Abdominal pain for evaluation. Dr Sanket Sontakke (DNB paediatrics 1st yr, Apollo children s hospital) GUIDE: Dr Shyamala J

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1 Abdominal pain for evaluation Dr Sanket Sontakke (DNB paediatrics 1st yr, Apollo children s hospital) GUIDE: Dr Shyamala J

2 13 year old girl presenting with Fever since 3 days Pain abdomen since 3 days Fever high grade with 1-2 spikes in a day -associated with chills and rigors -similar episode of fever 10 days back Abdominal pain -diffuse, dull lower abdominal with no radiation. - not associated with vomiting. Relieved with analgesics

3 Admitted with menorrhagia last year, with deranged coagulation, anemia and profound shock requiring resuscitation with fluids, inotropes, packed cell transfusion Chest Xray - consolidation of both lower lobes and a pleural reaction Echo revealed LV dysfunction / pericarditis Vasculitis pack- ANA+, Anti dsdna+, Cardiolipin IgM raised Symptoms and lab criteria positive for SLE Received methylpresnisolone (30mg/kg) 4 doses and Enalapril for LV Dysfunction

4 Patient was on Tab Prednisolone 1mg/kg/day at the time of presentation She had regular periods No other significant past history

5 Patient well nourished, alert, febrile on presentation No pallor Had tachycardia with well perfused extremities. Normotensive P/A-warm -diffuse tenderness more in left lumbar region -No free fluid -No palpable mass

6 GI / Renal Silent perforation with peritonitis Pancreatititis Subphrenic abscess Mesenteric adenitis Meckel s diverticulitis IBD Irritable bowel syndrome Pyelonephritis Renal stone PID ( rare in sexually inactive females) Ovarian torsion/cyst

7 WBC,CRP,ESR raised USG Abdomen - left ovarian torsion Diagnostic laparoscopy done Left suppurative salpingitis Abscess drained Antibiotics for coverage ( 14 days total)

8 PID refers to infection and inflammation of the upper genital tract involving the endometrium, fallopian tubes, ovaries, and adjacent pelvic spaces. Incidence of PID in women 15 to 39 years of age seems to be 10 to 13 per 1000 women with a peak incidence of about 20 per 1000 women in the age group 20 to 24 years

9 Possibility of PID in this case scenario? Pathophysiology of PID Management of PID

10 (1)It is generally a disease of young, sexually active women of reproductive age group (2)Sexual activity is a prerequisite for acquiring this disease thus, PID is considered to be rare in sexually inactive girls (3)Our review of the literatures revealed 11 cases of tubo - ovarian abscesses in sexually inactive females* Hartmann KA, Lerand SJ, Jay MS. Tubo-Ovarian Abscess in Virginal Adolescents: Look for Underlying Etiology. J Pediatr Adolesc Gynecol 2007; 20: 127. Dogan E, Altunyurt S, Altindag T, Onvural A: Tubo-ovarian Abscess Mimicking Ovarian Tumor in a Sexually Inactive Girl. J Pediatr Adolesc Gynecol 2004; 17: Arda IS, Ergeneli M, Coskun M, Hicsonmez A: Tubo-ovarian abscess in a sexually inactive adolescent patient. Eur J Pediatr Surg 2004; 14: Teng FY, Cardone JT, Au AH: Pasteurella Multocida tubo-ovarian abscess in a virgin. Am J Obstet Gynecol 1996; 87: 883. Hartmann KA, Lerand SJ, Jay MS. Tubo-ovarian abscess in virginal adolescents: exposure of the underlying etiology. J Pediatr Adolesc Gynecol 2009; 22: Gensheimer WG, Reddy SY, Mulconry M, Greves C. Abiotrophia/Granulicatella tubo-ovarian abscess in an adolescent virginal female. J Pediatr Adolesc Gynecol 2010; 23: 9-12.

11 PID is predominantly an ascending infection from the lower to the upper genital tract. Microbial agents may reach the upper genital tract by three routes: Ascending infections from the cervix and endometrium caused by sexually transmitted microorganisms; Secondary to direct spread from nearby pelvic organs with inflammatory process, such as appendicitis; and Hematogenous.

12 Multiple sexual partners, increased incidence of STD and PID. (The risk of developing PID increases by a factor of 5 in these patients) Iatrogenic" PID is common. Opening of the cervical canal or introduction of foreign material into the uterine cavity facilities ascending spread of infection from the cervix cervical dilatation, abortion, curettage, tubal insufflation, hysterosalpingography, and IUD insertion ( Introduction of an IUD increases the risk of PID by 1.5 to 5 times, depending upon the type of IUD employed)

13 PID has a multimicrobial etiology Neisseria gonorrhea and Chlamydia trachomatis are the most common pathogens in PID. Other aerobic and anaerobic agents, such as Mycoplasma hominis, peptostreptococcus, and Bacteroides species, account for 25% to 50% of PID Mycobacterium tuberculosis

14 PID is predominantly an ascending infection from the lower to the upper genital tract. Microbial agents may reach the upper genital tract by three routes: 1) ascending infections from the cervix and endometrium caused by sexually transmitted microorganisms; 2) secondary to direct spread from nearby pelvic organs with inflammatory process, such as appendicitis 3) hematogenous Pus c/s Pseudomonas sp No AFB on stain or c/s HPE- No evidence of granulomas / AFB

15 Minimal clinical criteria for diagnosis -Cervical motion tenderness OR -Uterine or adnexal tenderness Additional criteria -Oral temperature>101 F -Abdominal,cervical or vaginal non purulent discharge -Abundant wbc on microscopy of vaginal secretion Increased ESR/CRP Lab documentation of cervical infection

16 Testing for gonorrhoea, chlamydia in sexually active women Blood cultures and culture samples from surgical specimen to isolate organism in adolescent girls Pregnancy test to rule out ectopic WBC, ESR, CRP, USG

17 REGIMEN 1 Levoflox:500mg once daily 14 days or Oflox: twice daily 14 days with/without metro:500mg 14 days REGIMEN 2 Ceftriaxone:250mg im single dose + Doxy:100mg oral twice for 14 days with/without metro

18 REGIMEN 3 Cefoxitin, 2gm im one dose Probenacid 1gm orally 1 dosage +Doxy with/without metro REGIMEN 4 Parental 3rd gen cephalosporin +Doxy with/without metro

19 Surgical emergencies/pregnancy No response clinically to oral antimicrobials Unable to follow out patient regimen Severe illness, nausea, vomiting Tubo-ovarian abscess

20 PID incidence of 9.7% Of the adolescent females diagnosed with PID, 47% had recurrent PID. Of the females with recurrent PID, 27% had three or more episodes. Only 36% of adolescent females diagnosed with PID ever reported that their partners had been treated. Pelvic inflammatory disease in adolescents: high incidence and recurrence rates in an urban teen clinic. Kelly AM, Ireland M, Aughey D J Pediatr Adolesc Gynecol 2004 Dec: 17(6):383-8 Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota, USA.

21 To prevent sequelae like: Chronic pelvic pain and inflammation Scarring and adhesions Subsequent infertility Increased risk of ectopic pregnancy

22 THANK YOU!