Gastro-tastrophies A Review of Pediatric GI Emergencies Objectives Discuss common presentations of Pediatric Abdominal Pain complaints Discuss work up and physical exam findings Discuss care, management and disposition of these patients Discuss appropriate referral of patients A. Jared Wiebel, PA-C, MPAS Iowa Physician Assistant Society Spring CME 2016 West Des Moines, IA Another belly pain Nausea, Vomiting and Diarrhea accounts for 6.4% of Doctor Visits annually Abdominal Pain is 3 rd most frequent acute diagnosis at 4% annually Following Obstetrics and Cardiac complaints, Abdominal Pathology is 3 rd highest M/M and litigious complaints 2014 CDC and US National Center for Health Statistics Age Groups 1 2 Pediatric Mortality <1 yr 1-4 yrs 5-9 yrs 10-14 yrs 15-24 yrs Short pregnancy 3 SIDS Cancer 4 5 6 Cancer Cancer Homicide Suicide Suicide Pregnancy complicatio Homicide Homicide Homicide Cancer ns Placenta problems Respiratory distress Flu/ RSV? Pneumonia Cancer Compiled from data available from CDC National Center for Health Statistics (NCHS) Spewing & Pooing Child Common presentation of symptoms as the patient is preverbal Often will determine further work up Character of vomiting o Feeding o Bloody o Bilious Character of stool o Normal o Loose o Odor o Blood (color change) >3 loose stools in a 24 hour period +/- Vomiting Often viral etiology Be aware of current updates from Public Health 1
Labs can be adjunct for clinical course Stool Cultures ORT vs IV Fluids 1. Dry mucous membranes 2. Cap refil >2 seconds 3. Toxic appearance 4. Absent tears Common Pitfalls of Documentation of witnessed ability to tolerate ORT Tenderness on exam is NOT Isolated vomiting without diarrhea is NOT Diagnosis of exclusion Appendicitis Most common cause of an acute abd in every generation of life Highest incidence is age 10-14 (M) and 15-19 (F) Younger the patient, the higher the incidence of perforation and mortality Imaging Appendicitis Plain Films: o Low yield of specific findings o Unnecessary radiation exposure for the child o Late findings associated with perf are more diagnostic CT Scan: o 87-100% specificity for diagnosis o Gold standard of Radiographic diagnosis o Safety net for other causes of abd pain US in Appendicitis Compression focused US is operator dependent Appendicitis on US Current meta analysis data between 2004-2014 showed an 85% specificity and 92% sensitivity False negatives are often anatomical Study of choice today as it is low cost, rapid exam, non-invasive, no contrast and no radiation exposure to the child 2
Treatment of Appendicitis Surgical consultation is emergent Correction of sepsis and electrolyte abnormalities Laparotomy for resection of the appendix Use of antibiotics in children with serial exams? Caused by a portion of the bowel telescoping into another segment of the bowel Most common cause of intestinal obstruction in Peds Rare before 3 mos of age Commonly see following GI illness thought to be caused by intralumen lymphoid hyperplasia Presentation Usually seen in 6-18 mo child with no PMH Cramping, intermittent colicky pain Pain ceases after a few minutes and child is back to normal Current Jelly with rectal pain or Guaic positive stool even in absence of gross blood on exam Diagnosis is often made with history alone US will show invagination of the bowel, reasonable first line study with high S/S Plain films may show a filling defect, however these are often read as normal Transverse US Coronal US 3
Air contrast enema (air insufflation) as preformed by Radiologist or Surgeon Malrotation & Volvulus Volvulus is a life threatening complication of malrotation Barium enema has higher risk associated for treatment 90% of these cases will occur in the first year of life however volvulus can occur at any age in life After successful reduction, pt will need admission for recurrent and bowel rest Irreversible ischemia can occur within a few hours of symptom onset Malrotation Approx 10 weeks gestation the midgut undergoes a 270 counterclockwise turn around the SMA Incomplete rotation leaves the cecum high in the abd with peritoneal attachments crossing the duodenum in an obstructing manner This area will twist and then cause vascular compromise and ischemia of the distal gut Volvulus Infant will appear in distress with abd pain/ distention, irritability, bilious vomiting and sepsis from peritonitis later in progression Imaging with Plain Films and CT will be most beneficial. Gross appearance of obstruction with birds beak appearance noted at the Duodenum Surgical consultation is emergent and should not be delayed for Radiology reports Volvulus on Plain Films Intractable Vomiting Marijuana causing intractable vomiting Withdrawal from substance abuse Isolate these children or order the proper tests to get your diagnosis 4
Non-accidental Child abuse is often to the head and abd Exam the skin for evidence of bruising Perforated or pneumobilia can be life threatening GYN Pathology Do not confuse pelvic pain for abd pain Focused GYN questions are difficult to extract from Pediatric populations Imaging and labs are often over-ordered Pitfalls leading to Gastro-tastrophies Abd pain is difficult to assess in the Pediatric population due to communication barriers Questions. Always document hydration status and ORT progress under your care Follow up within 8-12 hours Refer to specialists who are more comfortable in assessing these patients Do not over image these patients thank you 5