CASE: This is a case of a 4 y/o male presenting with acute abdominal pain. Abdominal pain is a common problem in children.

Although most children with acute abdominal pain have self limited conditions, the pain may herald a surgical and medical emergency. Table 1 lists many causes of acute abdominal pain in children. (Leung and Sigalet, 2003) GASTROINTESTINAL CAUSES Gastroenteritis Appendicitis Mesenteric Lymphadenitis Constipation Abdominal Trauma Intestinal Obstruction Peritonitis Food Poisoning Peptic Ulcer Meckels Diverticulum Inflammatory Bowel Disease Lactose Intolerance LIVER,SPLEEN AND BILIARY TRACT DISORDERS Hepatitis Cholecystitis Cholelithiasis Splenic Infarction Rupture of the Spleen Pancreatitis GENITOURINARY CAUSES Urinary Tract Infection Urinary calculi Dysmenorrhea Mittelschmerz Pelvic Inflammatory Disease Threatened abortion Ectopic Pregnancy Ovarian/Testicular torsion Endometriosis Hematocolpos DRUGS AND TOXINS Erythromycin Salicylates Lead Poisoning Venoms

METABOLIC DISORDERS Diabetic ketoacidosis Hypoglycemia Porphyria Acute Adrenal Insufficiency

PULMONARY CAUSES Pneumonia Diaphragmatic Pleurisy

HEMATOLOGIC DISORDERS Sickle cell anemia Henoch-Schonlein purpura HemolyticUremic Syndrome

MISCELLANEOUS Infantile Colic Functional Pain Pharyngitis Angioneurotic Edema Familial Mediterranean Fever

In evaluating children with abdominal pain, a thorough history is required to identify the most likely cause. An initial evaluation of the history is followed by a physical examination and a reassessment of certain points in the history. Age is a key factor in the evaluation of abdominal pain. Table 2 shows the differential diagnosis of acute abdominal pain by predominant age Birth to One year Infantile Colic Gastroenteritis Constipation Urinary Tract Infection Intussusception Volvolus Incarcerated hernia Hirschsprungs Disease Two to Five Years Gastroenteritis Appendicitis Constipation Urinary Tract Infection Intussusception Volvolus Trauma Pharyngitis Sickle Cell Crisis Henoch-Schonlein purpura Mesenteric Lymphadenitis Six to 11 years Gastroenteritis Appendicitis Constipation Functional Pain Urinary Tract Infection Trauma Pharyngitis Pneumonia Sickle Cell Crisis Henoch Schonlein purpura Mesenteric Lymphadenitis 12 to 18 years Appendicitis Gastroenteritis Constipation Dysmenorrhea Mittelschmerz Pelvic Inflammatory Disease Threatened Abortion Ectopic Pregnancy Ovarian/Testicular Torsion

The case is a 4 y/o male, hence, other causes of acute abdominal pain were ruled out such as infantile colic, incarcerated hernia, hirschsprungs disease, functional pain, dysmenorrhea, mittelschmerz, , pelvic inflammatory disease, threatened abortion, ectopic pregnancy, ovarian and testicular torsion. Fever in the patient indicates an underlying infection or inflammation. However, review of systems revealed that there is no cough, no sore throat, no difficulty in swallowing. Therefore, pneumonia and pharyngitis as cause of the abdominal pain in this patient is not a consideration. A history of trauma may indicate the cause of abdominal pain. But it is also not considered since there is no obvious history of trauma. Gastroenteritis is the most common cause of abdominal pain in children. However, diarrhea is often associated with gastroenteritis or food poisoning and should also be common among household contacts for which the patient does not have. Constipation is ruled out since abdominal pain is most often left-sided or suprapubic and the patient has no change in bowel movement pattern. A family history of sickle cell anemia may indicate the diagnosis. The patients ethnic background is important because sickle cell anemia is most common in blacks of African origin.The case is a 4 y/o Filipino male, hence, sickle cell anemia is eliminated. Joint pain, rash and hematuria suggest Henoch-Schonlein purpura which are all absent in the patient.

Intestinal obstruction produces a characteristic cramping abdominal pain. Causes of intestinal obstruction include volvulus, intussusception, incarcerated hernia, and postoperative adhesions. The patient in this case has no signs of intestinal obstruction such as abdominal distention, decreased bowel sounds and persistent vomiting. No history of any operation was also mentioned. Mesenteric lymphadenitis is often associated with adenoviral infection for which the patient in this case does not have. The condition mimics appendicitis except the pain is more diffuse, no signs of peritonitis and generalized lymphadenopathy may be present which cannot be seen in the patient. Appendicitis is the most common surgical condition in children who present with abdominal pain. It presents classically with fever, vomiting, point tenderness over McBurney point, and signs of peritoneal irritation. Psoas sign, Obturator test, guarding, rebound tenderness were all negative in this patient. Hence, appendicitis is ruled out. Here is a case of a 4 y/o male with abdominal pain, fever and vomiting. My initial impression was Systemic Viral Illness (SVI), t/c UTI since there is also frequency in urination. Initial laboratory studies in the patient include a complete blood count and urinalysis. CBC showed leukocytosis (WBC:12.6) which indicates an infection. Urinalysis showed 10-13 pus cells/hpf which clearly points to a urinary tract infection (UTI) in this case. Laboratory Results: CBC: Hgb-110 Hct-0.35 WBC-12.6 Seg-74 Lym-20 Mono-4 Eos-2 Plt-483 Urinalysis: pus cells-10 to 13/hpf rbc-4 to 6 Protein-trace Mucous Threads-moderate Sugar-negative Occult blood-negative Bacteria-few Knowing that the patient has UTI, urine culture and sensitivity was requested since it is still the gold standard in the diagnosis of the said disease. I also requested for an ultrasound of the kidneys and urinary bladder to check if there is any abnormality in the urinary tract . Thrapeutics include Paracetamol at 10mkd, Cefuroxime at 20mkd and Oresol vol/vol replacement. I advised the patient to have small frequent feedings, to follow up after two days if still febrile and to follow up anytime if symptoms persist. Otherwise, the patient can follow up after a week with urine cs and utz of kub results, as well as a repeat urinalysis result. Upon follow up after a wk, the patient symptoms resolved. Urine CS revealed a negative result, UTZ of KUB showed normal findings and repeat urinalysis after a week of treatment revealed normal result.

DIAGNOSIS: Urinary Tract Infection

OBJECTIVES: 1. Know the definition of UTI in children and its prevalence 2. Determine the etiology and pathogenesis of UTI 3. Give the clinical presentation of UTI based on age and its diagnosis 4. Current treatment recommendations for UTI and its prevention