Pediatric Abd Flashcards
Abd pain is one of the most common reasons for a visit to the ED, are most causes benign or malignant?
Benign
What are some reassuring signs/sx of abd pain?
Frequent watery diarrhea
Normal appetite
Fever onset before pain
The “JUMP TEST”
Is fever an early or a late finding in appendicitis?
Late
Beware of vomiting (with/without) diarrhea, why?
without; could be head trauma, UTI, pregnancy, or SBO
If your patient is an adolescent female c/o abd pain, what should you always order?
urine pregnancy test
Where should you always examine in male patients with abd pain? Why?
the groin
Could be referred pain from epididymitis or testicular pain or penile discharge
What are some potential causes of referred abd pain? (hint: think chest or other infxn)
lower lobe PNA (can refer pain or mimic appendicitis) or GAS infxn (generalized achy abd pain)
If a pt has _______ they will usually present c/o vomiting with diarrhea
stomach virus
T/F Bilious emesis in a neonate is a surgical emergency until proven otherwise
True
If an infant pt presents with blood in the stool and is ill appearing, what condition may they be presenting with?
intussusception
Pain before vomiting is classic for what abd pain complaint/condition?
appendicitis
If a pt presents with focal involuntary guarding, what is this considered?
an abd emergency
Is intussusception an abd emergency?
yes
If a pt has a SBO or volvulus, they may present c/o ____ and ____ _____
vomiting and abd distension
If a pt presents with bilious vomiting, what color is it? What condition might this complaint indicate?
green; obstruction
The following abd emergencies are common in what age group? Malrotation w/ volvulus Necrotizing Enterocolitis (NEC) Intestinal atresias/stenosis Hirschsprung disease (no stooling)
Neonates
If a pt presents with pyloric stenosis what type of vomiting will they have? What color? What age range is typical?
Projectile, non-bilious vomiting, 1-2 months old
If a pt presents with intussusception, how might their abd be described? What may they be doing with their legs? What is the typical age range?
Colicky abd pain, draw up legs, 6-10 months old
In adolescent females c/o abd pain, what abd emergencies are we concerned about?
Ectopic pregnancy Ovarian cyst/torsion Appendicitis STD/PID Tubo ovarian abscess
In preschool age range patients c/o abd pain, what abd emergencies should be considered as causes?
Appendicitis Intussusception Testicular/ovarian torsion Incarcerated hernia Non Accidental Trauma (NAT) w/blunt abdominal trauma
What medical condition is described as an “abnormal rotation of mesentery during embryonic development” where the cecum is in the mid-abdomen and is fixated to the right lateral wall by bands of peritoneum? What can this condition result in?
Intestinal Malrotation
Midgut suspended on narrow pedicle vs wide mesentery
Intestines can twist around the narrow pedicle resulting in volvulus
Can a pt with malrotation and volvulus have a normal PE?
Yes
What may be seen on XR of a pt with malrotation and volvulus?
Lack of distal bowel gas, without even distribution of gas throughout the belly
What is the diagnostic study of choice for a pt suspected to have malrotation and volvulus? What will be seen upon inspection of imaging result?
Upper GI series is study of choice
Trace contrast passes in corkscrew configuration and abnormal position of duodenum will be seen
What is the suggested management for a patient with malrotation and volvulus?
IV fluid resuscitation NG tube to intermittent suction Call surgeon Upper GI series Laparotomy
A patient in opioid withdrawal may present with constricted pupils. Why may a pt with intussusception also present with constricted pupils?
Pt is in so much pain, causing endogenous release of opioid-withdrawal chemicals in the body
In a pt with intussusception, what signs may be seen on XR to help confirm your dx?
intestinal obstruction with distended loops of bowel, absence of colonic gas
May also see characteristic target sign and or crescent sign
On US, a very nearly 100% sensitive and specific test for intussusception, what may be seen?
Classic image is “bull’s eye” or “coiled spring” representing layers of intestine within the intestine
What is the most common abd emergency in early childhood?
intussusception
80% of intussusception cases occur in pts ___ y/o
<2 y/o
____% of pts have viral illness symptoms before onset of intussusception
30%
Viral infections can accentuate ____ tissue in intestines
lymphatic
Hypertrophy of Peyer patches in terminal ileum can serve as ______ in pts with intussusception
lead point
What are Peyer patches?
Small masses of lymphatictissue found throughout the ileum region of SI
Where does intussusception most frequently occur?
ileocecal junction
Children ____ y/o more likely to have pathologic lead point identified
> 5 y/o
What is the classic triad of intussusception?
Classic triad of pain, palpable sausage shaped mass, currant jelly stools (occurs < 15% of the time)
Blood in stools is a (late/early) finding that indicates what has happened?
Late; Ischemia of the intestines
What is the most important intervention in the management of intussusception?
Resuscitate with IVF (NS bolus)
If a pt with intussusception is vomiting frequently, how should you decompress the stomach?
If frequent vomiting, decompress stomach with NGT
You should consider IV abx if you are concerned for what possible complication of intussusception?
Perforation
After you have ruled out any possibility of perforation, what procedure can be performed to tx intussusception?
Air enema reduction
Air enema reduction has a success rate of ___-___% in ileo-colic intussusception
75-90%
What are potential complications of performing an air enema?
Prolonged symptoms (> 3 days)
Signs of peritonitis
Evidence of free air on plain XR
When is surgery indicated in patients with intussusception?
When nonoperative reduction fails or is incomplete
T/F Manual reduction is performed in most cases of surgical intussusception
True
When should resection with primary anastomosis be performed?
Manual reduction fails
Concern for necrotic bowel
Lead point is identified
Is recurrence of intussusception an indication for surgery?
No
T/F Each recurrence of intussusception is handled as if it is the first episode, and the provider will attempt air enema again
True
The recurrence rates of intussusception are as follows:
__-__% after non-operative reduction
__-__% after manual reduction
___% after resection
5-10%
1-3%
<1%
What labs and imaging are recommended in the workup of a pt with suspected appendicitis?
None
Imaging is not necessary for classic presentation, but may be useful for equivocal presentations
An inflamed appendix next to the bladder can cause WBC in urine, which would mimic what other condition/dx?
UTI
What imaging studies should be considered in sexually active adolescent females prior to CT?
Consider pelvic US
What are the advantages of US over CT?
Quick, easy, no radiation
What are the disadvantages of US when compared to CT?
Operator dependent, difficulty to visualize in obese patients or if aberrant location, overlying gas
How do you manage appendicitis in the ED?
Obtain IV access, administer IVF and IV pain medication and anti-emetics (odansetron in pediatric population)
and IV antibiotics (Zosyn if concern for perforation, otherwise Ancef)
Elevated WBC with left shift could indicate what clinical condition?
appendicitis!
A 16 y/o F pt presents to the ED c/o sudden onset of unilateral lower abdominal pain on the right side with associated N/V. She denies fever and dysuria. What do you suspect she has?
This is the classic presentation for ovarian torsion
T/F Ovarian torsion can occur at any age
True
Ovarian torsion accounts for up to ___% of all cases of abdominal pain in children
2.7%
Approximately ___% women are pregnant when diagnosed w/ ovarian torsion
20%
Ovarian torsion impairs _____ & ____ outflow from the ovary, while ____ inflow persists
Venous and lymphatic; arterial
Ovarian torsion is most frequent during what stage in life?
Reproductive years
On what side, right or left, does ovarian torsion most commonly present on?
R>L 3:2
T/F Prolonged symptoms does not preclude possible ovarian salvage
T
T/F Ovarian torsion may be intermittent
T
Fever before pain is (more/less) likely surgical in nature
Less
What are some potential red flags for children with abd pain?
Bilious emesis Vomiting w/ abdominal distention Blood in stool of ill appearing infant Pain before vomiting Focal abdominal pain Involuntary guarding
