DOCSLIB.ORG

Current Approach to the Diagnosis and Emergency Department Management of Appendicitis in Children

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Current Approach to the Diagnosis and Emergency Department Management of Appendicitis in Children CME REVIEW ARTICLE Current Approach to the Diagnosis and Emergency Department Management of Appendicitis in Children Susan C. Lipsett, MD and Richard G. Bachur, MD of negative appendectomies.2 More recently, the negative appen- Abstract: Concerns about radiation exposure have led to a decrease in the dectomy rate in children approaches 4%, with higher rates in use of computed tomography in suspected appendicitis, with increased re- young children and female adolescents.3 liance on ultrasound. Children with suspected appendicitis should be risk Because of increasing recent concerns about radiation stratified using a combination of clinical signs and symptoms, white blood exposure in children, the rate of CTusage in the evaluation of ap- cell count, and ultrasound in order to guide further evaluation and manage- pendicitis has decreased significantly with a balancing increase ment. Magnetic resonance imaging is a promising imaging modality in ultrasound utilization. Reassuringly, this trend appears to have but remains costly. Ongoing research is evaluating the role of nonoper- had no adverse effect on the rate of ED revisits, appendiceal perfo- ative management in children with confirmed appendicitis. ration, or negative appendectomy rate.4 Recent progress in the Key Words: abdominal pain, appendicitis, clinical decision rule, evaluation of suspected appendicitis has focused on strategies diagnostic testing, surgery that integrate clinical scores, the white blood cell (WBC) count, – and ultrasound findings to risk-stratify children and facilitate (Pediatr Emer Care 2017;33: 198 205) management decisions. TARGET AUDIENCE EPIDEMIOLOGY This CME activity is intended for physicians who care for The incidence of acute appendicitis in the United States is 11 children with acute abdominal pain, including general pediatri- per 10,000 people per year, with a lifetime risk of appendicitis cians, emergency physicians, and surgeons. between 5% and 10%.5 Appendicitis is most common in children 10 to 19 years of age and has a slight male predominance.5 It LEARNING OBJECTIVES is also slightly more common in the summer months.5 Risk fac- After completion of this article, the reader should be able to: tors for perforation include longer duration of symptoms and younger age.6–8 1. Describe trends in diagnostic imaging for children with suspected appendicitis. DIFFERENTIAL DIAGNOSIS 2. Integrate clinical presentation, laboratory studies, and ultra- The differential diagnosis of a child presenting with suspected sound findings to assess a child’s risk of appendicitis and guide appendicitis is broad and is summarized in Figure 1. Special con- further workup. sideration should be given to the female adolescent, who is at risk 3. Provide appropriate initial management for children with con- of ectopic pregnancy and ovarian pathology, and to the very firmed appendicitis in the emergency department. young child, who is at increased risk of perforation. cute appendicitis remains a diagnostic challenge for pediatric HISTORY AND PHYSICAL EXAMINATION A acute care clinicians. In this article, we review the historical The first symptom of appendicitis in a child is usually a com- perspective and epidemiology of acute appendicitis in children. plaint of periumbilical or generalized abdominal pain. Classically, We will then outline a basic framework for the diagnostic ap- but not always, over the course of hours, the pain worsens and mi- proach to children with suspected appendicitis, which integrates grates toward the right lower quadrant (RLQ). Low-grade fever, clinical findings, laboratory studies, and imaging modalities. anorexia, nausea, and vomiting may be present, but the abdominal pain generally precedes these symptoms. The child may complain HISTORICAL PERSPECTIVE of pain with walking. The location of pain in appendicitis may Appendicitis was first described in 1886, with prompt surgi- vary, depending on the length and position of the appendix. Thus, cal management recommended as definitive treatment.1 Until the clinicians should not eliminate appendicitis from consideration in late 20th century, diagnosis was purely based on history and phys- children presenting with pain in the right upper quadrant, flank, ical examination, with an acceptable negative appendectomy rate groin, or suprapubic region. Similarly, the duration of the symp- of 20% to 25%.2 The increase in utilization of computed tomogra- toms will affect the intensity of the symptoms and signs, making phy (CT) over the last 2 decades led to a steady decrease in the rate the diagnosis quite difficult in the early stages. The physical examination should begin with a general as- sessment of the appearance and activity level of the child. An ac- Staff Physician (Lipsett) and Chief (Bachur), Division of Emergency Medicine, tive child who is walking easily around the room is less likely to Boston Children’s Hospital, Boston, MA. have appendicitis than the child who is laying quietly in bed resis- The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no tant to movement. Key components of the examination include financial relationships with, or financial interest in, any commercial careful examination of the lung fields to evaluate for pneumonia organizations pertaining to this educational activity. and a genitourinary examination especially in males (testicular Reprints: Susan C. Lipsett, MD, Division of Emergency Medicine, Boston torsion, hernia) and amenorrheic pubescent girls (hematocolpos). Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (e‐mail: [email protected]). In sexually active girls, a bimanual examination may be indicated Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. to assess for cervical motion tenderness and adnexal tenderness or ISSN: 0749-5161 fullness. The abdominal examination should focus on the location 198 www.pec-online.com Pediatric Emergency Care • Volume 33, Number 3, March 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Pediatric Emergency Care • Volume 33, Number 3, March 2017 Diagnosis and ED Management of Appendicitis FIGURE 1. Differential diagnosis of children with suspected appendicitis. of maximal tenderness, with the RLQ being most suggestive of ap- appendicitis exhibited features such as RLQ tenderness, percus- pendicitis; many clinicians refer to the point of maximal tender- sive tenderness, and guarding.9 ness relative to McBurney point, the position one third of the distance medially along a line drawn from the anterior superior il- LABORATORY EVALUATION iac spine to the umbilicus. Examination of the abdomen should also attempt to identify signs of peritonitis such as rebound tender- A complete blood count with differential should be obtained ness, guarding, and referred pain to the RLQ from palpation of the for all children in whom appendicitis is suspected, as the WBC count and absolute neutrophil count (ANC) have been shown to left lower abdomen (Rovsing sign). Unwillingness to jump or 10–12 cough is also suggestive of peritoneal irritation. Bowel sounds will be useful in predicting risk of appendicitis. be hypoactive in advanced appendicitis. Right-lateral-wall tender- Other laboratory tests, although not generally useful in ness on rectal examination can also be suggestive of appendicitis, predicting risk of appendicitis, may help to exclude alternate eti- but rectal examinations have become less routine in young chil- ologies. A urine pregnancy test should be obtained for all dren. Less specific findings in patients with an inflamed retrocecal postpubertal females. A normal urinalysis rules out new-onset di- appendix include an obturator sign (pain with internal rotation of abetes and decreases the likelihood of urinary tract infection or the right hip) and psoas sign (pain with extension of the hip or flex- nephrolithiasis. It is important to remember that many children “ ” ion of the hip against resistance). with appendicitis will have sympathetic, or sterile, pyuria with Table 1 summarizes the frequency of specific signs and a few WBCs in the urine due to ureteral or bladder irritation. If symptoms in children with suspected appendicitis. It should be the abdominal pain is more prominent in the right upper quadrant noted that many children present with atypical features; for exam- or if there is persistent vomiting, transaminases, serum bilirubin, ple, in the cited study, 40% of children with confirmed appendici- and lipase may be indicated to evaluate for hepatobiliary pathology tis did not have anorexia, 30% did not have maximal tenderness in or pancreatitis. Serum electrolytes should be obtained in ill- the RLQ, and 20% had pain duration of more than 48 hours. Al- appearing or very dehydrated patients. C-reactive protein, al- though possibly associated with increased risk of perforation and most 20% of children with confirmed appendicitis had report of 13–15 diarrhea. In addition, a substantial number of children without complicated clinical course, does not discriminate appendici- tis from other causes of abdominal pain. TABLE 1. Frequency of Signs and Symptoms in Children With CLINICAL SCORES Suspected Appendicitis9 Although history, physical examination, and laboratory find- ings are helpful in the evaluation of a patient with suspected appen- Finding Appendicitis, % No Appendicitis, % dicitis, no single finding sufficiently predicts a child’s risk. Thus, several clinical
Load more

Recommended publications
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • The Abnormal Presentation of Complicated Appendicitis Goubeaux C* and Adams J Removed
    Open Access Journal of Family Medicine Case Report The Abnormal Presentation of Complicated Appendicitis Goubeaux C* and Adams J removed. Heritage College of Osteopathic Medicine, Ohio University, Dublin, OH 43016, USA Discussion *Corresponding author: Craig Goubeaux, Heritage Acute appendicitis is one of the most common pathologies in College of Osteopathic Medicine, Ohio University, Dublin, medicine with more than 250,000 cases reported per year [5]. The OH 43016, USA lifetime prevalence is reported to be between 7-8% [5,7]. Diagnosis is Received: January 31, 2019; Accepted: March 12, typically based on a careful clinical history and physical examination 2019; Published: March 19, 2019 [1.7]. The signs and symptoms classically associated with appendicitis are periumbilical pain initially that migrates to right lower quadrant, The Case rebound tenderness, low-grade fever, anorexia, and elevated white A 60-year-old white male presented to our family practice with a blood cell count. chief complaint of isolated right upper quadrant (RUQ) abdominal There are pathologies that may mimic appendicitis such as an pain. It began one week prior after suspected food poisoning with anomalous congenital band, Meckel’s diverticulitis, spontaneous one episode of vomiting. The pain was a constant, dull ache ranging urinary extravasation, renal artery thrombosis or renal infarction between 1-5/10. It did not limit his activities as a farmer. He used [3]. Additionally, a mobile cecum is a congenital anomaly that may NSAIDs to help with the pain. During the past week all other review of systems were negative. Vitals signs were within normal lead to abnormal presentation of appendicitis which occurs in about limits.
    [Show full text]
  • Acute Abdomen
    Acute abdomen: Shaking down the Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy 2.3 ANCC to discover its cause. We show you how to quickly and accurately CONTACT HOURS uncover the clues so your patient can get the help he needs. By Amy Wisniewski, BSN, RN, CCM Lehigh Valley Home Care • Allentown, Pa. The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity. NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 43 suspects Determining the cause of acute abdominal rapidly, indicating a life-threatening process, pain is often complex due to the many or- so fast and accurate assessment is essential. gans in the abdomen and the fact that pain In this article, I’ll describe how to assess a may be nonspecific. Acute abdomen is a patient with acute abdominal pain and inter- general diagnosis, typically referring to se- vene appropriately. vere abdominal pain that occurs suddenly over a short period (usually no longer than What a pain! 7 days) and often requires surgical interven- Acute abdominal pain is one of the top tion. Symptoms may be severe and progress three symptoms of patients presenting in www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 43 NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 44 the ED. Reasons for acute abdominal pain Visceral pain can be divided into three Your patient’s fall into six broad categories: subtypes: age may give • inflammatory—may be a bacterial cause, • tension pain.
    [Show full text]
  • Missed Appendicitis Diagnosis: a Case Report Jocelyn Cox, Bphed, DC1 Guy Sovak, Phd2
    ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2015/294–299/$2.00/©JCCA 2015 Missed appendicitis diagnosis: A case report Jocelyn Cox, BPhEd, DC1 Guy Sovak, PhD2 Objective: The purpose of this case report is to highlight Objectif : Cette étude de cas vise à souligner la nécessité and emphasize the need for an appropriate and thorough d’une liste appropriée et détaillée de diagnostics list of differential diagnoses when managing patients, as différentiels lors de la gestion des patients, car il n’est it is insufficient to assume cases are mechanical, until pas suffisant de supposer que les cas sont d’ordre proven non-mechanical. There are over 250,000 cases mécanique, jusqu’à la preuve du contraire. Il y a plus de of appendicitis annually in the United States. Of these 250 000 cas d’appendicite par an aux États-Unis. Parmi cases, <50% present with classic signs and symptoms of ces cas, < 50 % présentent des signes et des symptômes pain in the right lower quadrant, mild fever and nausea. classiques de douleur dans le quadrant inférieur droit, It is standard for patients who present with appendicitis de fièvre légère et de nausées. Il est normal qu’un to be managed operatively with a laparoscopic patient qui se présente avec une appendicite soit géré appendectomy within 24 hours, otherwise the risk of par une intervention chirurgicale (appendicectomie complications such as rupture, infection, and even death par laparoscopie) dans les 24 heures, sinon le risque increases dramatically. de complications, telles que rupture, infection et décès, Clinical Features: This is a retrospective case report augmente considérablement.
    [Show full text]
  • Imaging of Acute Appendicitis in Adults and Children
    Diagnostic Imaging Imaging of Acute Appendicitis in Adults and Children Bearbeitet von Caroline KEYZER, Pierre Alain Gevenois 1. Auflage 2011. Buch. IX, 256 S. Hardcover ISBN 978 3 642 17871 9 Format (B x L): 19,3 x 26 cm Gewicht: 688 g Weitere Fachgebiete > Medizin > Sonstige Medizinische Fachgebiete > Radiologie, Bildgebende Verfahren Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte. Clinical Presentation of Acute Appendicitis: Clinical Signs—Laboratory Findings—Clinical Scores, Alvarado Score and Derivate Scores David J. Humes and John Simpson Contents Abstract Appendicectomy is the most commonly performed 1 Clinical Presentation ............................................... 14 emergency operation worldwide with a lifetime risk 1.1 History........................................................................ 14 of appendicitis of 8.6% in males and 6.7% in 15 1.2 Examination ............................................................... females (Flum and Koepsell 2002; Addiss et al. 2 Laboratory Investigations....................................... 16 1990). The diagnosis of acute appendicitis is 3 Scoring Systems ......................................................
    [Show full text]
  • A RISK MANAGEMENT APPROACH to ABDOMINAL PAIN in PRIMARY CARE Symptoms Most Predictive of Appendicitis Are Right Lower Torsion
    EMERGENCY MEDICINE – WHAT THE FAMILY PHYSICIAN CAN TREAT UNIT NO. 6 A RISK MANAGEMENT APPROACH TO ABDOMINAL PAIN IN PRIMARY CARE Symptoms most predictive of appendicitis are right lower torsion. inammatory disease (PID) and appendicitis can be virtually for a patient with abdominal pain yields little information, aneurysm or a dissection in elderly patients presenting with quadrant pain (RLQ), and migration of pain from the indistinguishable via the anterior abdominal examination, and unless one is specically looking for air-uid levels indicative of ank pain. Up to one-third of patients with abdominal aortic SUMMARY Dr Lim Jia Hao periumbilical region to RLQ. Anorexia, which has been Palpation should begin with light palpation to localise the it will be the pelvic examination that can reveal the true intestinal obstruction in a patient exhibiting obstructive aneurysms may have haematuria, which can further confound classically taught to be useful in diagnosing appendicitis has region of tenderness and to elicit guarding. Deep palpation aetiology. While both conditions can result in painful cervical symptoms. Abnormal calcications associated with gallstone the physician. Detection of vascular emergencies can be dicult e assessment of abdominal pain in the primary healthcare been found to have little predictive value.6, 7 A gynaecological follows for the detection of organomegaly and masses. However, motion and adnexal tenderness, it is the presence of disease, kidney stones, appendicoliths, as well as aortic if the diagnosis is not entertained from the outset. setting will require the family physician to employ the ABSTRACT just as important to recognise the patients that require a referral and sexual history should be obtained when evaluating women, this can be deeply distressing to the patient with severe mucopurulent discharge from the cervix that will allow the calcications can sometimes be seen on the plain lm as well.
    [Show full text]
  • Acute Abdomen in the Emergency Department
    IAJPS 2018, 05 (11), 11847-11852 Muhanad Khalid Kondarji et al ISSN 2349-7750 CODEN [USA]: IAJPBB ISSN: 2349-7750 INDO AMERICAN JOURNAL OF PHARMACEUTICAL SCIENCES Available online at: http://www.iajps.com Review Article ACUTE ABDOMEN IN THE EMERGENCY DEPARTMENT Muhanad Khalid Kondarji1, Mohammed Khalid Kondarji2, Abdullah Mohammed Alzahrani1, Hussa Ali Alrashid2, Turki Ghaleb Al Ahmadi1, Faisal Mohammed Hinkish3, Fisal Amjed Abdulaziz4, Hamoud Marzuq Alrougi1, Rayan Tareq Alrefai1, Hassan Ibrahim Alasmari1 1 King Fahd Hospital, Jeddah 2 King Abdulaziz University 3 Althaghr Hospital 4 Taibah University Abstract: Introduction: 7% of the patients come to the emergency department with the chief complain of acute abdominal pain. They can have minor causes, but also be due to very serious causes, which requires urgency in care and serious diagnosis and management. Acute abdominal emergencies are a big contributor to morbidity and mortality. Aim of the work: In this study, we aim to understand the standard way to approach a case of acute abdominal pain in the emergency department. Methodology: we conducted this review using a comprehensive search of MEDLINE, PubMed and EMBASE from January 1970 to March 2017. The following search terms were used: acute abdomen, abdominal pain management, clinical evaluation of abdominal pain, management acute abdomen Conclusion: Acute abdomen is an extremely common presentation in the emergency department. However, it is not easy to assess, diagnose, and manage. Rate of misdiagnoses and fatalities are high; therefore, physicians should always consider all possible and start with more serious etiologies. Proper assessment and management of acute abdomen can lead to significant improvement of morbidity and mortality.
    [Show full text]
  • Positive Psoas Sign in a Disabled Child-Not Always Appendicitis, Seldomly Due to Duodenal Perforation by Sharp Foreign Body
    Case Report Published: 01 Aug, 2019 SF Journal of Radiology and Clinical Diagnosis Positive Psoas Sign in a Disabled Child-Not Always Appendicitis, Seldomly due to Duodenal Perforation by Sharp Foreign Body Klein E1*, Merhav G1, Kassis I2 and Ilivitzki A1 1Department of Radiology, Rambam Health Care Campus, Haaliya Hashniya 8 st, Haifa, Israel 2Pediatric Infectious Disease Unit, Rambam Health Care Campus, Haaliya Hashniya 8 st, Haifa, Israel Abstract We present a rare cause for "positive psoas sign" secondary to duodenal perforation by an ingested wooden skewer in a disabled 13 years old male. The unreliable clinical evaluation made the appreciation of a "positive psoas sign" obscured. We highlight the possible occurrence of this pathology in young or disabled children, and the importance of CT leading to this diagnosis, with the utilization of multiplane MIP reconstructions. This case also points that the psoas muscle is a long structure in the retroperitoneum, and irritation of its upper most part may also present as positive psoas sign. Keywords: Psoas sign; Psoasabscess; Skewer; Perforation; Missed diagnosis Case Report A 13 years old male is seen in the pediatric emergency room (ER) due to new onset of limp on the right lower limb, nausea and agitation. His past medical history consists of prematurity with severe psychomotor delay including mental retardation as a sequalae. Past surgical history consists of fundoplication procedure due to diaphragmatic hernia and feeding jejunostomy which was thereafter closed. Medical history was negative for any recent illness with fever, nothing to support food poisoning OPEN ACCESS or any trauma. Physical examination revealed a positive psoas sign, with no tenderness upon deep palpation of the abdomen, and additional point tenderness upon palpation of the distal femur.
    [Show full text]
  • Abdominal Pain
    10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group.
    [Show full text]
  • 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
    [Show full text]
  • General Medicine - Surgery IV Year
    1 General Medicine - Surgery IV year 1. Overal mortality rate in case of acute ESR – 24 mm/hr. Temperature 37,4˚C. Make appendicitis is: the diagnosis? A. 10-20%; A. Appendicular colic; B. 5-10%; B. Appendicular hydrops; C. 0,2-0,8%; C. Appendicular infiltration; D. 1-5%; D. Appendicular abscess; E. 25%. E. Peritonitis. 2. Name the destructive form of appendicitis. 7. A 34-year-old female patient suffered from A. Appendicular colic; abdominal pain week ago; no other B. Superficial; gastrointestinal problems were noted. On C. Appendix hydrops; clinical examination, a mass of about 6 cm D. Phlegmonous; was palpable in the right lower quadrant, E. Catarrhal appendicitis. appeared hard, not reducible and fixed to the parietal muscle. CBC: leucocyts – 3. Koher sign is: 7,5*109/l, ESR – 24 mm/hr. Temperature A. Migration of the pain from the 37,4˚C. Triple antibiotic therapy with epigastrium to the right lower cefotaxime, amikacin and tinidazole was quadrant; very effective. After 10 days no mass in B. Pain in the right lower quadrant; abdominal cavity was palpated. What time C. One time vomiting; term is optimal to perform appendectomy? D. Pain in the right upper quadrant; A. 1 week; E. Pain in the epigastrium. B. 2 weeks; C. 3 month; 4. In cases of appendicular infiltration is D. 1 year; indicated: E. 2 years. A. Laparoscopic appendectomy; B. Concervative treatment; 8. What instrumental method of examination C. Open appendectomy; is the most efficient in case of portal D. Draining; pyelophlebitis? E. Laparotomy. A. Plain abdominal film; B.
    [Show full text]
  • Abdominal Pain
    Abdominal Pain With Dr Sanjay Warrier, Consultant Breast Surgeon at Royal Prince Alfred Hospital Case 1 – You are in the emergency department where a 50 year old man has just presented with abdominal pain 1. Initial approach: Analgesia aids assessment o Ensure there are appropriate lines inserted and analgesia is charted to manage pain Subjective assessment o General examination of the patient – how well/unwell are they? Objective assessment o Review the patient’s vital signs (if abnormal, go through ABC assessment and escalate as appropriate) 2. History: Assess the pain (Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating and Relieving factors, Severity) Associated symptoms should include dysuria, diarrhoea, nausea, vomiting Past medical history Past surgical history Embryology o Foregut . Gives rise to oesophagus, stomach, proximal duodenum, liver, gallbladder, pancreas, spleen . Supplied by coeliac trunk . Pain typically referred to epigastrium o Midgut . Gives rise to distal duodenum, jejunum, ileum, caecum, appendix, ascending colon, proximal 2/3 of transverse colon . Supplied by branches of superior mesenteric artery . Pain typically referred to the umbilical region o Hindgut . Gives rise to distal 1/3 of transverse colon, descending colon, rectum and upper anal canal . Supplied by branches of inferior mesenteric artery . Pain typically referred to suprapubic region o Visceral midgut pain typically commences as vague pain felt in the umbilical region. As it involves the parietal peritoneal it will become sharper in nature and be localised over the affected organ Summarised by Dr Abhijit Pal, Resident, RPAH. December 2014 3. Examination: Appropriate exposure and position (exposed abdomen, patient supine, arms by side) Inspection (previous surgical scars, abdominal breathing, guarding) Palpation (move systematically through all 9 quadrants superficially and then deeply) 4.
    [Show full text]