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Belly Pain and Vomiting: NO YES Perforation When to Worry? Hemmorrhage Hematoma Judith J

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Belly Pain and Vomiting: NO YES Perforation When to Worry? Hemmorrhage Hematoma Judith J ABDOMINAL PAIN TRAUMA?? Belly Pain and Vomiting: NO YES Perforation When to Worry? Hemmorrhage Hematoma Judith J. Stellar, MSN, CRNP AGE?? Contusion Surgery Clinical Nurse Specialist ACUTE CHRONIC The Children’s Hospital of Philadelphia Peritonitis GER, Milk Allergy, Obstruction SCC, IBD Rectal Bleeding Constipation Functional Disorders INFANTS: Birth to 1 Year NEWBORNS TWO TO FIVE YEARS – Anomalies of the GI tract Gastroenteritis – NEC Constipation – Perforation Appendicitis – Volvulus UTI INFANTS up to 1 year Intussusception – Colic, Constipation Volvulus – Gastroenteristis Trauma – UTI Sickle Cell – Incarcerated Hernia HSP – Intussusception Pharyngitis – Volvulus – Hirschsprung’s Disease SCHOOL AGE: 6 to 11 Years ADOLESCENTS: 12 to 18 yrs. Appendicitis Appendicitis Gastroenteritis Ovarian / Testicular Constipation Torsion Functional pain IBD UTI Gastroenteritis Trauma Constipation Sickle Cell Dysmenorrhea HSP Mittelscherz Mesenteric Adenitis PID 1 Is All Belly Pain The Same? STEPWISE APPROACH Visceral Pain HISTORY – Irritation to viscus tension, stretching, ischemia – Visceral pain fibers: bilateral, unmyelinated, enter – Medical, Surgical, Family spinal cord at various levels REVIEW OF SYSTEMS – Pain: dull, poorly localized and midline Parietal Pain – Sequence of events, Extra-intestinal – From the body wall, peritoneum symptoms, Growth failure, Weight loss, – Myelinated fibers to specific dorsal root ganglia Recent illness – Pain: sharp, intense, localized THOROUGH PHYSICAL EXAM – Aggravated by movement or coughing Referred Pain Laboratory Studies – Similar to parietal pain Radiologic Studies – Results from shared central neuron pathways – Pain: felt in distant location--Shoulder, Flank ABDOMINAL PAIN: HISTORY: RED FLAGS RED FLAGS Age of patient Young age Pain aggravated by movement Pain History indicating Well-localized pain acute process Night time awakening; restriction of activities Poor growth or weight loss Poor growth / weight loss Rash, Joint pain Associated symptoms: vomiting, diarrhea, Blood in stool urinary tract symptoms, respiratory, sore throat Blood in Urine Extra-intestinal manifestations: rash, mucosal Multiple sexual ulcers, joint pain partners, unprotected Abnormal physical exam sex Abnormal labs +/- radiographic studies VOMITING When Should You Worry? Bilious emesis Bilious is a surgical emergency Bloody until proven Associated with other otherwise. symptoms Poor Growth Electrolyte imbalance 2 Physical Exam: Physical Exam: Inspection General Appearance Moving? Involuntary guarding? Color: pale, jaundice, rash, purpura Breathing pattern Contour Hydration status Scars, Bruising Development Hernias Visible Peristaltic Waves Physical Exam FIGURE 1B. Anatomic Auscultation basis for the psoas – Bowel sounds sign: inflamed Percussion appendix is in a – Dullness, Tympani retroperitoneal location Palpation in contact with the – Superficial then deep psoas muscle, which is – Painful area last stretched by this – Voluntary vs Involuntary maneuver. Guarding – Peritoneal Signs? – Rebound tenderness FIGURE 2B. Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus FIGURE 1A. The psoas sign. Pain on passive muscle, which is extension of the right thigh. Patient lies on left stretched by this side. Examiner extends patient's right thigh maneuver. while applying counter resistance to the right hip (asterisk). 3 Radiologic Work-Up Plain Films – CXR: r/o pneumonia – Air-Fluid Levels FIGURE 2A. The obturator sign. Pain on – Free Air passive internal rotation of the flexed thigh. – Masses, FB, Examiner moves lower leg laterally while Calcifications applying resistance to the lateral side of the Contrast Studies knee (asterisk) resulting in internal rotation of Ultrasound the femur. CT Plain Films Plain Films Free Air Dilated Loops Fecalith Air-Fluid Levels Laboratory Work-Up CBC, with differential (? Bandemia) Chemistries Urine pregnancy test Urinalysis +/- LFT’s, amylase, lipase +/- Rapid Strep Stool studies: occult blood, culture, white cells Constipation 4 th 5th week5 Week Normal 8th week Malrotation Rotation th 10 week 11th week MALROTATION Malrotation Failure of normal rotation & fixation Abnormal bands form Free floating bowel twists around SMA Diagnosed with UGI If found incidentally surgery still performed 2-3 hours of compromised blood supply leads to gut necrosis 5 Division of Ladd’s Bands Spreading the Mesentary SMA Syndrome SMA Syndrome SMA Syndrome Ovarian Cyst 6 Giant Mesenteric Cyst Ovarian Torsion Pelvic Inflammatory Disease Treatment: Medical Ovarian Cyst with Torsion Antibiotics Counseling Pathophysiology of Acute Abdomen Peritonitis and Perforation Definition - Any intra-abdominal condition requiring urgent surgical intervention. Solid Organ Injury Perforation of Hollow Viscous or Vascular Injury Etiology Hemoperitoneum Leakage of GI Contents 1. Abdominal Inflammation/ Peritonitis: Lysed RBC NEC, perforated appendicitis, infection, pancreatitis 2. Obstruction: gut ischemia and necrosis Peritonitis Localized Abscess with subsequent perforation (Acute Abdomen) - Less acute process Increase Capillary Permeability - Pain, fever 3. Perforation: Blunt or penetrating trauma, Capillary Leak-Transudation - Interval OR IBD,anastomotic leak, iatrogenic cause (3rd Spacing) 4. Hemorrhage: vascular injury Hypovolemia, Shock, Death 7 APPENDICITIS APPENDICITIS Classic Symptoms: PAIN- Periumbilical then localizes to RLQ, followed by nausea Most common acute and vomiting, fever surgical condition of the Only 50% of cases present abdomen this way 7% of the population Onset of symptoms over 12 affected to 24 hours Peak age: 10 to 30 years Perforation thought to be at about 36 to 48 hours after Diagnosis: Based on H & P onset of symptoms Can be very unpredictable APPENDICITIS: WORK UP APPENDICITS History-pulmonary Sx, sore throat? Appendix may lie in – Sequence of events: pain first? a variety of Physical Exam-include rectal exam positions, including – Peritoneal Signs? retrocecal – pelvic exam for adolescent girls Up to 30% of cases Plain Films may have a ―hidden‖ appendix, thus – CXR, Obstruction Series affecting the disease Laboratory presentation and – CBC w/ diff, UA, HCG, Chemistries physical exam – Stool cultures Ultrasound; Abdominal CT 8 Thickened Appendix with Appendix with Fecalith Suppuration at Tip Inflamed Appendix Perforation 9 Appendiceal Abscess IBD: Clinical Presentation Poor growth, weight loss Delayed surgical intervention can result in Poor appetite, nausea, vomiting abscess formation Anemia, fatigue, malaise Attempt IR drainage Extra-intestinal manifestations: fever, PICC line and IV Antibiotics 10 to 14 days joint pain, uveitis, rash, mouth ulcers Readmit for ―Interval Malabsorption: abdominal pain/ Appendectomy‖ cramping, frequent loose stools with mucous and/or blood. Perianal disease: fistulas Urgent Intervention in Crohn’s Disease Gall Bladder Disease Severe Inflammation with impending perforation Abscess secondary to fistulous or perianal disease Stricture Biliary Colic Acute Cholecysitis Acute Cholangitis Biliary Pancreatitis Gall Bladder Disease 10 Abdominal Trauma More often blunt injury Blunt trauma treated conservatively unless there is clinical deterioration – Includes bedrest, serial exams, serial labs and films, slowly liberalize activity Vascular injury and hemoperitoneum causes peritoneal irritation--operative intervention if hemodynamically unstable Perforative injury requires urgent surgical intervention LIVER FRACTURE Seat Belt Injury: Seat Belt Injury: Bowel Wall Thickening Abscess 11 Pancreatic Trauma ―Don’t Mess with the Pancreas‖ M. Nance, MD Different than liver or spleen This is a glandular organ—very secretory Can have diffuse pancreatitis with autodigestion of surrounding tissues May or may not subsequently develop a pseudo- cyst Requires bowel rest and conservative management FIGURE 2. Contrast-enhanced axial computed tomographic ERCP for stent placement to internally drain section of the upper abdomen showing peripancreatic and pseudocyst retroperitoneal edema (large arrows) and stranding. The Open surgical intervention (―cystgastrostomy‖) last pancreas itself (small arrow) appears relatively normal resort Pancreatic Pseudocyst JEJUNAL PERFORATION- 15 mo. girl s/p abuse Meckel’s Diverticulum Remnant of omphalomesenteric duct Located on antimesenteric border of terminal ileum within 60cm of: ileocecal valve 57% are lined with ectopic gastric mucosa often leading to ulceration & painless hemorrhage Also can lead to diverticulitis, intussusception, obstruction, perforatioon, requiring surgical intervention 12 Diagnostic Test: ―Meckel’s Scan‖ Nuclear Med Scan where isotope is taken up by gastric mucosa, whether within the stomach or Meckel’s Diverticulum ectopic. Intussusception Signs and Symptoms Intussusception Folding of the intestine into itself (telescoping) Sudden onset of intermittent, crampy Second most common cause abdominal pain of intestinal obstruction 90% near the ileocecal valve Anorexia Lead Points: Meckel’s, polyp, Vomiting (nonbilious then becoming bilious) tumor, anastomosis Irritable, then lethargic between episodes Gastroenteritis Hyperperistalsis Currant jelly stool (heme positive) 5% of cases recur after Tachycardic, hypotensive, temperature treatment elevation-late signs (impending necrosis) Radiographs Plain Film - paucity of gas and stool in the colon Air or Barium Enema - can be both diagnostic and therapeutic – Surgeon present for contrast enema – IV access: fluids, sedation, pain relief, and antibiotics 13 Barium Reduced Enema- Intussusception Identification of with filling of the Intussusception appendix. Ileo-Ileal Intussusception Surgical Treatment Indications – Failed air or barium reduction – Evidence of bowel perforation or peritonitis Surgical Management – Transverse incision (RLQ) – Manual reduction – Resection and end-to-end anastomosis – Incidental appendectomy 14.
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