What is the problem? 11/27/20141ped.emergency.Dr.Alsaif

ped.emergency.Dr.Alsaif 1

What is the problem?

11/27/2014


Clinical scenario

A 5 year old girl brought by her mother to emergency room with 3 days history of abdominal pain and one episode of vomiting before arrival to the hospital.

How to approach to diagnosis?

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Anatomic origin of pain

The classic division of abdomen:

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Anatomic origin of pain Abdomen is divided into 9 regions: 2 vertical lines (RT&LT midclavicular) 2 horizontal lines (subcostal and intertubercular)

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History Place/Location ask child to use one finger to locate the

pain. Quality: pain can be a sharp stabbing pain (i.e. trauma)

or diffuse, poorly, localized pain (i.e. chronic or visceral pain).

Radiation: pain can radiate from its point of origin in any direction.

Severity: degree of pain on a scale of 10 Timing/Onset: onset of the pain, duration of pain,

course during the day, does it wake them at night, and the frequency of episodes.

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History

Alleviating Factors: Anything that reduces the pain like body position, movements ,medications. Aggravating Factors: Anything that increases the pain like body position, movements, relation to food intake. Associated Symptoms: Hematemesis, vomiting, nausea, melena, diarrhea,

fever, and weight loss.

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Associated symptoms for abdominal painAssociated Symptom Relevance

Diarrhea Gastroenteritis, Protein losing enteropathy

Bloody stool Ulcerative colitis, necrotizing enterocolitis, dysentery, constipation

Hematemesis Peptic Ulcer Disease, Gastritis

Bilious emesis Small bowel obstruction

Jaundice Hepatitis or Biliary obstruction

Joint pain/swelling IBD, HSP

Skin Lesions IBD, HSP, Liver disease

Testicular pain Testicular torsion

Dysuria/polyuria/hematuria Urinary tract infection/Pyelonephritis

Vaginal/Penile discharge STI

Dysmenorrhea Endometriosis

Shortness of breath Pneumonia or empyema


History

Ask about: Bowel movement patterns and stool quality

(size, hard/soft, odour). Ingestion of toxin or foreign object accidental

or non-accidental trauma. Dietary history: in young children, too much

milk can lead to constipation.

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History

Ask about: Past medical history and medical illness:

Cystic fibrosis predisposes to gallstones.Spina bifida/cerebral palsy/developmental delay

predisposes to constipation.Sickle cell disease predisposes to splenic auto-

infarction.Recurrent respiratory tract infections suggest

mesenteric adenitis.

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History

Ask about: Family medical history, especially

inflammatory bowel disease. Travel history, social and psychiatric (potential

stressors) history.

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Physical exam

General exam: ABCDE Including vital signs and growth parameters, is there evidence of failure to thrive?. Inspection: Iook for contour, symmetry, pulsations,

peristalsis, skin markings, wall protrusions (hernias), any signs of trauma (ie. bruising, swelling), and abdominal distension.

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Physical exam

Auscultation: Auscultate before palpation in the abdominal

exam. Iisten for bowel sounds, abdominal bruits. Pressure

of the stethoscope also tests for tenderness. Percussion: (tympanic vs non-tympanic). Percuss for liver span and spleen tip. Assess for ascites.

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Physical exam

Palpation: Tenderness with light and deep palpation. Guarding and rebound tenderness Palpate for liver, spleen, kidney and abdominal

masses (including fecal mass).

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Physical exam

Digital rectal exam: First exam the anus for fissures and skin tags.

Then assess for tone, stool, and blood. Special Tests: There are a number of special tests for each

differential diagnosis.

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findings on physical exam for common differential diagnoses

Medical Condition Findings on Physical Exam

Constipation Abdominal tenderness, palpable fecal mass, look for imperforate anus or stenosis, spina bifida, developmental delay, cerebral palsy

Acute appendicitis Patient avoids movement, rebound tenderness, McBurney sign (pain at 2/3 between umbilicus and right ASIS), Rovsing sign (pain in right lower quadrant on left-sided palpation), Psoas sign (pain in right lower quadrant when child on left and right hip hyperextended), obturator sign (pain in right lower quadrant on internal rotation of flexed right thigh)

Gastroenteritis Diffuse pain with no rebound tenderness, abdominal distension, hyperactive bowel sounds

Irritable bowel syndrome Periumbilical tenderness, no rebound tenderness

Trauma Signs of bruising and tenderness

Celiac Disease Growth failure, distended abdomen, diffuse abdominal tenderness.

Inflammatory bowel disease Appears thin, abdominal tenderness, anal skin tags, possible sign of bloody stool on DRE, examine for skin lesions (erythema nodosum, pyoderma gangrenosum), iritis, and joint inflammation

Urinary tract infection Fever, suprapubic and costovertebral angle tenderness, irritability, foul-smeling urine, gross hematuria

Primary dysmenorrhea Lower abdominal tenderness

Pneumonia and Empyema Tachypnea, cyanosis, decreased breath sounds, crackles and rales, dullness on percussion, febrile


Associated Signs

Jaundice suggests hemolysis or liver disease. Pallor and jaundice point to sickle cell crisis. Psoas & Obturator test If positive: Inflamed retrocecal appendix Ruptured appendix or Iliopsoas abscess.

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Associated Signs

Murphy's sign: (interruption of deep inspiration by pain when

the physician's fingers are pressed beneath the right costal margin).

Suggests acute cholecystitis.

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Associated Signs

Cullen's sign (bluish umbilicus) Grey Turner's sign (discoloration in the flank)

Unusual signs of internal hemorrhage.

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Associated Signs

Purpura and arthritis: Henoch-Schönlein purpura

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Laboratory investigations for common differential diagnoses

Medical Condition Relevant Diagnostic Tests

Constipation None if history does not suggest an alternative diagnosis.

Acute appendicitis CBC (WBC normal or elevated), urinalysis, urine pregnancy

Gastroenteritis Serum electrolytes, stool culture, stool for virology

Irritable bowel syndrome None, based on history and clinical findings

Trauma CBC for blood loss, abdominal CT with contrast

Celiac Disease IgA

Inflammatory Bowel Disease CBC, ESR/CRP, electrolytes, albumin, LFTs, Bilirubin, Stool culture, AXR

Urinary tract infection Urine dipstick (for leukocyte esterase and nitrite), urine microscopy, urine culture (best if suprapubic aspirate)

Primary dysmenorrhea None, based on history and clinical findings

Pneumonia and Empyema CBC, Chest x-ray, sputum culture


Red flags in abdominal pain

Certain historical and examination findings should raise ‘‘red flags’’ that a severe life-threatening underlying abdominal process is present and prompt early triage to an emergency department.

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History Inability to maintain po intake Projectile vomiting Overt gastrointestinal blood loss Syncope Pregnancy Recent surgery or endoscopic procedure Fever Caustic or foreign body ingestion11/27/2014



Physical examination Pathologic changes in vital signs Bloody, melenic stool Hernia (incarcerated and tender) Hypoxia Cyanosis Change in level of consciousness Jaundice Peritoneal signs Abdominal pain out of proportion to examination11/27/2014



Laboratory results Renal failure Metabolic acidosis Leukocytosis Elevated transaminases Elevated alkaline phosphatase and bilirubin Anemia or polycythemia Hyperlipasemia/hyperamylasemia Hyperglycemia/hypoglycemia11/27/2014



Radiography Abdominal free air Gallbladder wall thickening Pericholecystic fluid Dilated biliary tree Bowel obstruction Dilated small bowel loops ± air fluid levels Intra-abdominal abscess Bowel wall thickening Air in the portal venous system Pneumatosis intestinalis

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Indications for Surgical Consultations

Severe or increasing abdominal pain with progressive signs of deterioration

Bile-stained or feculent vomitus Involuntary abdominal guarding/rigidity Rebound abdominal tenderness Marked abdominal distension with diffuse tympany Signs of acute fluid or blood loss into the abdomen Significant abdominal trauma Suspected surgical cause for the pain Abdominal pain without an obvious etiology11/27/2014

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What is the problem? 11/27/20141ped.emergency.Dr.Alsaif