1. ………………..…………………………………………………………………………………………………………………………………….. Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults Steven Teich, M.D. Daniel Cohen, M.D. Ann Dietrich, M.D. Osama El-Assal, M.D. John Shultz, M.D.

2. ………………..…………………………………………………………………………………………………………………………………….. Study Aims Aim 1: Describe the presentation of acute abdomen in medically fragile, high risk children and adults to expedite the recognition of a surgical emergency Aim 2: Develop a diagnostic algorithm for patients with special care needs with possible intra-abdominal emergency

3. ………………..…………………………………………………………………………………………………………………………………….. Background There are an estimated 9 million children and 23 million adults in the U.S. with special health care needs Large subset of special health care needs patients at risk to develop acute surgical abdomen due to co-morbidities  Multiple abdominal surgeries  Indwelling abdominal devices  Chronic constipation  Nissen fundoplication

4. ………………..…………………………………………………………………………………………………………………………………….. Background Adhesive peritoneal bands occur in 93-100% of patients with prior abdominal surgery Nissen fundoplication increases the risk of adhesive SBO up to 21% in children Incidence of complications after VP shunt varies from 5-47% - CSF pseudocyst -Inguinal hernia -SBO -Intestinal perforation -CSF ascites -Intestinal entanglement -Shunt displacement

5. ………………..…………………………………………………………………………………………………………………………………….. Background Nonverbal children and adults with altered sensation often unable to communicate symptoms classically associated with acute abdomen and often present with subtle manifestations Therefore, this patient population at greater risk for acute abdominal surgical emergencies and delayed or missed diagnoses with potentially catastrophic outcomes

6. ………………..…………………………………………………………………………………………………………………………………….. Study Design Study conducted at Nationwide Children’s Hospital, Columbus, OH (#IRB09-00151) Retrospective case-controlled study with patients serving as their own control Review of hospital discharge data including ICD9 codes and surgical case records Inclusion criteria: patients with neuro-developmental delay with diagnosis of acute surgical abdomen within 48 hours of hospital admission from the Emergency Department between May 2005 and October 2009

7. ………………..…………………………………………………………………………………………………………………………………….. Study Design Acute surgical abdomen defined as an abdominal surgical procedure demonstrating a pathological process or an IR procedure for abdominal pathology (e.g. drainage of CSF cyst) Each subject had to have an index ED visit during which an acute surgical abdomen was diagnosed and a control ED visit which proved to be negative for an acute surgical emergency The control visit required to have occurred within two years of the acute surgical abdomen visit but at least two months distant to avoid repeat presentation for the same illness

8. ………………..…………………………………………………………………………………………………………………………………….. Study Definitions Feeding intolerance  Decreased oral intake or vomiting in orally fed patient  Abdominal distention, discomfort, or increased gastrostomy tube output after oral or gastrostomy feeds Pain  Described by patients able to communicate  Interpreted by caregivers as changes in behavior consistent with feeling abdominal pain such as grimaces or moaning with abdominal touch Constipation  New onset or worsening

9. ………………..…………………………………………………………………………………………………………………………………….. Results 169 patients with special needs had abdominal procedures over the study time period 24 patients met the selection criteria after screening for elective surgical procedures and lack of a qualifying ED control visit

10. ………………..…………………………………………………………………………………………………………………………………….. Demographic Data VariableNumber Age (years)14.37 + 9.58 (22, 31, and 43 year olds) Gender16 male/ 8 female Residence19 home/ 5 facility Mode of Feeding17 tube/ 10 mouth/ 3 combined Implants/Surgical Procedures11 VP shunt 17 gastrostomy tube 16 Nissen fundoplication 4 tracheostomy 1 central line Number of ED visits/year (Over past 3 years) 1.49 + 1.28 ED visit/admission ratio2.06 + 2.35

11. ………………..…………………………………………………………………………………………………………………………………….. ED Index Visit (Surgery) EtiologyNumber (%) Adhesive SBO11 (45.8%) Shunt-related CSF cyst 5 (20.8%) Volvulus 3 (12.5%) Malrotation 2 (8.3%) Hiatal Hernia 1 (4.1%) VP-tube related intestinal entanglement 1 (4.1%) Peritonitis 1 (4.1%) Total24 (100%)

12. ………………..…………………………………………………………………………………………………………………………………….. ED Control Visit (No Surgery) EtiologyNumber (%) Ileus 6 (20.8%) Gastroenteritis 4 (16.6%) Unknown 3 (12.5%) UTI 2 (8.3%) URI 2 (8.3%) Colitis 1 (4.1%) Sepsis 1 (4.1%) Pancreatitis 1 (4.1%) Feeding intolerance 1 (4.1%) Pneumonia 1 (4.1%) SMA Syndrome 1 (4.1%) Cyclic vomiting 1 (4.1%) Total24 (100%)

13. ………………..…………………………………………………………………………………………………………………………………….. Symptoms at Presentation VariableSurgical AbdomenControl Visitp Value Respiratory distress Yes 11 No 13 Yes 9 No 150.47 Fever Yes 8 No 16 Yes 12 No 120.20 Vomiting Yes 18 No 6 Yes 10 No 140.008 * Feeding intolerance Yes 9 No 15 Yes 4 No 200.059 Constipation Yes 8 No 16 Yes 4 No 200.20 Diarrhea Yes 3 No 21 Yes 10 No 140.019 * Abdominal pain Yes 19 No 3 Yes 11 No 130.011 * Abdominal distention Yes 17 No 7 Yes 10 No 140.034 * Behavior changes Yes 18 No 6 Yes 13 No 110.13 * p < 0.05

14. ………………..…………………………………………………………………………………………………………………………………….. Physical Findings at Presentation VariableSurgical AbdomenControl VisitP Value Tachypnea (>98%ile)Yes 13 No 11 Yes 11 No 130.50 Tachycardia (>98%ile)Yes 15 No 9 Yes 14 No 100.99 MAP83.67 + 15.2 (N=23) 80.34 + 20.53 (N=22)0.55 DehydrationYes 18 No 5 Yes 12 No 110.031 * Abdominal DistentionYes 17 No 7 Yes 9 No 150.007 * Abdominal TendernessYes 18 No 6 Yes 5 No 190.006 * * p < 0.05

15. ………………..…………………………………………………………………………………………………………………………………….. Laboratory Results and Diagnosis of Acute Surgical Abdomen VariableSurgical AbdomenControl Visitp Value WBC13,900 + 7,1009,900 + 4,0000.008* Segs61.5 + 22.457.8 + 23.20.036* Bands13.2 + 16.612.6 + 16.60.66 Bicarbonate25.9 + 7.926.0 + 6.10.091 Sodium140.9 + 5.5138.3 + 3.60.013* Potassium4.3 + 0.83.8 + 0.480.59 Chloride99.2 + 19.798.5 + 19.30.022* Glucose149.2 + 50.8122.8 + 44.80.002* BUN22.8 + 20.614.6 + 6.90.044* Creatinine0.8 + 0.600.55 + 0.290.047* * p < 0.05

16. ………………..…………………………………………………………………………………………………………………………………….. Early ED Management and Diagnosis of Acute Surgical Abdomen VariableSurgical Abdomen Control Visitp Value O 2 requirementYes 4 No 20 Yes 6 No 180.50 Fluid resuscitationYes 18 No 6 Yes 12 No 120.031* Number of fluid boluses1.30 + 1.100.78 + 0.950.036* * p < 0.05

17. ………………..…………………………………………………………………………………………………………………………………….. Radiology Testing VariableSensitivitySpecificityNegative Predictive Value Positive Predictive Value AAS0.571.00.621.0 Abdominal CT 0.941.00.921.0

18. ………………..…………………………………………………………………………………………………………………………………….. Patient #1

19. ………………..…………………………………………………………………………………………………………………………………….. Patient #1

20. ………………..…………………………………………………………………………………………………………………………………….. Patient #2

21. ………………..…………………………………………………………………………………………………………………………………….. Patient #2

22. ………………..…………………………………………………………………………………………………………………………………….. Predictive Variables For Surgical Abdomen Variablep Value Abdominal distention0.027 Abdominal pain0.009 Vomiting/ Increased gastrostomy output0.001 No diarrhea0.017 Abdominal tenderness0.001 Elevated WBC0.006 Number of fluid boluses0.041

23. Yes Abdominal ultrasound PositiveNegative Observe and reassess every 2 hours No Acute abdominal series PositiveNegative High Risk Patient with Clinical Suspicion or ≥ 2 of : Vomiting/Increased G tube output Abdominal pain, Tenderness, Dehydration, Absence of diarrhea, or Elevated WBC: High Risk Patient with Clinical Suspicion or ≥ 2 of : Vomiting/Increased G tube output Abdominal pain, Tenderness, Dehydration, Absence of diarrhea, or Elevated WBC: V-P shunt Abdominal CT with contrast PositiveNegativeDefinitive treatment

24. ………………..…………………………………………………………………………………………………………………………………….. Conclusions First study on high-risk patients with suspicion for acute surgical abdomen Presence of abdominal pain, abdominal distention, increased gastrostomy tube output or vomiting, abdominal tenderness, and signs of dehydration are significant predictors of need for emergency surgery in high risk, medically fragile patients

25. ………………..…………………………………………………………………………………………………………………………………….. Conclusions We propose abdominal ultrasound as the initial modality for patients with VP shunts when presenting with a possible acute surgical abdomen Positive AAS is reliable finding but negative AAS can be misleading and a further confirmatory test is indicated Abdominal CT is most reliable imaging modality Our pathway for atypical, medically fragile patients at high risk for an acute surgical abdomen needs to be validated by a prospective study with a larger cohort

26. ………………..…………………………………………………………………………………………………………………………………….. Questions?