abdominal pain in the pediatric patient
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Abdominal Pain in the Pediatric PatientTRANSCRIPT
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ABDOMINAL PAIN in the PEDIATRIC PATIENTTim Weiner, M.D.Dept. of SurgeryUniversity of North Carolinaat Chapel Hill
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In GeneralCommon problems occur commonlyintussusception in the infantappendicitis in the childThe differential diagnosis is age-specificIn pediatrics most belly pain is non-surgicalMost things get better by themselves. Most things, in fact, are better by morning.Bilous emesis in the infant is malrotation until proven otherwiseA high rate of negative tests is OK
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The HistoryPain (location, pattern, severity, timing)pain as the first sx suggests a surgical problemVomiting (bile, blood, projectile, timing)Bowel habits (diarrhea, constipation, blood, flatus)Genitourinary complaintsMenstrual historyTravel, diet, contact history
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Diagnosis by Locationgastroenteritisearly appendicitisPUDpancreatitisnon-specificcolicearly appendicitis
constipationUTIpelvic appendicitisbiliaryhepatitis
appendicitisenteritis/IBDovarianspleen/EBV
constipationnon-specificovary
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The Physical ExaminationWarm hands and exam roomTry to distract the child (talk about pets)A quiet, unhurried, thorough examPlan to do serial examsDo a rectal exam
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The Abdominal Examinationbreath soundsMurphys signsausage
Dances signreboundtender at McBurneys pointcecal squishherniastorsionbreath soundsspleen edge
constipationRovsings sign
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Relevant Physical FindingsTachycardiaAlert and active/still and silentAbdominal rigidity/softnessBowel soundsPeritoneal signs (tap, jump)Signs of other infection (otitis, pharyngitis, pneumonia)Check for hernias
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Blood in the StoolNewborningested maternal blood, formula intolerance, NEC, volvulus, HirschsprungsToddleranal fissures, infectious colitis, Meckels, milk allergy, juvenile polyps, HUS, IBD2 to 6 yearsinfectious colitis, juvenile polyps, anal fissures, intussusception, Meckels, IBD, HSP6 years and olderIBD, colitis, polyps, hemorrhoids
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Blood in the VomitusNewborningested maternal blood, drug induced, gastritisToddlerulcers, gastritis, esophagitis, HPS2 to 6 yearsulcers, gastritis, esophagitis, varices, FB6 years and olderulcers, gastritis, esophagitis, varices
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Further Work-upCBC and differentialUrinalysisX-rays (KUB, CXR)USAbdominal CTStool culturesLiver, pancreatic function tests(Rehydrate, ?antibiotics, ?analgesiscs)
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Relevant X-ray FindingsSigns of obstructionair/fluid levelsdilated loopsair in the rectum?FecalithPaucity of air in the right sideConstipation
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Operate NOWVascular compromisemalrotation and volvulusincarcerated hernianonreduced intussusceptionischemic bowel obstructiontorsed gonadsPerforated viscusUncontrolled intra-abdominal bleeding
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Operate SOONIntestinal obstructionNon-perforated appendicitisRefractory IBDTumors
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AppendicitisCommon in children; rare in infantsSymptoms tend to get worsePerforation rarely occurs in the first 24 hoursThe physical exam is the mainstay of diagnosisClassify as simple (acute, supparative) or complex (gangrenous, perforated)
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Incidental AppendectomyCan be done by inversion techniqueAbsolute indicationLadds procedureRelative indicationsHirschsprungs pullthroughOvarian cystectomyIntussusceptionAtresia repairWilms tumor excisionCDH
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IntussusceptionTypically in the 8-24 month age groupDiagnosis is historicalintermittent severe colic episodesunexplained lethargy in a previously healthy infantContrast enema is diagnostic and often therapeuticPost-op small bowel intussusception
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The Medical BellyachePneumoniaMesenteric adenitisHenoch-Schonlein PurpuraGastroenteritis/colitisHepatitisSwallowed FBPorphyriaFunctional ileusUTIConstipationIBD flarerectus hematoma
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LaparoscopyDiagnosisnon-specific abdominal painchronic abdominal painfemale patientsundescended testestraumaTreatmentappendicitisMeckels diverticulumcholecystitisovarian detorsion/excisionlysis of adhesions
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The Neurologically Impaired PatientThe physical exam is important for non-verbal patientsThe history is important for the spinal cord dysfunction patientClose observation and complementary imaging studies are necessary
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The Immunologically Impaired PatientA high index of suspicion for surgical conditions and signs of peritonitis may necessitate operationperforationuncontrolled bleedingclinical deteriorationBlood product replacement is essentialTyphlitis should be considered; diagnosis is best established by CT
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The Teenage FemaleMenstrual historyregularity, last period, character, dysmenorrheaPelvic/bimanual exam with culturesPregnancy test/urinalysisUSLaparoscopyDifferential diagnosismittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis
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In SummaryMy dear surgeon, beware- haste not,Pleads the child silently,Listen to my mother, and then-Examine and again examine me:This will improve my lotAnd assure you accuracy.