Morning Report

Gary Rex Nelson, MD September 23, 2011

Disclosures
I have no financial relationships to disclose. John Deere in no way funds any portion of my training.

My tummy hurts..
15-year-old male who presents with abdominal pain for 4 days.
History of chronic abdominal pain, s/p work-up for duodenal ulcers (has a family history). Constant pain, right lower quadrant. Decreased appetite, but no vomiting, diarrhea or fevers. Pain is worse with movement. Labs are notable for a WBC of 8.6, CRP of 2.2, ESR 10. Normal amylase and lipase. Exam notable for rebound tenderness, tender to palpation, especially in RLQ.

Differential
Bad
Appendicitis Yersinia ileitis (pseudoappendicitis) Crohn disease/Ulcerative colitis Obstruction/Volvulus HSP Intussusception Female reproductive tract Other infections

Wont likely kill you

Constipation Constipation Functional pain Gastroenteritis NSAID enteritis

Abdominal Pain: Why is it such a pain?

Visceral pain versus somatic pain.
Localized pain after peritoneal irritation.
Can still be referred (ie: shoulder pain if diaphragm is irritated).

Visceral pain is poorly localized

Primarily from stretch, hypoxia, acidosis of affected viscera.

I really think its constipation.

(J Pediatr 2007;151:666-9)
962 kids >/= 4 years
9% (83) acute abdominal pain More girls (12%) than boys (5%) 19% without identified cause 2% had a surgical cause 48% had acute or chronic constipation

No difference in outcomes if presenting in ER versus clinic

Stuff to watch for

Fever, elevated WBC, CRP or ESR up Blood in stool, vomiting, intermittent severe pain RLQ pain or other focal pain In the case of inflammatory bowel disease, be sure to look for the extra-intestinal signs
Uveitis, mouth lesions, perianal lesions, arthritis (especially the knees)

Clean it out
Lots of different approaches
No good data

What we use:
Golytely, up to 10 ml/kg/hr, but we stop at 350 ml/hr normally. Mineral oil enema, followed by an NS enema Can also use a bisacodyl suppository or PO bisacodyl or senna

Cautions:
What we put in must come out Dont count Golytely as fluid in

Keep it clean:
Have to have a good home regimen; Miralax, lactulose, dark Karo syrup Wean, dont stop at least not for a while