1. Case Mortality & Mobility Conference Date: 2005-11-29 Presented by R2 劉顯達 Instructor: VS 張玉喆

2. ED at Keelung CGMH  General data  邱 X 茹  Chart number: 7168240  Age: 2 years and 7 months old  Gender: female  BW: 13kg  No other systemic diseases  Vaccine as schedule

3. 94-10-24 PM5:29 arrived at ER  T 37.1, P 150, R 24, BP 129/78 mm Hg  E4V5M6  檢傷分類 : 二級  病患主訴腹痛  Chief complaints  Fever for 1 day (40 degree)

4. Present illness  watery diarrhea without bloody or mucus stools 3-4 times  no URI s/s  intake record: 5AM:130 ml 5AM:130 ml 9AM:cake*1 9AM:cake*1 2PM:140 ml 2PM:140 ml  Activity: ok  Urine output: 換二次尿布  在家不太願意走路  What else do you want to know?

5. What information do you want to know?  Anorexia and vomiting suggest distension of an intraabdominal viscus  Rectal bleeding points to infectious enterocolitis, intussusception, Meckel's diverticulum, or more rarely, inflammatory bowel disease (IBD). inflammatory bowel disease (IBD).  Extraabdominal complaints, such as cough, sore throat, and headache, are commonly present; they often indicate pneumonia, pharyngitis, or a viral syndrome.  Urinary symptoms may occur with pyelonephritis, and polydipsia with polyuria may herald the onset of diabetes mellitus with abdominal pain from ketoacidosis.

6. Physical examination  Appearance: alert  HEENT: mucus: mild dry tear(+) tear(+)  Chest: breathing sound: clear heart sound: tachycardia heart sound: tachycardia  Abdomen: mild distended bowel sound: hypoactive bowel sound: hypoactive  Extremities: no skin rash/vesicle  What else do you want to do ？

7. Physical examination  jaundice (hepatitis, hemolytic anemia)  palpable mass at abdomen (intussusception)  guarding or persistent abdominal tenderness with gentle palpation (acute appendicitis, intussusception or malrotation )  rash or arthritis (Henoch-Schönlein purpura)  cardiac murmurs (rheumatic fever)  friction rubs (pericarditis)  “acetone” on the breath (diabetes mellitus).

8. Causes of Acute Abdominal Pain Textbook of Pediatric Emergency Medicine(2006) Infancy (<2 yr) Preschool Age (2 – 5 yr)School Age (>5 yr)Adolescent Common Colic (age <3 mo) Gastroesophageal reflux disease (GERD) Acute gastroenteritis “ Viral syndromes ” Acute gastroenteritis Urinary tract infection (UTI) Trauma Appendicitis Pneumonia, asthma Sickling syndromes “ Viral syndromes ” Constipation Acute gastroenteritis Trauma Appendicitis UTI Functional abdominal pain Sickling syndromes Constipation “ Viral syndromes ” Acute gastroenteritis Gastritis (primary or alcohol induced) Colitis (food intolerance) GERD Trauma Constipation Appendicitis Pelvic inflammatory disease UTI Pneumonia, bronchitis, asthma “ Viral syndromes ” Dysmenorrhea Epididymitis Lactose intolerance Sickling syndromes Mittelschmerz Less Common Trauma (possible child abuse) Intussusception Intestinal anomalies Incarcerated hernia Sickling syndromes Milk protein allergy Meckel's diverticulum Henoch-Sch ö nlein purpura (anaphylactoid purpura) Toxin Cystic fibrosis Intussusception Nephrotic syndrome Pneumonia, asthma, cystic fibrosis Inflammatory bowel disease Peptic ulcer disease Cholecystitis, pancreatic disease Diabetes mellitus Collagen vascular disease Testicular torsion Ectopic pregnancy Testicular torsion Ovarian torsion Renal calculi Peptic ulcer disease Hepatitis Cholecystitis or pancreatic disease Meconium-ileus equivalent (cystic fibrosis) Collagen vascular disease Inflammatory bowel disease Toxin Very Uncommon or Rare Appendicitis Volvulus Tumors (e.g., Wilms') Toxin (heavy metal — PB) Disaccharidase deficiency Malabsorptive syndromes Incarcerated hernia Neoplasm Hemolytic uremic syndrome Rheumatic fever, myocarditis, pericarditis Hepatitis Inflammatory bowel disease Choledochal cyst Hemolytic anemia Diabetes mellitus Porphyria Rheumatic fever Toxin Renal calculi Tumor Ovarian torsion Meconium-ileus equivalent (cystic fibrosis) Intussusception Pyomositis of abdomen Rheumatic fever Tumor Abdominal abscess

9. Life-threatening Causes of Acute Abdominal Pain Textbook of Pediatric Emergency Medicine(2006) Infancy (<2 yr)Preschool Age (2 – 5 yr)School Age (5 – 12 yr)Adolescent (>12 yr) Abdominal Intestinal anomalies (generally <1 mo) Intussusception Trauma (possible child abuse) Severe gastroenteritis (with prostration) Incarcerated hernia Hirschsprung's disease Volvulus Appendicitis Tumors (e.g., Wilms') Trauma Intussusception Appendicitis Incarcerated hernia Meckel's diverticulum Obstruction secondary to prior abdominal surgery Peritonitis (i.e., primary, nephrosis) Trauma Appendicitis Megacolon (from inflammatory bowel disease) Peptic ulcer disease (with perforation) Peritonitis (primary or secondary) Aortic aneurysm Acute, fulminant hepatitis Trauma Ectopic pregnancy Appendicitis Intraabdominal abscess secondary to pelvic inflammatory disease, cholecystitis, appendicitis, inflammatory bowel disease Peptic ulcer disease — bleeding or perforation Pancreatitis Megacolon (from inflammatory bowel disease) Aortic aneurysm Acute fulminant hepatitis Nonabdominal Heart disease, esp. myocarditis, pericarditis Metabolic acidosis due to inborn errors of metabolism Toxic overdose Sepsis Hemolytic uremic syndrome Toxic overdose a Hemolytic uremic syndrome Diabetic ketoacidosis Sepsis Myocarditis, pericarditis a Toxic overdose a Sepsis Diabetic ketoacidosis Collagen vascular disease a Collagen vascular disease Diabetes mellitus (infection or ketoacidosis) Drug abuse/ov

10. Evaluation of the child with abdominal pain Textbook of Pediatric Emergency Medicine (2006)

11. Algorithm for evaluating acute abdominal pain in children American family physician (2003)

13. Initial impression  Abdominal pain  r/o acute gastroenteritis

14. Plan  94-10-24 PM5:35 (0hr 6mins)  KUB

15. KUB 2005-10-24 PM5:44 (0hr 15mins)

16. Report of KUB  Ileus of abdomen and retention of fecal material in colon  Pneumoperitoneum

17. Plan  94-10-24 PM5:56 (0hr 27mins)  CBC/DC, CRP, B/C, U/A, Sugar, BUN, Cr, AST, Amylase  D51/4S run 60 ml/hr  94-10-24 PM7:00 (1hr 31mins)  Up right CXR  Ketone body

18. Lab data WBC 14.9 1000/cmm RBC 4.20 milon/cmm HGB 14.2 g/dL HCT 33.5 % MCV 79.2 umm MCH 27.1 pg/cell MCHC 34.0 g/dL RDW 13.6 % PLT 358 1000/cmm SEG 56 % LYM 37 % MONO 2 % EOSINO 5 % GLU 204 mg/dL BUN 59 mg/dL Cr 0.4 mg/dL Amylase 38 U/L AST 23 U/L CRP 192.5 mg/dL

19. Lab data– U/A coloryellowketone(-) turbidityturbidUBG0.1 SP. Gravity 1.010Bilirubin(-) PH7.0BloodTrace Leukocyte3+RBC 1-3 HPF Nitrite(-)WBC 5-8 HPF Protein(-)Squamous 0 Cell/HPF Glucose(-)

20. Chest PA standing 2005-10-24 PM7:12 (1hr43min)

21. Report of chest PA standing  Mild pulmonary infiltration of lungs, suggest follow-up  pneumoperitoneum  Ileus of abdomen

22. Diagnosis  Peritonitis, hollow organ perforation

23. Plan  94-10-24 PM7:15 (1hr 46mins)  Consult GS  94-10-24 PM7:26 (1hr 57mins)  NPO  Ceftriaxone 500mg iv st  Metronidazole 200mg ivf st  Voltaren 1tb supp st  Transfer to Linkou

24. Clinical course at Linkou CGMH  2005-10-24 PM8:47  Arrived to SER  2005-10-25 AM0:48  Operation  OP Finding: fecal peritonitis fecal peritonitis punch out perforation at cecal area punch out perforation at cecal area hyperemic change of appendix hyperemic change of appendix  2005-11-1 discharge

25. Chest including abd. 2005-10-24 PM9:13 (0hr26min)

26. Decubitus abdomen 2005-10-24 PM9:26 (0hr39min)

27. Report of CXR and decubitus abdomen  Decubitus abdomen showed: free air noted  Chest PA showed: intact bony thorax, no cardiomegaly, otherwise, nothing remarkable

28. OP finding  Fecal peritonitis  Punch out perforation at cecal area  Hyperemic change of appendix

29. Pathology-1  Diagnosis: large intestine, cecum, repair--- -ulcer, perforated  Micro D: sections show ulceration of the colonic mucosa. It is perforated with marked acute inflammation, no malignancy, granuloma or specific microorganism is seen.

30. Pathology-2  Diagnosis: appendix, appendectomy---- periappendicitis  Micro D: sections show a thin layer of purulent exudate on the serosa. The appedix itself is unremarkable.

31. Pneumoperitoneum  Rigler sign (also known as the double-wall sign), indicating the presence of gas on both sides of the bowel wall  The falciform-ligament sign, which was visible as a linear density  The football sign, which is seen on supine abdominal radiographs, refers to a large oval radiolucency in the shape of an American football. The oval radiolucency seen in the football sign represents massive pneumoperitoneum, which distends the peritoneal cavity.

32. Pneumoperitoneum NEJM (2004)

33. Pneumoperitoneum Pneumoperitoneum Radiology 2004

34. Pneumoperitoneum

35. Study from CGMH JPGN 2004  5 years records of 33 children under 15 years old admitted to Chang Gung Memorial Hospital with non- traumatic bowel perforation from 1998 July to 2003 June.  21 cases were related to infection (5 with Salmonella infection, 2 with pseudomonas, 1 with E. coli, 1 with Clostridum Septicum, the other was mixed flora), the others are related to adhesion ileus, intussusceptioon, vulvulus, necrotizing enterocolitis.  The site of perforation was most in Colon with 13 casees.  Pneumoperitoneum was found in 19 cases before operation.

36. Key point  A child with acute abdominal pain is often a major diagnostic challenge and requires careful and detailed observations, often repeated several times, searching for clues to the diagnosis.  Always keep in mind it may not be correlated with the disease and children’s presentation  Age is a key factor in evaluating the cause; the incidence and symptoms of different conditions vary greatly over the pediatric age spectrum.

37. Reference   Acute Abdominal Pain in Children. American family physician. Vol.67:2321-6 (2003)   Falciform-Ligament Sign of Pneumoperitoneum. The New England Journal of Medicine. Volume 351:e16 (2004)   Outcome of bowel perforation. Journal of Pediatric Gastroenterology and Nutrition. Vol.39 supp1. S340 (2004)   Radiology 231:81-82 (2004)   Textbook of Pediatric Emergency Medicine (2006)