Deadly Misdiagnoses: Kids with GI Complaints Objectives Understand key assessment techniques for recognition of serious illness in children. Ronald Dieckmann, MD Professor of Clinical Pediatrics and Emergency Medicine, UCSF Director of Pediatric Emergency Medicine, San Francisco General Hospital Outline the appropriate ED evaluation and treatment for infants and children with bilious vomiting. Outline the appropriate ED evaluation and treatment for infants and children with severe abdominal pain. Outline the appropriate ED evaluation and treatment for infants and children with bloody diarrhea. Be aware of congenital anomalies and childhhood-specific diagnoses in pediatric GI complaints. Bilious vomiting CASE 1 Previously normal 6 mos old stopped feeding yesterday and has had brown-green vomiting all day today, with abdominal distention. Child is sleepy and irritable. VS: HR 200/min, RR 65/min, BP cannot be obtained, T 39. Child cries with any movement and will not fix gaze. SFGH Case Study Sick or not sick? Problems in assessment The child may be nonverbal or unable to describe symptoms. Palpation is often normal, especially with obstructive conditions.
Assessment problems Auscultation is of limited value. Vital signs are hard to get and hard to interpret. Goals of ED assessment Specific diagnosis is rarely important in first phases of ED resuscitation and stabilization. In the ED, our main goal is to identify physiologic problems, based upon rapid assessment characteristics. Our first treatment task is to reverse physiologic problems. Specific diagnosis often occurs in the imaging suite, the OR, or after inpatient consultation/testing. Three things to look for Appearance Appearance Circulation to skin Work of breathing TICLS ( tickles ) Tone Interactiveness Consolability Look/gaze Speech/cry
Approach to avoid Appearance The child s appearance is the best indicator of oxygenation, perfusion, CNS function and metabolic status. Traditional vital signs do not even come close! No hands-on exam is needed to make this assessment, only a doorway impression. 6 month old with cough and fever last night 18 month old with fever and bloody diarrhea
Work of Breathing Circulation to Skin Abnormal airway sounds Abnormal positioning Retractions Flaring Pallor Mottling Cyanosis Case 1 ED Assessment The child appears critically ill, and in shock The abdomen is grossly distended and peritoneal signs are present. Stool + Inflammation with perforation or obstruction are important primary causes Initial ED management 5 lines ETI, with continuous digital capnometry Two IV or IO lines, then 20-60 ml/kg boluses NG and urinary bladder catheter 16
Easy equipment formulas Equipment selection/drug dosing Calculate ETT size first Length is the most accurate index Age is less accurate but a reasonable option: (16 + age in yrs)/4 Size of fifth fingernail or diameter of nares NG and UBC sizes are 2 X ETT size ETT length (at lip line) is 3X ETT size Chest tube size 2 X NG, or 4 X ETT size Use a length-based tape Basic 3 part system Color-tape Color-coded crash cart Color-coded drug manual 17 18 Computerized Decision Support Bilious vomiting Case 1 differential diagnosis Inflammation with perforation Intestinal obstruction Duodenal atresia, stenosis, web Duplication Hirschsprung disease Incarcerated inguinal hernia Intussusception Meckel diverticulitis Midgut volvulus
Neonate Laboratory evaluation Do not forget meconium ileus and imperforate anus WBC: 23,000, hct 46%, platelets 330K Chemistries: Na 127, K 3.0, Cl 88, HCO3 16, anion gap 26 LFTs normal UA: 3+ ketones, 2-5 WBCs/hpf, - bacteria Imaging Ultrasound Abnormal SMA with spiral sign Plain abd X-ray Barium study
Why not CT? Sedation for CT Children, especially < 5 yrs, are 10x more vulnerable to radiation than adults Radiation induced malignancies are a serious concern b/o radiosensitivity of certain organs (brain, thyroid) and long period for development Etomidate 0.15 0.3 mg/kg IV/IO Recent multi-center trial showed etomidate to be superior to conventional pentobarbital at 5 mg/kg IV/IO Lifetime cancer risk in 1 year old from CT exposure: 0.07 0.18%!! 25 26 No unstable kids in CT! Definitive treatment Taking the unstable child to CT is dangerous! 27 Detorsion of midgut volvulus
Facts of life Volvulus Midgut volvulus with malrotation Gut malrotation is a embryological failure of rotation and bowel fixation that occurs in 1/500 births. Obstructing Ladd bands first fix the cecum, then compress the small bowel. Midgut volvulus and SMA ischemia and torsion of the entire midgut is a catastrophic complication (70%). Presentation: neonates, 75-90% are < 12 months old. Bowel necrosis occurs in 1 to 2 hours. Summary CASE 1 Bilious vomiting suggests intestinal obstruction distal to Ampulla of Vater. Resuscitate the critical child with 5 lines, aggressive boluses of NS 20 ml/kg, and antibiotics for sepsis. Obtain immediate surgical consultation before imaging. If child stable, start with ultrasound for most suspected cases of abdominal inflammation or obstruction. SFGH Case Study Take home point Bilious vomiting in an infant is midgut volvulus until proven otherwise.
Congenital GI anomalies Biliary atresia Esophageal atresia Hirschsprung disease Imperforate anus Malrotation and midgut volvulus Meckel diverticulum Pyloric stenosis Small bowel atresia, stenosis Belly pain CASE 2 3 year old boy brought to ED because of abdominal pain and diarrhea since yesterday. Child is distressed and crying, while clinging to father. VS: HR 160/min, RR 40/min, BP 85/palp, afebrile. + Rovsing, RLQ tender, rectal tender, guaiac - stool SFGH Case Study Facts of life Pain in children Belly pain by age Pain in kids is underrecognized and undertreated in the ED. Many children are more likely to fear needles than a fatal diagnosis, so consider ouchless and non-parenteral drug administration techniques. Begin with standard narcotic doses and titrate upwards. Infant Colic Congenital anomalies Gastroenteritis Incarcerated hernia Lactase deficiency and cows milk protein allergy Intussusception Midgut volvulus
Belly pain by age Henoch Schonlein purpura Toddler Appendicitis Gastroenteriris Henoch Schonlein purpura Hemolytic uremic syndrome Incarcerated hernia School-aged child Appendicitis Gastroenteriris Henoch Schonlein purpura Inflammatory bowel disease Recurrent abdominal pain Belly pain by age Take home points Adolescent Ectopic pregnancy Inflammatory bowel disease Menstrual disorders and ruptured ovarian cyst Ovarian torsion or testicular torsion Pelvic inflammatory disease Narcotics will not obscure significant physical findings in abdominal pain. They are more likey to improve the accuracy of the assessment.
Options for analgesia Management Tip Fentanyl IV or IM, 1 ucg/kg Morphine IV or IM, 0.1 mg/kg Intranasal fentanyl 1.5 ucg/kg Consider intransal fentanyl for immediate pain relief. Use atomizer device to nebulize drug, and squirt half of the dose into each nostril. Laboratory evaluation Fever and belly pain Case 2 differential diagnosis WBC: 16,400, hct 45%, platelets 225 K Chemistries and LFTs normal UA: 2+ ketones, 5-10 WBCs/hpf, - bacteria Gastroenteritis Inflammatory processes Appendicits Meckel diverticulitis Mesenteric adenitis Pneumonia Pyelonephritis
Take home point Ultrasound Lower lobe pneumonia may mimic an abdominal inflammation. Peri-appendicial fluid Treatment Summary CASE 2 Treat serious pain immediately with narcotics and give crystalloid boluses if assessment suggests inflammatory process. Do careful anatomic exam, and rectal, and do pelvis exam in girls through rectum. Total WBC may be more predictive of appendicitis in children. Pyuria without bacteriuria is common. Start with ultrasound for most stable suspected cases of abdominal inflammation or obstruction. SFGH Case Study
Missed pediatric appendicitis Age < 5 years Diarrhea Dysuria Emesis before pain No anorexia Bloody diarrhea CASE 3 20 mos old girl with fever to 41 C at home Child has had 2 days of severe abdominal pain and bloody diarrhea. No emesis. VS: HR 180/min, RR 45/min, BP 75/palp, T 36 SFGH Case Study ED Assessment Child is pale, irritable and poorly interactive. Exam shows fever, no source of infection, and non-focal neuro evaluation. No belly tenderness, rectal nontender, stool is frank blood. Multiple petechiae on skin. SFGH Case Study Bloody diarrhea Case 3 differential diagnosis Fissures, fistulae Gastroenteritis Hemolytic uremic syndrome Henoch Schonlein purpura Inflammatory bowel disease Intussusception Meckel diverticulitis Sepsis
Laboratory data WBC: 18,000 Hct 16% Platelets 25K Creatinine: 4.5 UA: 2+ heme, 3+ prot, 10-20 RBCs Facts of life Hemolytic uremic syndrome HUS is a heterogeneous disorder, and the most common cause of ARF in children In USA, cause is usually shiga toxin producing E. coli 0157:H7 from improperly cooked meats There is often a prodrome of gastroenteritis or URI, then sudden severe illness with lethargy and pallor Clinical features: microangiopathic anemia, acute renal failure, and thrombocytopenia in an infant < 2 years Renal failure is acute and rapidly progressive Management tip Treatment Early transfusions SFGH Case Study Send blood culture for E. Coli 0157:H7. Antibiotics do not help in HUS. Management of renal failure, often early dialysis Aggressive management of hypertension and hyperkalemia Possible plasmaphoresis in severe children > 5 years Hypertension and chronic renal failure develop in later childhood for 15-20% of patients
Take home point Important systemic or extra-abdominal conditions with GI presentations Always consider HUS and sepsis in a sick young child with bloody diarrhea and thrombocytopenia. Hemolytic uremic syndrome Henoch Schonlein purpura Pneumonia Pyelonephritis Sepsis Streptococcal pharyngitis Summary CASE 3 SFGH Case Study Thanks! Bloody diarrhea in a sick child is a critical sign of illness. Always consier sepsis in any child who has these presenting features. Thrombocytopenia will usually distinguish HSP from HUS. The E Coli 015:H7 organism is responsible for most HUS. Treatment goals include transfusions and organ system support.