Evaluation of the Acute Acute Abdomen • 10% of emergency room visits • 40% d/c with diagnoses: unknown etiology Melissa Whitmill, M.D. • 60% d/c with wrong diagnoses Assistant Professor of Clinical • Acute vs. chronic pathology The Ohio State University • Atypical presentations most difficult

The Acute Abdomen Pathophysiology of Pain • Somatic Pain • Any Abrupt Onset of significant abdominal 9 Segmental spinal nerves pain 9 Pressure, inflammation, distention • Requires urgent decision, diagnoses, and treatment • Visceral pain • Treatment is often surgical 9 Sympathetic, parasympathetic or somatic • Diagnoses often unclear, but treatment must be appropriate • Referred Pain 9 IE Kehr’s sign

1 Patient Evaluation Associated Symptoms • History of Present Illness • , • Pain description, Assoc sxs, gyn/gu hx • Fever, chills • PMHx, Fam hx, Soc Hx • Anorexia, Weight loss • PE • Food intolerance • Special Abdominal Focus • Constitutional symptoms • Work up: Basic then Advanced • Change in Bowel habits • “When you hear hooves its horses!” • GU symptoms

Description of Pain Gynecological / GU Symptoms • Onset and duration • Character and severity • Last Menses • Location and radiation • Sexual History/ Contraception • Obstetric History • What makes it better/ What makes it worse • Vaginal Discharge/ pain • Progression of Pain • Dysuria, frequency • Associated Symptoms • Pneumaturia, hematuria

2 Past Medical History Physical Exam • General Appearance • Previous GI disease or treatment • Vital Signs • Cardiac or Pulmonary Disease • HEENT • Medications • Chest/CV • Other Systemic Illnesses • Abdomen (Look, Listen, Feel) • Recent Unassociated Illnesses • Gyn / rectal / GU • Trauma • Extremities / neuro/psych

Family and Social Abdominal exam: History LOOK • Gastrointestinal Disease (ie IBD) • Distention • Other familial Disorders • Breathing, splinting • Cancer • Travel • Discoloration • Environmental Exposure (include food) • Scars • Drugs and Alcohol • • Illness of household contacts

3 Abdominal exam: Work up: Basics LISTEN • Percussion • CBC, Lytes, UA • Auscultation • Abd Xrays (KUB, CXR, upright) • Bowel Sounds • other labs: Amylase, LFT’s, HCG 9 Presence 9 Character • EKG 9 Frequency

Abdominal exam: Workup: Advanced

FEEL • Ultrasound: Pelvis/RUQ • Localized tenderness • Abdominal vs. flank or CVA • Computerized Tomography • Masses • NG tube (also may be treatment) • • Endoscopy, UGI, contrast enema • • Peritoneal Signs • Laparoscopy and laparotomy 9 Guarding, rebound, referred rebound

4 Etiology • Appendicitis • Mesenteric • History: periumbilical pain migrates to RLQ • • IBD anorexia, short time course • • • Exam: tenderness in RLQ, -pelvic, • Perforated ulcer • PID Rovsing’s sign, Psoas, obturator, referred • • Gastroenteritis rebound • Perforated bowel • Nephrolithiasis • CT or US may be helpful •

Other Causes Appendicitis

• • DM ketoacidosis • Cholangitis • Uremia • Pneumonia • Hypercalcemia • MI • porphyria • Ovarian pathology • intussusception • Hepatitis • lupus • • HIV • Others

5 Small Bowel Obstruction Perforated Ulcer • History of surgery--adhesions • Crampy pain, vomiting, obstipation • History: PUD, NSAID’s, other illness • Xrays often diagnostic • Free air on Abd Xray • Causes: • Generalized 9 Adhesions • Most patients have no previous ulcer 9 Hernia history 9 Neoplasm 9 Intussusception

Small Bowel Obstruction Free Air

6 Diverticulitis Pancreatitis

• History: , LLQ pain,fever, • History: gallstones, ETOH , pain radiating prev hx of diverticulitis. to back • Exam: LLQ tenderness, +/- • Exam: Generalized tenderness, ?peritonitis • CT is diagnostic • Amylase elevated (>200-5000) • Mostly non operative Rx, • False elevations in SBO, perforation, • Surgery for perf, free fluid, antibiotic failure ectopic, parotitis, • Abscesses need drained ( by CT) • US for stones, CT to evaluate panc

Diverticulitis Pancreatitis

7 Cholecystitis Gastroenteritis

• History: post prandial RUQ pain, recurrent episodes, ~30% present with acute attack • History: Widely varied, diarrhea, vomiting, crampy pain, not localized, household • Exam: RUQ tenderness, +/- , fever, contacts, previous history Murphy’s sign • Exam: +/- fevers, diffuse tenderness, tender • Labs: amylase, LFT’s, WBC, lytes but not peritonitis, • US: stones, thickened GB wall, Fluid • RX: IVF, bowel rest, observation • RX: , antibiotics

Cholecystitis Pelvic Inflammatory Disease • History: sexually active women, previous STD, vag discharge, dysuria • Exam: Cervical motion tenderness,vag discharge, +\- adnexal mass( R\O TOA) • Labs: WBC, UA, HCG • US may be helpful • IV antibiotics, observation

8 Mesenteric Ischemia Ectopic Pregnancy

• History: Pregnant, menstrual • History: chronic intestinal ischemia, irregularity,complete sexual history cardiac arrhythmias, ASCVD, smoking, low flow, hypercoagulable state. • Exam: , Adnexal mass, LQ tenderness • Exam: Pain out of proportion to exam. • Labs: WBC, amylase, lactate • Labs: Pos. HCG • Abd x-rays: “thumb printing” • US may be diagnostic, fast, available • RX: Operative

Mesenteric Ischemia Ureterolithiasis

• History: flank pain, hematuria, radiation to groin, previous hx. • Exam: restless, significant pain, no abd tenderness. • Labs: UA, crystals, RBC. Normal WBC • IVP, CT • Hydration, pain control

9 Ureterolithiasis The Acute Abdomen: A pediatric surgeon’s view

Jonathan I. Groner MD Professor of Clinical Surgery The Ohio State University

Pitfalls Definition of Acute Abdomen • Old age, young age 9 Development of an acute abdominal • Immunocompromised pt condition requiring urgent therapy (generally surgical) 9 HIV, steroids, ? Diabetes 9 Pain of more than 6 hours duration is • Compromised exam often surgical in nature (Cope’s textbook) 9 Spinal cord injury, mental status 9 Pediatric population generally defined as age<18

10 Etiology of Acute Appendicitis Abdomen in Children • Most common surgical emergency for • Acute appendicitis pediatric surgeons • Meckel’s diverticulum • Possibly more common in western • Intussussception societies • Necrotizing enterocolitis • Peak incidence in 2nd decade of life • Small bowel obstruction (age 11 through 20) • Blunt abdominal trauma • “The great imitator” can be confused with • Child Abuse (special topic) other diseases

Diagnosis of Acute Abdomen Differential Diagnosis • Worsening or diffuse • Gastroenteritis • Abdominal distention • Urinary tract infection • Signs of shock/dehydration (late) • Mesenteric adenitis • “Backwards” syndrome of infants with peritonitis: • Pneumonia (right lower lobe) 9 Hypothermia instead of fever • Meckel’s diverticulum 9 Apnea instead of tachypnea • Inflammatory bowel disease 9 Low WBC instead of high WBC

11 Appendicitis Acute Appendicitis

• “Acute:” appendix is inflamed but intact. Classic symptoms: Illness duration < 1day • Anorexia • “Gangrenous:” appendix is inflamed with • Nausea necrosis of the appendiceal wall • Mild abdominal pain of gradual onset • “Ruptured:” appendix is inflamed with • Pain gradually becomes more pronounced rupture of the appendiceal wall and spillage in the right lower quadrant and persists of infection into abdomen • Low grade fever

Appendicitis - Diagnosis Acute Appendicitis Classic findings: • Rule: A careful history and a thorough • Right lower quadrant abdominal physical examination are the keys to tenderness making the diagnosis of appendicitis • Referred tenderness • Rule: You can’t CT scan every child who • Easily reproducible examination walks into the emergency department with • Mild tachycardia abdominal pain • Low grade fever – patient often looks flushed

12 Acute Appendicitis

Appendicitis – Gangrenous Appendicitis – Perforated Symptoms Physical examination • Usually ill > 48 hours • Patient appears ill and dehydrated • Usually fever > 101.5 • Vomiting, “diarrhea” • Frequent vomiting, generalized abdominal pain • Generalized abdominal tenderness • Generalized abdominal tenderness • may have signs of shock – can require significant fluid resuscitation • May appear dehydrated • May have bowel obstruction at presentation

13 Appendicitis - Ruptured

• IV fluids: 20 ml/kg normal saline bolus (may repeat) • Antibiotics: gentamicin and clindamycin • Foley catheter • NG tube (if signs of bowel obstruction) • Variety of operative approaches Ruptured appendix with multiple abscesses

Appendicitis - Treatment Gastroenteritis

• NPO • Generalized abdominal pain - crampy • IV fluids • Non-tender abdomen • IV antibiotics • Either vomiting or diarrhea must be present • Acute: appendectomy (laparoscopic vs. • Exposure to infectious source (ill sibling, open) contaminated food exposure, camping trip, • Gangrenous: appendectomy (laparoscopic foreign travel) vs. open)

14 Diarrhea Meckel’s Diverticulum • Diarrhea refers to frequent high volume watery stool output • A bleeding Meckel’s diverticulum usually presents as painless lower GI hemorrhage • Some patients with ruptured appendicitis which may be massive will complain of diarrhea • Many of these patients are having rectal • A perforated Meckel’s diverticulum may irritation from peritonitis or pelvic abscess mimic advanced appendicitis leading to rectal spasms and frequent low • Occasionally presents as bowel volume bowel movements obstruction • A careful history is important

Meckel’s Diverticulum Meckel’s Diverticulum

The disease of “two’s” Imaging • Lesion present in 2% of people • Due to the presence of gastric mucosa, the • Two feet from the terminal ileum lesion can be found on a nuclear medicine scan fairly easily • Two mucosa types (gastric and intestinal) Treatment • Two common surgical problems • Operation involves excision with primary 9 Perforation anastamosis 9 Bleeding

15 Intussussception

• Telescoping of intestine onto itself causing obstruction • Most common type is idiopathic (no known cause) • Typical age group is 3 months to 3 years • Episodic pain with minimal symptoms in between • Infants may be lethargic

Intussussception

Diagnosis and Treatment • Barium Enema: historical, not used anymore due to risk of perforation • Ultrasound: “target sign” • CT scan: multilayered mass (caution: transient, asymptomatic intussusceptions can also be seen on CT scan)

Meckel’s diverticulum with small bowel obstruction

16 Intussussception Small Bowel Obstruction Etiology Air Contrast enema • Congenital • Diagnostic 9 Malrotation • Therapeutic 9 Inguinal hernia • Low risk of perforation • Post-operative • Standard of Care 9 Any abdominal operation • Generally performed by pediatric radiologists only 9 VP shunt 9 Nissen – danger (difficult to diagnose)

Small bowel obstruction in an infant due to an incarcerated right inguinal hernia

17 Necrotizing Enterocolitis (NEC) Strangulated bowel A common cause of acute abdomen in the NICU obstruction but rare in the rest of the world due to 9 Leading killer in NICU’s across the United inguinal States hernia in an 9 Primarily infectious process infant 9 Etiology poorly understood 9 Often rapidly progressive 9 Rare in full term infants (but seen occasionally in infants with cardiac disease)

Small Bowel Obstruction Necrotizing Enterocolitis (NEC) Nissen Fundoplication patients • May have developmental delay • Most cases are diagnosed in the NICU or special care nursery • Often have a gastrostomy tube • Patients at risk are profoundly premature • Usually cannot vomit! or have significant cardiac disease • SBO can be difficult to diagnose • Not present at birth but occurs within the • May have “closed loop” obstruction first few days of life • May need urgent exploration

18 Abdominal wall discoloration in an infant with severe NEC

Blunt Abdominal Trauma • Children are more susceptible to intra- abdominal injuries due to blunt trauma than adults because: 9 Thinner abdominal wall 9 Less fat around solid organs 9 More flexible rib cage 9 Higher risk behaviors?

19 “Seat belt sign” Each of these children had major intra-abdominal injuries

Child fell off bicycle – note handlebar mark in right lower quadrant

Child Abuse – special topic

• #1 injury-related killer of children at NCH for the last 3 years • A “silent epidemic” of major proportions • Patients often have multisystem injuries • Patients often make multiple visits to multiple EDs or clinics • Patients may show up in your office with unrelated complaints Blunt injury to colon with perforation and peritonitis

20 Child Abuse Child Abuse • Beware of history that does not make • 90% of children who experience physical sense or changes abuse are injured by age 3 • Beware of injuries blamed on too-young • The vast majority of children who are siblings intentionally injured are injured by a caregiver (mother, father, boyfriend, • Beware of young child with multiple ED babysitter), NOT a stranger visits for injuries • Failure to recognize abuse on an ED visit • Child Abuse can happen in a family of any can be fatal race, ethnicity, or socioeconomic background

Child Abuse Common “histories” in child abuse cases: • Injury history 9 Child fell off a couch 9 Child fell on a toy 9 Child injured by a very young sibling • Non-specific history 9 Infant has been fussy for hours and laceration due to blunt 9 Infant refuses to eat trauma (intentional injury) 9 Infant “passed out” at home

21 Child Abuse

• All suspected child abuse cases should be referred to a pediatric trauma center • These children usually need skeletal survey, eye exam, social work interview, exam by child abuse specialist • Siblings in the home should be examined Pancreatic transection in 4 year old as well (blunt trauma - intentional injury)

Conclusions • Acute abdomen in children can be due to infectious disease or trauma • Shock can be difficult to diagnose in children with acute abdomen • Standard initial management includes IV hydration, antibiotics • Many of these patients may deserve transfer to a children’s hospital

Characteristic bruises in a child abuse victim

22 The End

23