Acute Abdominal Pain in a 4 y/o  

V.R. is a 4 yr 8 mo old female with a 9 day h/o runny nose, 5 days of vomiting, fever, abdominal pain and back pain who presents to the ER on 9/5/00.  She had seen her PMD 4 days prior and was diagnosed with gastroenteritis.  She had taken nearly no po over the past week.  She was admitted for worsening signs and symptoms of dehydration and probable gastroenteritis, with green liquid diarrhea and cough beginning the day before admission, noted to have fever of 105 at home, 102.2 in the ER.  Exam was significant for hypoactive bowel sounds and a slightly distended abdomen.  She was given IV resuscitation and one dose of Ceftriaxone. 

 Past medical history significant for multiple upper respiratory tract infections, OM requiring myringotomy tubes and three episodes of bronchitis already this year.  No medication allergies, positive tobacco smoker in home.  IZ’s UTD except Hep A.

 Exam on admission:

T 102.2            P 148               R 40’s                         BP 99/48         O2 sat 94% RA

gen – sleepy, but arousable

skin – poor turgor with dry mm

HEENT – TM’s with tubes in place, O/W normal

neck – NT with FROM

chest – CTA

CV – tachycardic, no M/G/R

abd – chubby, dec BS, soft, no masses, no guarding, no HSM

back – trace L CVA tenderness

gu/ext – WNL

labs –  WBC 12.1 with 78% polys, 16% bands, 5% lymphs

            Chemistry – Na 137, K 2.9, Cl 98, HCO3 23, BUN 47.7, Cr 1.0, Mg 2.5

            LFT – AST 194, ALT 120, AP 165

            UA – 1.025, 1+prot, 1+blood (culture negative)

Upon arrival to the pediatric floor the patient developed some wheezing and desaturation, responding to oxygen and Albuterol.  Her fluid deficit and K were replaced over 24 hours and a CXR was obtained to evaluate her coarse breath sounds and wheezing.  Her abdomen remained very tender, primarily in the RUQ and a KUB and surgery consult were requested.

Surgical consult – not likely surgical acute abdomen

KUB – large liver, normal stool and gas pattern

CXR – right upper lobe consolidation

The patient was continued on Ceftriaxone with the initiation of respiratory therapy including CPT, although she was not requiring O2. 

She developed a total lung white out on hospital day 2 and lateral decubitous film showed developing pleural effusion, which was eventually tapped on hospital day number 7 as the patient had continued spiking fevers and abdominal pain. 

The effusion was exudative.  The patient defervesced and subsequent search for an organism was unsuccessful with negative body fluid cultures, blood cultures, pharyngeal cultures and urine antigen screen.  Mycoplasma titers still pending.  PPD negative.

Differential Diagnosis of Acute Abdomen

Surgical                   Non-Surgical          Rare

Appendicitis                  Colic                             Henoch-Shonlein Purpura

Intussusception                      Constipation                           Pancreatitis

Malrotation                             Gastroenteritis                      Gallstones

Pyloric Stenosis                      Urinary Tract Infection           Ulcer disease

Incarcerated hernia                Pneumonia                              Lead toxicity

Hirschsprung’s disease          Lactose Intolerance               Toxic ingestion/mushrooms

                                                                                                Porphyria

                                                                                                Diabetic Ketoacidosis

                                                                                                Sickle Cell anemia

                                                                                                Abdominal migraine/epilepsy

Most Frequent Diagnosis in Children Admitted with Abdominal Pain

 1.      Unknown cause (36% in one study)

2.      Gastroenteritis

3.      Appendicitis (8% in one study)

4.      Constipation

5.      Urinary tract infection

6.      Viral illness

7.      Streptococcal pharyngitis

8.      Pneumonia

9.      Otitis

Pneumonia in Infants and Children

 Epidemiology:

·         Most common in winter and spring.

·         15-20 cases/1000/yr in first year of life

·         30-40 cases/1000/yr age 1-5

·         declining incidence in older children

·         Boys 2x Girls

Age is the most important variable in determining the probable infecting organism and resultant antimicrobial therapy.  Sputum hard to get from kids, blood cultures only positive 17% in outpatient setting, serum and urine antigen tests with variable results.  Most commonly viral etiology with only 10-30% bacterial.

Most common organisms:

Clinical Presentation:

Bacterial –     cough, high fever, chills, dyspnea

-         auscultatory findings of lung consolidation

-         CXR with lobar consolidation and pleural effusion

-         WBC 15 to 20 with neutrophil predominance

Viral         -     cough, wheezing, stridor, fever < bacterial

-         CXR with diffuse streaky infiltrates

-         WBC often normal with lymphocyte predominance

Lower lobe – MAY PRESENT WITH ABDOMINAL PAIN

Clinical presentations of note:

H. influenza b – often associated with bacteremia, meningitis and other sites of infection

                          (arthritis, pleural effusion, cellulitis)

Staph aureus   -  rare in infants, presents acutely ill with empyema, pneumatocoeles and

                           respiratory failure

-  maybe preceded by skin infection

Afebrile pneumonia – often in infants 1-3 mos old with Ureaplasma, Chlamydia, CMV,

                           Pneumocystis or RSV

Immunocompromised – Pneumocystis, gram negative enterics, fungi (aspergillosis, histo),

                           mycobacterium or CMV, anaerobes, measles, varicella

Cystic Fibrosis – Staph aureus (infancy), Pseudomonas or B. cepacia (older children)

Diagnosis:

Definitive diagnosis requires organism identification:

-         sputum hard to get

-         viral – culture, PCR, immunofluorescent stain (RSV, influenza, parainfluenza,

      adenovirus)

-     nasopharyngeal, urine, BAL culture – CMV, enterovirus

-     serum immunoglobulin titers - Mycoplasma

-     culture or antigen detection from blood/effusion/urine – Strep pneumo, H. flu

-     sputum culture/gastric aspirate - Mycobacterium

ALL CHILDREN SHOULD HAVE A PPD PLACED

May require invasive procedures (immunocompromise, unusual clinical picture):

-     bronchoscopy and BAL

-     lung aspiration

-     lung biopsy

Treatment:

Dependent upon age and whether more consistent with viral or bacterial etiology:

Neonatal/congenital – life-threatening à hospitalize, IV antibiotics

Older children – hospitalize if:

1.      moderate to severe respiratory distress

2.      failure of oral antibiotic trial

3.      inability to take po secondary to vomiting or poor compliance

4.      lobar consolidation in more than one lobe

5.      immunosuppression

6.      empyema

7.      abscess/pneumatocoele

8.      underlying cardiopulmonary disease (BPD or pulmonary hypertension)

Antibiotics to cover most common organisms for age group:

1^st week of life – cover Group B Strep and coliforms

            i.e. ampicillin and gentamycin

after week 1 – add Staph aureus coverage if CXR reveals effusion/pneumatocoele

            i.e. nafcillin and gentamycin

1 to 4 months – cover Chlamydia (in addition to the next category)

            i.e. erythromycin

up to 5 years – cover H. flu, Strep pnuemoniae

            i.e. amoxicillin, ceftriaxone, pediazole, clarithromycin, bactrim x 10d as OP,

                  cefuroxime in hospital, cefotaxime + oxacillin in ICU

5-10 years – cover Mycoplasma pneumoniae and Strep pneumoniae

            i.e. clarithromycin, azithromycin, erythromycin

penicillin resistant – ceftriaxone or vancomycin

Prognosis:

Most children recover rapidly and completely.

CXR returns to normal in 6-8 weeks.

If lasts greater than one month or recurs à look for underlying illness.

i.e. PPD, sweat chloride, serum Ig and IgG subclass determination,     

      bronchoscopy (foreign body), barium swallow (TEF)