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Acute appendicitis and Acute Abdominal Pain
- 1. AcuteAppendicitis Presented by: Saavedra, Martin Henry F.
- 2. Objectives • To present a case of a nine year old with abdominal pain • To discuss the pathophysiology, diagnostics, and therapeutics of a patient with an Acute Appendicitis • To discuss the recognition of Acute Abdomen in children.
- 3. â—Ź 9 year old female â—Ź Filipino â—Ź Roman Catholic â—Ź From Manila CHIEF COMPLAINT: Hypogastric pain of 8 days in duration. PatientA.A.
- 4. 8 days PTA: - Hypogastric pain, squeezing character. - Private consult done - No diagnostics done - Given Cefuroxime of unrecalle dose for 7 days - Advised CBC and urinalysis - Advised repeat CBC, urinalysis and to do urine CS prior antibiotic use HISTORYOFPRESENTILLNESS
- 5. 7 days PTA: - Hypogastric pain persists - Associated fever Tmax 38.0 - Vomiting and loose stools after antibiotic use - Follow-up with private physician leukocytosis on CBC - Advised ER consult at a hospital - UERM ER consult - CBC, Urinalysis with elevated WBC - Fecalysis normal - Surgery referral; non-surgical, considered probable UTI - Co-Amoxiclav 40mkd for 1 week and Paracetamol 15mkd for Fever - Advised repeat CBC, urinalysis on day 3 antibioticsand to do urine CS prior antibiotic use HISTORYOFPRESENTILLNESS
- 6. 5 days PTA: - Decreased hypogastric pain but still persistent - Still with intermittent fever - ER follow-up - No guarding or tenderness on palpation - Leukocytosis on CBC, urinalysis normal on day 3 antibiotics - Blood CS as OPD HISTORYOFPRESENTILLNESS Interim - Persistent and mild hypogastric pain resolved by warm compress - Intermittent fever persisted - No recurrence of vomiting or loose stool
- 7. 2 hours PTA: - ER consult - Increased intensity of hypogastric pain - Guarding and generalized abdominal tenderness - Leukocytosis on repeat CBC and urinalysis - Surgery referral done and advised admission as a case of possibly rupturede acute appendicitis HISTORYOFPRESENTILLNESS
- 8. 8 7 6 5 4 3 2 1 DOA Cefuroxime Co-Amoxiclav Paracetamol Abdominal Pain Fever Loose Stools Vomiting
- 9. Birth and Maternal History ● Patient was born full term via normal spontaneous delivery to a then 28-year-old G2P2 (2002) mother. Birth weight and length were unrecalled, APGAR score of the patient were unrecalled but was noticed to have good cry and good spontaneous movement upon birth. No other feto-maternal complications noted during birth and pregnancy. Feeding History ● The patient’s grandmother did not know if the patient was breastfed. At present, patient is a picky eater, and prefers eating fruits and vegetables. No known allergies to food and medications. PastMedicalHistory
- 10. Immunization History ● The patient’s grandmother is unaware of the immunization history of the patient. Developmental History ● The patient is at par for age. No developmental delays noted. She is currently a grade 1 student with good grades in school and is said to have good interactions with her peers. Past Medical History ● No know past illnesses. No recent trauma/accident/surgeries. No known allergies. PastMedicalHistory
- 11. Family History ● Paternal – hypertension, skin cancer ● No history of blood disorders, asthma, allergies Social History ● The patient lives with her grandparents and 2 siblings in a 2-storey house in Manila with a clean environment. Her parents are OFWs. PastMedicalHistory
- 12. PHYSICALEXAM General Survey Awake, alert, responsive, not in distress, in pain Vital Signs BP: 90/60 HR: 98 bpm RR: 24 cpm Temp: 37.0 oC O2 Sat: 96% RA Anthropometrics Weight 20 kg Z-score: below -2 Wasted Height 128cm Z-score: 0 Normal BMI 13.5kg/m2 Z-score: 0 Normal Skin Smooth, warm, pinkish conjunctiva, no cyanosis, no hematoma, no rashes, no jaundice HEENT Head: Normocephalic Eyes: Pink palpebral conjunctivae, anicteric sclerae, non-sunken eyeballs Ears: Patent ear canals, both ears; well-curved pinna, formed with instant recoil, no discharge on both ears Nose: Patent nares, no flaring, septum at midline, no discharge Mouth and Throat: no tonsillopharyngeal congestion, no cervical lymphadenopathy Chest and Lungs Equal chest expansion, no retraction, equal tactile fremitus, resonant on all lung fields, clear breath sounds Cardiovascular Adynamic precordium, normal rate, regular rhythm, distinct s1 and s2, no murmurs, no heaves and thrills Abdomen Flat, non-distended, normoactive bowel sounds, (+) direct tendernes on RLQ, LLQ, and hypogastic area, (+) guarding on the hypogastic area. Non tender RUQ and LUQ, no rebound tenderness Extremities Full and equal pulses, CRT<2s, no cyanosis, edema
- 13. DIAGNOSTICS Complete Blood Count Normal Values 04.24.2020 04.25.20 04.27.20 Hemoglobin 120 - 140 g/L 116 88 105 Hematocrit 37-47% 34 25 31 RBC 4.5-5.5 x 10^12/L 4.3 3.2 3.7 MCHC 32-37% 34 35 34 MCH 27.5 -33.2 pg 27.2 27.5 28.6 MCV 80 -94 fl 80 79 83 RDW 11.0-15.0% 12.4 12.5 13.2 WBC 5.0-10.0x10^9/L 31.5 27.1 14.4 Neutrophils 37 -92% 72 89 73 Lymphocytes 20 -50% 28 11 27 Monocytes 0-14% 0 0 0 Eosinophils 0-6% 0 0 0 Basophils 0-1% 0 0 0 Platelet 150-440 553 493 481 MPV 7.5-11.5 8.1 8.1 8.0 RBC Morphology Normochromic, normocytic Normochromic, normocytic Hypochromic, Normocytic Sl. Hypochromic, Normocytic
- 14. DIAGNOSTICS Urinalysis Test 04.24.2020 Color Yellow Turbidity Turbid Reaction Acidic Specific Gravity 1.005 Protein Trace Sugar Negative RBC 0-2/hpf WBC 10-20/hpf Bacteria Few Epithelial Cells Moderate Mucus Thread Rare
- 15. DIAGNOSTICS Right lower quadrant UTZ 04.24.20 IMPRESSION: 1. Markedly dilated focal bowel segment believed to involve the recto-sigmoid colon. Suggest barium enema for further evaluation. 2. Non-visualized appendix 3. Bilateral mild pelvocalectacia and ureterectasia likely due to compression effect of the pelvic pathology. Negative for parenchymal disease and lithiasis 4. Essentially normal sonogram of the urinary bladder Chest X-ray 04.24.20: Normal Chest
- 16. â—Ź Day of Admission â—‹ At the ER â– Leukocytosis in CBC and urinalysis â– Guarding, firm abdomen, generalized tenderness on palpation â– Evaluated by Surgery service and advised admission as a case of Acute Appendicitis possibly ruptured. COURSEINTHEWARDS
- 17. â—Ź Day of Admission â—‹ At the Wards â– Started on Metronidazole and Ceftriaxone â– RLQ UTZ shows possible pelvic pathology; appendiz not visualized â– Emergency appendectomy done â– Procedure tolerated without incident â– Tachycardic post-op; given IV mild â– Other Vital signs stable â– Good pain control â– Surgical site well coapted with no bleed or discharge COURSEINTHEWARDS
- 18. â—Ź 1st Hospital Day â—‹ Still on NPO; expresses hunger; no flatus or BM â—‹ Good pain control â—‹ Two Febrile episodes (Tmax 38.9) attributed to phlebitis; resolved on change of IV line â—‹ Tachycardia persisted; attributed to blood loss during OR which was more than allowable for weight (350cc vs 160cc) â—‹ Repeat CBC shows decreased Hgb and Hct, and improvement in leukocytosis â—‹ Surgical site well coapted without discharge COURSEINTHEWARDS
- 19. â—Ź 2nd Hospital Day â—‹ HE normalized after 10cc/kg transfusion of PRBC â—‹ Flatus and BM noted; progression to clear liquids â—Ź 3rd Hospital Day â—‹ Repeat CBC done; increased Hgb and Hct, WBC increased but far lower than previous (14.4 vs 27.1). â—‹ Progress to soft diet; good appetite and adequate fluid input/output â—‹ Antibiotics continued COURSEINTHEWARDS
- 20. â—Ź 4th Hospital day â—‹ Progressed to DAT â—‹ Stable Vital signs â—‹ Surgical site unremarkable â—Ź 5th Hospital day â—‹ Remained afebrile, â—‹ Antibiotics shifted to oral â—‹ Continue antibiotics to complete 10 days â—‹ Follow-up in 1 week â—‹ Discharged well and stable. COURSEINTHEWARDS
- 21. Ruptured Appendicitis with localized peritonitis S/P Emergency Appendectomy (04.24.20) FINALDIAGNOSIS
- 23. â—Ź Inflammation of the appendix o Obstruction, inflammation, or infection â—Ź Most common acute surgical condition in children. â—Ź Peak incidence in the second decade of life. â—Ź Broad clinical presentations were associated to large variations in evaluation and management. ACUTEAPPENDICITIS
- 24. â—Ź Increases with age: 1-2 per 10,000 from birth-4 years; 19-28 per 10,000 younger than 14. â—Ź Lifetime risk of 7-9%. â—Ź 1-8% of children needing abdominal evaluation at the ER. â—Ź Peak incidence between 10-18 years . â—Ź Rarer in young children (<5% below 5 years; <1% below 3 years). â—Ź Low mortality <1%; high morbidity mostly due to perforation. INCIDENCE
- 25. â—Ź Perforation rates at 40%; negative appendectomy rates 10-20% â—Ź More severe in very young children â—Ź Family history confers a nearly threefold increased risk for appendicitis. INCIDENCE
- 26. ● Exact cause is not completely understood. ● Possible Causes: ○ Fecalith/Appendicolith – common in developed countries with low fiber diets ○ Incompletely digested substances ○ Lymphoid hyperplasia – submucosal lymphoid tissue multiply steadily during childhood ○ Intraluminal scarring from trauma ○ Tumors or malignancies ETIOLOGY
- 27. ○ Microorganisms ■Bacteria – E.coli, Klebsiella, Pseudomonas, Salmonella, Shigella, Anaerobic bacteria ■Viruses – Coxsackie B, Adenoviruses ■Parasites – A.lumbricoides ○ Others ■Cystic Fibrosis in children ■Inflammatory bowel disease in adults ETIOLOGY
- 28. â—Ź Begins with luminal obstruction. â—‹ Inflammation, infection, fecalith, foreign body, lymphoid hyperplasia, tumors. â—Ź Intraluminal pressure increases (mucus secretion of epithelium builds-up.) â—Ź Venous congestion and edema, impaired arterial perfusion, ischemia of the appendiceal wall due to pressure build up. â—Ź Bacterial proliferation and invasion of the wall, and necrosis. â—Ź Eventual Perforation. PATHOPHYSIOLOGY
- 29. â—Ź Spillage of contents into omentum and tissues. â—Ź Peritonitis and other complications such as infection follows. PATHOPHYSIOLOGY
- 30. PATHOPHYSIOLOGY
- 31. PATHOPHYSIOLOGY
- 34. â—Ź Broad spectrum of clinical presentation â—Ź Vary depending on the timing of presentation, patient age, the abdominal/pelvic location of the appendix â—Ź May appear well with mild symptoms early â—Ź Abdominal pain as the primary symptom â—‹ Vague and poorly localized initially â—‹ Involvement of adjacent peritoneal surface from inflammation localizes pain to RLQ â—‹ Localization usually in 2-8hrs but up to 12-36hrs â—Ź Muscle spasm in the overlying abdominal wall (firm abdomen) CLINICALMANIFESTATIONS
- 35. ● Nausea and vomiting following onset of abdominal pain. ● Anorexia is consistently seen. ● Diarrhea and urinary symptoms seen especially in perforated appendicitis as inflammation spreads through the pelvis. ● Fever is usually low-grade (<38.3C) unless perforation occurs ● Murphy’s Triad ○ Pain ○ Vomiting ○ Fever CLINICALMANIFESTATIONS
- 36. â—Ź Perforation should be suspected if: â—‹ There is presence of progression for more than 36-48 hours â—‹ High fever â—‹ Diffuse abdominal pain and tendernes â—‹ A rigid, board-like abdomen â—‹ Leukocytosis â—‹ A right lower quadrant mass (phlegmon) â—Ź The use of antibiotics early in the course may mask the progression of appendicitis CLINICALMANIFESTATIONS
- 38. CLINICALMANIFESTATIONS Manifestation Frequency Abdominal Pain >95% Anorexia >70% Constipation 4-16% Diarrhea 4-16% Fever 10-20% RLQ Migration 50-60% Nausea >65% Vomiting 50-75% Manifestation Frequency Abdominal Tenderness >95% RLQ Tenderness >90% Rebound Tenderness 30-70% Rectal Tenderness 30-40% Cervical motion Tenderness 30% Rigidity 10% Obturator Sign 5-10% Psoas Sign 3-5% Rovsing’s Sign 5% Palpable Mass <5%
- 39. PATIENT • 8 days PTA • Continuous abdominal pain squeezing in character in the hypogastric area • 7 days PTA • Persisting hypogastric pain • Low grade fever • 2 episodes of loose stools and vomiting • Patient was said to not have been eating much due to pain
- 40. PATIENT • 5 days PTA • Decrease in abdominal pain but still continuous • Episodes of low-grade and intermittent fever • 2hrs PTA • Persisting and intensified abdominal pain • Did not eat during the day due to pain • No vomiting or loose stools
- 42. â—Ź Hallmark is still a careful and thorough history and physical examination â—Ź Localized Abdominal Tenderness as the single most reliable finding in the diagnosis of appendicitis â—Ź Abdomen is flat early on; distention suggests advanced disease PHYSICALEXAMINATION
- 43. â—Ź Bowels sounds are hyperactive initially and become hypoactive as disease progress to perforation â—Ź Guarding behavior â—‹ Volunatry vs Involuntary â—‹ Child hunched forward and uneasy when about to touch abdomen PHYSICALEXAMINATION
- 45. ● Blumberg’s Sign ○ Commonly known as rebound tenderness ○ Elicited by the deep palpation of the abdomen followed by the sudden release of the examining hand ○ Indicative of peritonitis PHYSICALEXAMINATION
- 46. ● Dunphy’s Sign – Coughing elicit’s pain in the abdominal area due to wall movement which may indicate peritonitis PHYSICALEXAMINATION
- 48. PATIENT • Firm abdomen on palpation with generalized tenderness mostly on the hypogastric area. • Guarding behavior on palpation of abdomen • (+) Direct tenderness, Psoas, Obturator, Rovsing’s and rebound tenderness • Bowel sounds remained normoactive
- 49. Diagnostics
- 50. ● CBC ○ WBC may be normal early ○ Typically 11,000-16,000/mm3 in non-perforated AP ○ May elevate >20,000 if perfraton occurs ○ “Left shift” or PMN >7,500/mm3 ● Urinalysis ○ To exclude genitourinary conditions ○ May have increased WBC or RBC due to proximity of urinary tract and bladder to the inflammed appendix but should not have bateria (sterile pyuria) DIAGNOSTICS
- 51. â—Ź Electrolytes â—‹ Generally normal unless there has been a delay in diagnosis, leading to severe dehydration and/or sepsis â—Ź Amylase and Liver enzymes â—‹ Helpful to exclude alternative diagnoses such as pancreatitis and cholecystitis â—Ź CRP â—‹ Increases in proportion to the degree of inflammation, but non-specific as well â—‹ May have a roll in identifying severity of disease DIAGNOSTICS
- 52. ● Plain Radiographs ○ Helpful in evaluating complicated cases in which small bowel obstruction or free air is suspected ○ Normal in 50% of patients with a low sensitivity; usually not recommended ○ Possible findings suggestive of appendicitis ■Sentinel loops of bowel & localized ileus ■Scoliosis from psoas muscle spasm ■Colonic air–fluid level above the right iliac fossa (colon cutoff sign) ■RLQ soft-tissue mass ■Calcified appendicolith (5-10% of cases) DIAGNOSTICS
- 53. ● Ultrasound ○ Highly operator dependent ○ Sensitivity and specificity near 90% ○ Low cost, readily available, rapid, no sedation or radiation ○ Helpful in populations with high negative appendectomy such as adolescent females with ovarian pathology ○ “Target appearance” of appendix ○ Findings: ■Wall thickness ≥6 mm ■Appendicolith ■Luminal Distention ■Lack of compressibility ■Complex mass in RLQ DIAGNOSTICS
- 54. ○ Findings which may suggest advanced disease ■Asymmetric wall thickening, ■Abscess formation ■Associated free intraabdominal/pelvic fluid ■Surrounding tissue edema ■Decreased local tenderness to compression ○ Main limitation of ultrasound is an inability to visualize the appendix, which is reported in 25–60% of cases. DIAGNOSTICS
- 55. â—Ź Computed Tomography â—‹ Gold Standard for evaluation â—‹ Readily available, rapid, lesser operator dependency â—‹ More expensive; radiation exposure â—‹ Has sensitivity of 97%, specificity 99%, positive predictive value 98%, and negative predictive value 98% â—‹ Findings â– Distended (>7mm) thick-walled appendix â– Inflammatory streaking of surrounding mesenteric fat (inaccurate in thinner children) â– Pericecal phlegmon or abcess â– Appendicolith more readily seen than in x-ray (40-50% vs 5-15%) DIAGNOSTICS
- 56. DIAGNOSTICS
- 57. â—Ź Magnetic Resonance Imaging â—‹ Equivalent to CT in diagnostic accuracy for appendicitis â—‹ Limited, more costly, usually needs sedation â—‹ No radiation â—‹ Useful in adolescent girls when advanced imaging is needed DIAGNOSTICS
- 58. PATIENT • CBC o Leukocytosis (WBC 31.5) with neutrophillic predominance at 72 • Urinalysis o 10-20 WBC; Few Bacteria • Ultrasound o Markedly dilated focal bowel segment believed to involve the recto-sigmoid colon o Non-visualized appendix o Bilateral mild pelvocalectacia and ureterectasia likely due to compression effect of the pelvic pathology. Negative for parenchymal disease and lithiasis o Essentially normal sonogram of the urinary bladder
- 60. ● Extensive list of illnesses that manifest similarly to appendicitis ● Infections from viruses, bacteria and parasites may present as abdominal pain with vomiting especially in younger children and may typically manifest with fever ● Many of the urinary tract diseases present also as abdominal pain ● Biliary tree diseases may also present similarly but pain localization is found differently and sometimes exacerbated by food intake; can be accompanied by jaundice ● Meckel’s diverticulitis is rare, but the clinical presentation closely mimics appendicitis.; diagnosis is rarely made before surgery. DIFFERENTIALDIAGNOSES
- 61. â—Ź Pancreatitis presents with pain located in the upper abdomen and radiates to the back; pain worsens after eating â—Ź High risk of incorrect diagnosis on children younger that 3yo due to atypical presentation and adolescent girls due to gynecologic presentations; up to 30-40% rates â—Ź Pelvic inflammatory disease is typically bilateral and longer in duration â—Ź Ovarian cysts may cause acute pain after rupture, elargement or hemorrhage â—Ź Ovarian torsion may also present similarly but pain is more severe and more frequent nausea and vomiting DIFFERENTIALDIAGNOSES
- 63. PATIENT ● Gastroenteritis  Episodes of vomiting and loose stools but was preceded by abdominal pain  Loose stools followed use of Cefuroxime  Pain was continuous and was not relieved by passage of stool or emesis ● UTI  Commonly presents as abdominal pain with fever  Leukocytosis and moderate bacteria on urinalysis 7 days PTA  No dysuria, incontinence or flank pain with the patient when considered originally ● Acute Appendicitis  Continuous and persisting abdominal pain  Abdominal pain precedes nausea and vomiting  Leukocytosis on CBC with neutrophilic predominance  Firm and tender abdomen on admission  Does not eat due to pain
- 64. Whatmayhavehappened… • Possibly Acute non-perforated appendicitis since 1 week prior to consult with an incidental finding of UTI at ER consult • Antibiotics used to treat UTI may have decreased the symptoms of appendicitis but not completely resolve the disease as seen 5 days PTA and in the interim (less abdominal pain and fever episodes) • Since the appendicitis was not resolved by the antibiotics, progression to perforation occurred over the next few days • ER consult with firm abdomen and generalized tenderness on PE with leukocytosis at 31.5 on CBC and urinalysis (but with few bacteria reminiscent of perforated appendicitis.
- 65. Management
- 66. â—Ź Antibiotics â—‹ Should be initiated promptly once diagnosis of appendicitis is made â—‹ Lowers the incidence of postoperative wound infections, SSIs and intraabdominal abscesses â—‹ Should be directed against typical flora found in the appendix, including anaerobic and gram negative organisms â—‹ Simple non-perforated: single dose of a broad spectrum agent such as Cefoxitin is sufficient â—‹ Perforated/Gangrenous: combination drugs such as Ceftriaxone/Metronidazole, Ticarcillin/Clavulanate, Pip-taz â—‹ Continued postoperatively for 2-3 days if perforated, longer if with complications (7-10days) MEDICALMANAGEMENT
- 67. â—Ź Correction of dehydration â—‹ Losses from fever, vomiting or other symptoms â—‹ Vascuar support in hypovolemia from sepsis â—Ź Electrolyte correction â—‹ Similar losses from symptoms particularly from vomiting, diarrhea or sepsis â—Ź Pain management â—‹ Should have been started from at time of diagnosis MEDICALMANAGEMENT
- 68. â—Ź Non-Operative Management â—‹ Increasing popularity â—‹ Percutaneous drainage, antibiotics and fluids â—‹ Spontaneous resolution of appendicitis in non-perforated cases â—‹ Mainly done to avoid complications associated with surgery â—‹ Interval appendectomy if symptoms persist (fever, abdominal pain, vomiting) â—‹ 10-20% risk of recurrence within 1 year â—‹ Lifetime risk unknown â—‹ May be costlier if appendicitis recurs or if there is treatment failure. MEDICALMANAGEMENT
- 69. â—‹ Uncomplicated â– Multiple studies demonstrate high effectiveness â– 75-80% success rate with no increased rate of perforation even if treatment fails â– Selection criteria â—Ź <48hr duration â—Ź >7 yo â—Ź Imaging confirmation of acute non-perforated appendix â—Ź Appendiceal diameter <1.2cm â—Ź Absence of appendicolith, abscess, or phlegmon â—Ź WBC >5,000, and <18000 â– Appendectomy if no improvement/treatment failure MEDICALMANAGEMENT
- 70. â—‹ Complicated â– More recent and not typically done â– Only if necessary equipment and staff are available with up to 80% success rate â– Can be done if: contained abscess or phlegmon but limited peritonitis â– Antibiotics continued to complete 10 days after discharge (Ciprofloxacin+Metronidazole) â– Appendectomy if no improvement â– Decision to do interval appendectomy after 4-6weeks MEDICALMANAGEMENT
- 71. â—Ź Prompt appendectomy as standard of treatment â—Ź Should proceed 12-24hrs after diagnosis â—Ź Laparoscopic appendectomy is preferred approach â—‹ Slightly better clinical outcome â—‹ Easier to do on obese patients â—‹ Easier to evaluate ovarian pathologies if suspected â—‹ Minimally invasive â—‹ Costly â—‹ Faster return to normal activity and better cosmetics â—‹ Lesser analgesia needed â—‹ Lower SSI rate SURGICALMANAGEMENT
- 72. â—Ź Open appendectomy â—‹ Simpler and easier to perform â—‹ Problematic on obese patients â—‹ Longer hospital stay â—‹ Cheaper to perform â—‹ Use of more powerful anesthesia â—‹ Easier compared to laparoscopic if appendix is placed atypically SURGICALMANAGEMENT
- 73. â—Ź Urgent (w/in 17hrs of admission) vs Emergent (w/in 5hrs of admission) â—‹ Depends on hospital policy, decision of surgeon, or complications of the disease â—‹ No difference in perforation rates (in simple), operative time, readmission rate, complications or length of stay noted SURGICALMANAGEMENT
- 74. â—Ź Interval appendectomy â—‹ Area of management that lacks consensus along with non-operative management â—‹ Done 4-6 weeks after non-operative management â—‹ Done to avoid recurrent appendicitis after non-operative management â—‹ An option if the patient would not be able to tolerate appendectomy at time of diagnosis SURGICALMANAGEMENT
- 75. PATIENT â—Ź Medical management o Venoclysis to replenish intravascular volume o Antibiotic management with Ceftriaxone and Metronidazole o Shifted to oral upon discharge with Metronidazole and Cefixime â—Ź Surgical Management o Open appendectomy was done o Purulent material in abdominal cavity removed and washed o Surgical site remained well closed with no bleeding or discharge
- 76. â—Ź 5th hospital day â—Ź Remained afebrile, with stable vital signs â—Ź Antibiotics shifted to oral â—Ź Continue antibiotics to complete 10 days â—Ź Discharged well and stable â—Ź Follow-up in 1 week PatientOutcome
- 77. REFERENCES Kliegman, R., Geme, J.S. (2019). Nelson: Textbook of Pediatrics (21st Ed., pp. 2048-2055). Canada: Elsevier. Kliegman, R., Lye, P. (2018). Nelson Pediatric Symptom- Based Diagnosis (1st Ed., pp. 161-181). Canada: Elsevier.
- 79. THANKYOU
- 81. â—Ź One of the most common complaints in a child and may require immediate evaluation â—Ź Diagnosis is usually dependent on the history and clinical features â—Ź Majority of abdominal pain is from a benign cause such as constipation â—Ź Most common medical cause is gastroenteritis; surgical is appendicitis â—Ź Differential diagnosis is wide and varies with age group â—Ź Challenge is to identify the correct diagnosis or disease with possibly life-threatening consequences Introduction
- 83. ● Accurate history is critical for making a diagnosis ● Location – have the child identify the location of the pain and any changes in its location; help identify the possible organ affected ● Character – description of the pain may help in identifying a diagnosis (ex. Appendicitis: sharp and steady, Cholecystitis: colicky and severe ● Timing – pain fewer than 6 hours may warrant only observation especially without associated symptoms; greater duration may need deeper assessment; also frequency of recurrence, how long after a specific activity History
- 84. ● Activity – effects of pain in a child’s activity is an important indicator of severity of underlying disease; What was the child doing when the pain occurred. ● Severity – degree of pain on a scale of 1 to 10 ● Radiation – radiation of pain may help in identifying a diagnosis (ex. sharp piercing pain radiating to the back: pancreatitis) History
- 85. â—Ź Associated symptoms â—‹ Fever â—‹ Nausea and Vomiting â—‹ Weight loss â—‹ Hematochezia and melena â—‹ Diarrhea or constipation â—‹ Consider non-abdominal symptoms that may present as it may shy diagnosis away from the abdomen as in viral infections. â—Ź Family history â—Ź Sexual/Menstural Hsitory â—Ź Social/Environmental history History
- 88. PhysicalExamination ● General Appearance – PE starts upon entering the room or approaching the patient; children with visceral pain may seem active and loud in mild abdominal pain to quiet and motionless or writhing in severe pain ● Vital Signs – the different vital signs may help indicate the severity or type of illness: fever may indicate an inflammatory process or infection if high grade, tachycardia if there is active bleeding in cases such as bleeding ulcerations, or tachypnea in pneumonia (Children with lower lobe bacterial pneumonia present with severe abdominal pain)
- 89. PhysicalExamination â—Ź Inspection - look for contour, symmetry, pulsations, peristalsis, vascular irregularities, skin markings, wall protrusions (hernias), any signs of trauma (Ie. bruising, swelling), and abdominal distension â—Ź Palpation - assess tenderness with light and deep palpation, assess for guarding and rebound tenderness, palpate for liver, spleen, kidney and abdominal masses (including fecal mass). Start far from location of pain and approach gradually â—Ź Percussion - assess general tone, percuss for liver span and spleen tip, assess for ascites. Avoid doing excessively as it may exacerbate pain
- 90. PhysicalExamination ● Auscultation - auscultate before palpation in the abdominal exam, listen for bowel sounds, pressure of the stethoscope may also be used for palpation and may be a valuable clue to areas of true tenderness ● Special Maneuver’s/Tests – Rovsing’s, Obturator, Psoas, Dunphy’s, Murphy’s, Rebound tenderness etc.
- 92. DiagnosticExamination â—Ź CBC â—‹ Hgb and Hct may reveal anemia from acute (ex. Diverticula, ulcers) or chronic (ex. Inflammatory bowel disease) blood loss â—‹ Increased WBC may indicate infection or blood dyscrasias â—‹ In cases of appendicitis WBC >18,000/mm3 may indicate perforation, peritonitis or gangrene; may also be elevated in bacterial AGE, pyelonephritis or PID â—‹ Normal or mildly elevated WBC may also be seen in appendicitis, in such cases clinical correlation is still important
- 93. DiagnosticExamination â—Ź Urinalysis â—‹ Findings correlated with symptoms may lead to a diagnosis â—‹ Presence of increased WBC and bacteria indicate UTI; either findings alone is inconclusive â—‹ Presence of WBC alone may indicate an inflammatory mass or event adjacent to the urinary tract â—‹ Hematuria is seen in urinary tract pathologies such as nephrolithiasis â—Ź Other laboratory tests should be ordered based on an index of suspicion such as amylase or lipase if pancreatitis is suspected or liver function tests in cases of possible hepatic pathology
- 94. â—Ź Plain Radiograph â—‹ Most useful when intestinal obstruction or perforation of a viscus in the abdomen is a concern â—‹ Helps assess the presence of lower lobe pneumonia which may present as upper abdominal pain â—‹ 10% of radiographs are positive as part of routine work-up for abdominal pain but up to 46% in patients with serious illnesses â—‹ Less operator dependent, readily available, cheap but with exposure to radiation DiagnosticExamination
- 95. â—Ź Ultrasonography â—‹ Ideal for children â—‹ Painless, readily available, no radiation, no IV contrast needed, and no sedation needed â—‹ Operator dependent and difficult if patient is uncooperative â—‹ Helps in discerning pelvic pathologies especially with females where gynecologic presentations may be confused with other problems DiagnosticExamination
- 96. â—Ź Computed Tomography â—‹ Useful in initial evaluation of abdominal trauma and in determining extent of abdominal masses. â—‹ Readily available, rapid, lesser operator dependency â—‹ More expensive; radiation exposure â—‹ Has high sensitivity and specificity DiagnosticExamination