APPROACH TO ABDOMINAL PAIN

Question 1

Approach to the Critically Ill Abdominal Pain

Answer 1

C - Fluid bolus 20 ml / kg NS

Maintenance Fluid
4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 10-20 kg
1 cc/kg/hr for every kg > 20 kg

D5 NS

KCl @ 0.5 mEq/kg/hr IV

Serum potassium <3mEq/L give total of 1 mEq/kg (up to adult dose)
Serum potassium 3-3.5 mEq/L give 0.2 mEq/kg and recheck

Obtain i-STAT labs, including glucose.

Analgesia:
morphine 0.05-0.1 mg/kg IV
OR
fentanyl 1 μg/kg IV

Ondansetron:
2 mg < 15 kg
4 mg > 15 kg
8 mg > 30 kg

Ceftriaxone:
50 mg/kg intravenous or intramuscular every 12 hours (max 2000 mg)
PLUS
Metronidazole:
10 mg/kg intravenous every 8 hours (max 500 mg)

Pip-Tazo:
Age 2 months to 9 months: 80 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose: 3000 mg piperacillin)
Age >9 months, children, and adolescents weighing <40 kg: 100 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose: 3000 mg piperacillin)
Children and adolescents weighing >40 kg: 3000 mg piperacillin intravenous every 6 hours

Early Surgical Consultation

Question 2

History & Physical

Answer 2

Ask About:

Colicky (intussusception) vs. None

Timing - Preceeding URTI (HSP), Diarrhea (intussusception), gradual onset with migration

Associated fever, rash, diarrhea, vomit (bilious)

Hydration inculding urine output

Always examin throat, lungs, genitals

Question 3

Red Flags

Answer 3

Bilious Emesis
Lethargy
Severe pain or irritability
Peritoneal Signs
Abdominal Distension
Signs of sepsis
Inconsistent History

Question 4

Surgical DDx: Neonates to 3 months with ASx

Answer 4

Malrotation with volvulus - bilious vomiting

Hirschsprung’s Enterocolitis - Abdominal distension, diarrhea

Pyloric Stenosis - non-bilious projectile vomit

Nectrotizing enterocolitis - vomiting, abdominal distension

Incarcerated Hernia

Duodenal Atresia

Testicular or Ovarian Torsion

Question 5

Medical DDx: Neonate to 3 months

Answer 5

Constipation
Colic
Omphalitis - Erythema of umbilicus
Reflux

Question 6

Surgical DDx: 3 months to 3 years old with ASx

Answer 6

Malrotation with volvulus - bilious vomiting

Hypertrophic pyloric stenosis - projectile non bilious vomit

Meckel’s diverticulum - rectal bleeding or bilious vomiting

Intussusception- vomiting, colickly abdominal pain listless

Appendicitis - vomiting, anorexia, fussiness

Incarcerated inguinal hernia - inguinal mass, vomiting

Testicular or ovarian torsion

Question 7

Medical DDx: 3 months - 3 years

Answer 7

Anaphylaxis

Henoch-Schonlein Purpura

UTI

Caustic Ingestion
Acute Gastroenteritis
Constipation
Mesenteric Adenitis
Ileus

Sickle Cell-related vaso-occlusive crisis

Question 8

Surgical DDx: 3 years old - adolescence

Answer 8

Appendicitis
Cholecystitis
Testicular torsion
Ovarian torsion
Ectopic
Malignancy

Testicular torsion

Question 9

Medical DDx: 3 years old - adolescence

Answer 9

Anaphylaxis

Henoch-Schönlein purpura*

Diabetic ketoacidosis

Pancreatitis
Constipation
Acute gastroenteritis
Mesenteric adenitis
Inflammatory bowel disease
Irritable bowel disease
Functional abdominal pain
Gastritis/gastric ulcer

Urinary tract infection
Renal stones

Strep pharyngitis
Pneumonia

Ovarian cyst
Pregnancy
Pelvic inflammatory disease

Toxic ingestion

Question 10

Investigations

Answer 10

CBC
Lytes
LFT’s
Lipase
CRP
UA

Abdominal Ultrasound

Abdominal XRAY: supine and upright / lateral decubitus r/o obstruction and free air

Upper GI Series: volvulus

Question 11

Initial Management

Answer 11

Bolus crystalloid 20 ml / kg

NPO

Empiric Abx:
Ceftriaxone 50 mg/kg intravenous or intramuscular every 12 hours (maximum dose 2000 mg) PLUS
Metronidazole 10 mg/kg intravenous every 8 hours (maximum dose 500 mg) or
Piperacillin-tazobactam 112.5 mg/kg (100 mg piperacillin/12.5 mg tazobactam) intravenous every 8 hours (maximum dose 3.375 g)