tx for foreign body ingestion

A
  • Blunt foreign bodies: observe 12-24 hours
  • 24hrs or of unknown duration: remove promptly to avoid injury
  • methods:
    • flexible endoscopy
    • rigid endoscopy
    • magill forceps
    • foley catheter
    • penny pincher technique
60
Q

Causes to abdominal trauma

A
  • Inflicted, MVA, blunt injury, bike accidents, falls….
  • Consider medical conditions: autism, CP, hemophilia, antigoagulant/antiplt therapy, EB virus
61
Q

Most commonly injured organs on abdominal injury

A

spleen & liver

62
Q

PE for abdominal injury

A
  • Abnormality on abd PE should be considered indicator of intra-abdominal injury (IAI)
  • Negative exam/absence comorbidities doesn’t totally r/o IAI
  • Abd tenderness, ecchymosis, abrasions are positive findings for IAI
  • Abnormal urine analysis is highly sensitive screen of IAI
63
Q

Injuries / factors that predict abdominal trauma

A
  • femoral fracture
  • Low SBP
  • Decreased mental status
    • GCS <13 mild indicator IAI
    • GCS <10-23% had significant IAI
64
Q

Diagnostics for abdominal trauma

A
  • CT scan if: abd wall/low chest bruising, abd pain/tenderness, low BP (not shock)
    • May need serial xrays
  • If none of above, do U/S , UA, and bloodwork
    • CBC, PTT/PT, INR, look at BUN/Cr and glucose on CMP, LFTs, amylase, lipase
    • If U/S positive, hematuria >5 RBC, and AST/ALT >200/125 then CT scan
65
Q

Tx for abdominal trauma

A
  • Stabilization: fluid resuscitation, possible transfusion, surgical consult and hospitalization
  • Hemodynamically stable non-operative management: monitor CBC, LFTs, UA
    • If abnormal findings get CT scan w/contrast
66
Q

What is acute cholecystitis?

A
  • Inflammation of gallbladder most commonly d/t obstruction of cystic duct from cholelithiasis (gallstones)
  • Acalculous cholecystitis: during significant systemic illness, is acute necroinflammatory disease, high morbidity/mortality rate
67
Q

Complications of cholecystitis

A

perforation of gallbladder, peritonitis, and abscess formation

68
Q

S/S of cholecystitis

A

• pain in RUQ or epigastrium • pain may radiate to right shoulder or back • N/V • anorexia • fever • jaundice • positive Murphy sign

69
Q

Diagnostics for acute cholecystitis

A
  • U/S for stones and thickened gallbladder wall
    • Can produce positive murphys sign during procedure
  • Elevation of liver enzymes, esp gamma glutamyltranspeptidase (GGTP) and alkaline phosphatase
  • Elevated WBC
  • Elevated direct bili
  • The amylase value can be elevated which makes differentiation w/pancreatitis difficult
70
Q

Tx for cholecystitis

A
  • Bowel rest – NPO
  • IV pain control
  • IVF
  • Abx if fever or pt ill/toxic-appearing
  • The surgeon determines timing of curative cholecystectomy
71
Q

Cause of ovarian cysts

A

predisposing factors include early menarche, obesity, infertility, hypothyroidism

72
Q

S/S of ovarian cysts

A
  • menstrual irregularities
  • pelvic pain
  • increasing size of abd
  • dyspareunia
  • if large: urinary frequency, constipation, pelvic heaviness
  • rupture – intra-abdominal pain and bleeding
  • torsion – acute pain, n/v, pallor and left shift
  • most common in childbearing years
73
Q

PE for ovarian cysts

A

• Bloating/swelling in the abd • Pelvic pain during exam • May be asymptomatic

74
Q

Diagnostics for ovarian cysts

A
  • Ultrasound
  • CT scan
  • Doppler flow studies
  • Ca-125 to look for cancer w/abnormal u/s – most helpful in post-menopausal women
  • LH, FSH, estrogen, and testosterone levels
  • Serum HCG
75
Q

Tx for ovarian cysts

A
  • Functional: usually no tx and self resolve in 8-12weeks
  • OCPs can be used to reduce the risk of new cysts (don’t work on current cysts)
  • Surgery – exploratory laparotomy or pelvic laproscopy
  • Cysts in premenopausal women more likely to go away
  • Refer to gyn if any of the following present: ascited, evidence of mets, FDR w/ovarian or breast CA
76
Q

Causes of perforated ulcer

A
  • Hx of peptic ulcer disease
  • Hx of NSAID use
  • Persistent H. pylori
  • Rare:
    • Crohn’s disease
    • Sarcoid
    • Lymphoma
    • Ischemia
    • TB
    • Syphilis
77
Q

S/S of perforated ulcer

A
  • severe, diffuse abd pain that can cause syncope d/t severity
  • pain often epigastric at first, then generalized pain worse w/movement
  • board-like rigidity (2-12hrs after onset)
  • cool extremities
  • low temperature
  • increasing abd distention + now high temp (>12hrs after onset)
78
Q

PE for perforated ulcer

A
  • Low temperature
  • Decreased liver dullness when percussed d/t air
  • Abd rigidity
  • Pain may radiate to both shoulders
  • Pelvic peritoneum on exam is often tender
79
Q

Diagnostics for perforated ulcer

A
  • Upper endoscopy w/biopsy to exclude underlying malignancy and other causes of ulceration
  • If H. pylori negative on gastric biopsy, get additional testing to r/o:
    • Stool antigen
    • Urea breath test
80
Q

Tx for perforated ulcer

A
  • Insert NG tube
  • IVF
  • IV PPI (helps stop bleeding, promotes healing of ulcers, enhances fibrin formation)
  • Broad spectrum antibiotics
  • Possible surgery
81
Q

Hepatitis A: cause

A
  • A is for ass.
  • Fecal-oral, lack of sanitary conditions, unvaccinated
82
Q

S/S hep A

A
  • acute onset and sometimes nonspecific symptoms
  • fever
  • malaise
  • anorexia
  • n/v/d
  • HAV often more severe when at older age
83
Q

PE Hep A

A
  • Fever
  • Jaundice (one week after onset of sxs)
  • Choluria (bili in the urine)
  • Mild hepatomegaly
84
Q

Diagnostics for Hep A

A
  • Incubation period is usually 15-45days
  • Detection of anti-HAV IgM in a pt w/typical clinical presentation (gold standard)
    • Positive at onset of sxs
    • Peaks during acute/early convalescent stage
    • Remains active from 4-6mos
    • Serologic detection of antibodies in stool/body fluid by electron microscopy is also available and cheaper
85
Q

Tx for Hep A

A
  • Supportive Tx for fever, diarrhea
  • Usually self-limited and minor
  • No diet has a major impact on outcomes
  • Should not return to school until 1wk after onset of illness
86
Q

Appendicitis: S/S

A
  • dull periumbilical pain (early) that migrates to RLQ (often w/in 24hrs of onset of sxs)
  • anorexia
  • vomiting (typically after onset of pain)
  • fever 24-48hrs after onset of sxs
  • RLQ tenderness
  • Signs of localized or generalized peritoneal irritation incl:
    • Involuntary muscle guarding w/abd palpation
    • Positive Rovsing sign (pain in RLQ w/palpation of left side)
    • Obturators sign (pain on flexion and internal rotation of right hip)
    • Iliopsoas sign (pain on extension of right hip)
    • Rebound tenderness (elicited w/steady pressure in RLQ for 10-15seconds and then releasing pressure – pain on removal of hand)
  • 44% of children present with atypical findings!!
  • Can utilize Pediatric Appendicitis Score
87
Q

Abdominal pain: indicators it’s appendicitis

A

FEVER – presence increases, absence decreases

Rebound tenderness: triples odds

Mid-abdominal pain migrating to RLQ more than RLQ alone

Normal WBC and neutrophils decrease likelihood

88
Q

Diagnostics for appendicitis

A
  • CBC w/diff
    • Elevated WBC (>12,000) increases odds of appendicitis
    • ANC
  • CRP
  • Ultrasound!
  • Though not all appendices >6mm if AA, U/S has high predictive value for AA
    • Combined with increased WBC and left shift, probability >99%
89
Q

Tx for appendicitis

A
  • Antibiotics
    • Historically: ampicillin, gentamicin, clindamycin
    • Piperacillin/tazobactam (zosyn) and cefoxitin (Mefoxin) also efficacious
    • Tx duration determined by presence of perforation (risk increases w/delay in recognition and surgery)
  • Surgery
90
Q

Does conservative tx for AA work?

A
  • Yes! If early and uncomplicated
  • conservative Tx with antibiotics only and observation for improvement may be sufficient and have no negative impact if surgery is needed later on
    • Can also alleviate need for general anesthesia and surgery
    • Perforated appendix in childhood does not seem to impact female fertility
  • When there is acute inflammation of the appendix (associated with obstruction) antibiotics may help relieve this kind of obstruction
91
Q

What is Hirschsprung disease?

A
  • motor disorder of the gut! Incomplete neural development = functional obstruction. typically in rectosigmoid colon
  • More specifically:
    • failure of neural crest cells (precursors of enteric ganglion cells) to migrate completely during intestinal development. = aganglionic segment of the colon fails to relax à functional obstruction
92
Q

Syndromes associated with Hirschsprung disease?

A

chromosomal anomalies, especially Down syndrome

93
Q

S/S of Hirschsprung disease

A
  • Usually in neonatal period!
  • bilious emesis, abdominal distension, and failure to pass meconium or stool in first 48h of life (though passage does not exclude dx)
  • possible enterocolitis: sepsis-like picture with fever, vomiting, diarrhea, and abdominal distension, which can progress to toxic megacolon
  • if small secition, may be dxed later: hx chronic constipation, failure to thrive
94
Q

Indications for testing for Hirschsprung Dz

A

Any neonate with symptoms of fever, vomiting, abdominal distension, and explosive diarrhea (enterocolitis)

Suspected in:

• Symptoms of obstruction, including bilious emesis, abdominal distension, and failure to pass stool.

●Failure to pass meconium within 48 hours of birth.

●Constipation and trisomy 21 (Down syndrome) or other condition known to be associated with HD, or a family history of HD.

●Constipation and physical examination suggestive of HD (abdominal distension, tight anal sphincter, or squirt sign on digital examination).

95
Q

Dx of Hirschsprung Dz

A

Based on clinical features, supported by contrast enema, anorectal manometry, abdominal radiograph (only use to r/o if v. low suspicion of dz)

Gold standard to establish Dx: rectal biopsy

96
Q

Tx for Hirschsprung Dz

A

Surgery

97
Q

What is Meckel’s diverticulum?

A

most common congenital anomaly of GI tract

incomplete obliteration of viteline duct –> formation of a true diverticulum of small intestine

98
Q

S/S of Meckel’s

A
  • Often asymptomatic, discovered incidentally
  • Symptomatic:
    • abdominal pain
    • GI bleeding (acute or insidious)
    • sx bowel obstruction
  • Suspect if: painless lower GI bleeding, recurrent intussusception, Sx acute appendicitis, esp if appendix removed.
  • Suspect in
99
Q

Diagnosis of Meckel’s diverticulum

A
  • Meckel’s scan, mesenteric arteriography, or abdominal exploration
  • Very difficult to distinguish from appendicitis!
100
Q

Tx Meckel’s diverticulum

A
  • Incidental finding: observe
  • Asymptomatic on abdominal exploration: resect
  • Manage complications: GIB, fluid loss, acid (PPIs)

FALL15 N833 Adv Pedi Probs (10 decks)

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