Mesenteric Adenitis

Question 1

What is your impression and goals of management?

*How is the approach different to an adult?

A 12-year-old boy presents to ED with abdominal pain. He has a history of a viral illness.

Answer 1

Impression: Mesenteric adenitis, given the history of viral illness. The most common causes of which include viral (adenovirus, coxsackie, EBV), bacterial (yersinia enterocolitica, GAS pharyngitis, staph aureus, E. coli), medical (IBD, lymphoma).

Differentials

• Acute abdomen → acute appendicitis, pancreatitis, cholecystitis
• Primary infective causes → UTI, gastroenteritis, pneumonia, EBV
• Other → constipation, testicular torsion, DKA

Goals

1. Conduct a rapid bedside assessment using the PAT for general impression of the patient, followed by an A-E assessment to ensure the child is HD stable
2. Take a targeted history, examination and investigations e.g. abdo U/S to confirm the diagnosis and exclude differentials including appendicitis
3. Manage accordingly, mainly with supportive care e.g. hydration, analgesia

Differences in approach to adults

• Differentials are different based on age
• In children often rely on parental history
• Imaging modality U/S in paeds, CT abdo in adults (exclude malignancy)

Question 2

Mesenteric adenitis: history

Answer 2

History

• Classic presentation → pain RLQ/poorly localised, episodic, severe
• Associated symptoms → fever, malaise, diarrhoea, anorexia, N/V, bowel changes
• Screen for peritonism (appendicitis) → car ride painful? Does it hurt to cough?
• Risk factors → recent infectious contacts/viral illness, history of IBD or lymphoma
• Targeted history to rule out differentials → appendicitis, pancreatitis, IBD (blood in stool, change in bowel habit, extra-articular manifestations), gastroenteritis, EBV (swollen lymph nodes), UTI (dysuria, frequency), lower lobe pneumonia (resp symptoms), DKA (vague abdominal pain), S/LBO (vomiting, distension, constipation, pain), testicular torsion (sudden onset loin-groin pain, recent trauma)
• Paediatric history → PMH, surgical hx, FH, developmental hx, vaccinations, allergies

Question 3

Mesenteric adenitis: examination

Answer 3

Initial assessment:

• Paediatric Assessment Triangle → screen for shock
• ABCDE
  
  • Concerns → sepsis, DKA, testicular torsion
  • Circulation → HR/BP/cap refill + IV access (VBG, EUC, BSL)
  • ± fluid resus (NS 20mL/kg IV bolus) if required
  • D → AVPU, GCS, PEARL
  • E → testicular torsion

Examination

• Vitals and fluid status → fever, hypotension & tachycardia (sepsis)
• Growth parameters, developmental milestones
• ENT → concomitant erythematous pharynx, cervical lymphadenopathy
• Abdominal examination
  
  • Mesenteric adenitis → poorly localised/RLQ tenderness ± rebound tenderness
  • Appendicitis → peritonism + signs (McBurney’s, Rovsing’s, psoas)
  • Exclude abdo masses, distension, palpable faeces, peritonism
• Scrotal → exclude torsion (tenderness, horizontal lie)

Question 4

Mesenteric adenitis: investigations

Answer 4

Investigations

Most children need no investigations

• Bedside → BGL (DKA), UA (UTI, DKA)
• Bloods → FBC, CRP, EUC, lipase
• Imaging
  
  • Abdominal ultrasound → 3+ LN >8mm (usually RLQ), exclude appendicitis
  • Consider CT abdo with IV contrast (if U/S inconclusive)

Question 5

Mesenteric adenitis: management

Answer 5

Supportive

• Fluid resuscitation + electrolyte replacement as required
• Analgesia → NSAIDs, IV morphine, intranasal fentanyl (if severe)
• Monitor and treat complications → suppuration and abscess, intussusception, rupture ± peritonitis

Disposition

• Keep NBM and refer for surgical review
• Discharge when there are no concerning clinical features, follow-up plan has been arranged with GP and parental education given regarding when to seek medical attention (increasing pain, fevers, new symptomatology)