[SISS] EVALUATION OF PEDIATRIC ABDOMINAL PAIN PLUS IMAGING Dr.

Isabedra

● Bp - 90/60mmHg
● HR - 125 bpm
Patient medical history
● RR - 23cpm
➔ Z.B., 8F ● TEMP - 37.8C
➔ CC: abdominal pain ● WT - 23.0kg
➔ HPI ◆ Heent - (+) naso aural discharge
◆ 3 days PTA ◆ Chest and lungs - unremarkable
● Colicky abdominal pain, intermittent, epigastric in ◆ Cardiovascular - tachycardic, regular rhythm, no
location with a pain scale of 4/10 murmurs
● Associated with decrease in appetite ◆ Abdomen - flabby abdomen, sift, (+) tenderness
● Given analgesic in a private clinic which provided RLQ with point of maximum tenderness at lateral ½
temporary relief of McBurney’s line on palpation, (+) Rovsing's sign,
● Abdominal pain still progressed now associated (+) Psoas sign, normoactive bowel sounds
with undocumented fever ◆ Extremities: grossly normal, equal peripheral pulses
◆ 1 day PTA
● Abdominal pain now localized at the right lower
quadrant area with associated symptoms such as Diagnostics
anorexia, 2 episodes of vomiting, low grade fever ➔ CBC
(37.8C), and pain scale of 10/10
● Patient was brought to the emergency room
department under pediatrics for assessment and
was subsequently referred to surgery service for
further evaluation and management hence
admitted.
➔ PMH
◆ (+) Complete immunization
◆ (+) History of hospitalization: Chickenpox )Varicella
Zoster) ** operate on patient if K is 3.6-4.2
◆ (+) History of blood transfusion and blood dyscrasia ** correct hyponatremia lowest accept before surgery is
◆ (+) Allergy to seafood 130
➔ FMH
◆ (+) HPN: father
◆ (-) asthma
◆ (-) cancer
➔ PERSONAL & SOCIAL
◆ unremarkable
➔ OB/GYNE
◆ Not applicable
➔ ROS ➔ Other lab workups
◆ GENERAL (+) malaise
◆ Integumentary - unremarkable
◆ Head and neck - unremarkable
◆ Respiratory - unremarkable
◆ Cardiovascular - unremarkable
◆ Gastrointestinal - unremarkable
◆ GUT - unremarkable
◆ Hematologic - unremarkable
◆ Endocrine - unremarkable
◆ Neuropsychiatric - unremarkable
➔ PE
◆ Gen survey: conscious, coherent, good skin turgor,
not in cardiorespiratory distress
◆ VS

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 [SISS] EVALUATION OF PEDIATRIC ABDOMINAL PAIN PLUS IMAGING Dr. Isabedra

◆ Paracetamol 300 mg TIV as needed for fever Temp

Salient features & preoperative diagnostics
equal to or greater 37.8
➔ Salient features ◆ Referred back to pedi service for clear prior to
◆ 8 y/o F procedure
◆ Abdominal pain localized at the RLQ ◆ Given class 2 stratification
◆ Decreased in appetite
◆ Anorexia
◆ Vomiting low grade fever
◆ Hx of chickenpox
◆ Hx of blood transfusion
◆ Allergic to seafood
◆ Hypertension in father
◆ Malaise
◆ BP 90/60 mm Hg
◆ (+) tenderness at the RLW with point of maximum
tenderness at the later 1/3rd of McBurney’s lien on
palpitation
◆ (+) rovsing's sign (+) psoas sign
◆ Abnormal N, L, & M count
➔ Preoperative diagnosis ➔ Post-op
◆ Acute appendicitis, probably ruptured ◆ Had persistent fever associated with tachycardia
● Epigastric pain which later localized to RLW ◆ Developed seizures approx 2 hours
● Decreased in appetite ● May be due to uncorrected hyponatremia pre op
● Vomiting ◆ Pedia service started anticonvulsants and
● Fever electrolytes correction
● Anorexia ◆ Had persistent tachycardia and intermittent seizure
● PE: tenderness in RLQ w/ maximum tenderness episode
at mcBUrneys, rovsing, psoas sign ◆ Fever was still evident though the post op duration
● Lab: leukocytosis on admission, neutrophilia, ◆ Despite aggressive intervention, px expired after 24
monocytosis hours post op
➔ Intraoperative finding
◆ 6 x 2 cm ruptured appendix
Final diagnosis
◆ Point of rupture, middle 3rd
◆ Base nonedematous and non-friable with localized ➔ Septic shock secondary to ruptured appendicitis with
localized peritonitis s/p appendectomy
peritonitis
➔ Basis
● Need to mention if edematous for consideration ◆ Sepsis is the symptoms secondary to infections that
of bleeding, spillage and perforation (because it is manifest as disruption in heart rate, RR,
near the cecum). temperature and WBC
● Perforation is common in the cecum because it is ◆ The precipitating infections (appendicitis that may
thinner (when it becomes more dilated) because lead to septic shock
of the ileocecal valve (with the highest pressure) ◆ Associated symptoms such as anorexia, 2 episodes
of vomiting, low grade fever (37.8), tachycardia,
hypotension
Course in the Ward ◆ Signs and symptoms of appendicitis in children
includes loss of appetite, n/v, abdominal pain, fever,
➔ Preoperative and rebound tenderness
◆ Started with IV antibiotics of Cefuroxime 750 mg Q8 ◆ 6x2cm ruptured appendix, the middle 3rd point of
● Compute for dosage: wt. in kg (23kg) x 100 = rupture
2300mg/day
● 2300 divided by 3 (3x a day) = 766mg (dosage Summary of Mortality Case Discussion
given is appropriate)
◆ Metronidazole 500 mg Q8 ➔ Z.B., 8y/o F, presented with signs and symptoms of
Acute Appendicitis was admitted and referred to the
● given for anaerobic
surgery service for Appendectomy procedure. Pre-op
● 30mg/kg/day she was started on IV antibiotics and given pyretics
● Dosage given is overdosage

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 [SISS] EVALUATION OF PEDIATRIC ABDOMINAL PAIN PLUS IMAGING
for fever.
➔ Intra op findings: 6x2cm ruptured appendix, middle
3rd point of rupture; base non edematous and
non-friable with localized peritonitis
➔ Post op diagnosis - ruptured AP with localized
peritonitis
◆ Post operatively the patient had persistent fever
and tachycardia and after 2 hours she presented
with seizures and even after aggressive treatment
the fever was persistent and patient dies after 24
hours post op.
➔ Final diagnosis: septic shock secondary to ruptured
appendicitis with localized peritonitis s/p
appendectomy
Appendicitis
Clinical presentation
➔ Symptoms
◆ periumbilical pain or diffuse pain
◆ Pain migrating to the RLQ
◆ Nausea, vomiting, and anorexia
◆ Murphy triad: pain, vomiting and fever ( in
sequence)
➔ Signs of AP
◆ fever/pyrexia
◆ Localized tenderness in the right iliac fossa (
McBurney’spoint
◆ Muscle guarding
◆ Rebound tenderness
➔ Direct and rebound tenderness at
◆ Rovsing sign: pain in the right lower quadrant when
the left lower quadrant is palpated are strong
indication of peritoneal irritation
◆ Lanz Point: tenderness at the junction of the right
third and left two-thirds of a line connecting both
anterior superior iliac spine
◆ Kummel point: right side below the umbilicus
◆ Obturator sign: RLQ pain on passive internal
rotation of the right hip with the hip and knee flexed
◆ Psoas sign: pain with extension of the right leg
(psoas sign) indicates a focus of irritation in the
proximity of the right psoas muscle
Dr. Isabedra
Diagnostic
➔ Based on result of a complete PE and on labs and x
ray findings
➔ Complete CBC demonstrates an elevated WBC count
➔ Leukocyte may exceed 10,000cells/mm3, and the
neutrophil count may exceed 75%
➔ The alvarado score is the most widely used scoring
system. A score below 5 suggests against a
diagnosis of appendicitis, whereas a score of 7 or
more is predictive of acute appendicitis.
➔ CT Scan
◆ Dilated appendix with distended lumen (>6mm
diameter).
◆ Thickened and enhancing wall
◆ Thickening of the cecal apex (up to 80%)
Management
➔ Perforated or ruptured appendicitis are considered
complicate condition
➔ Usually present after 24 hours of onset, although 20%
present within 24 hours
➔ Such patients are acutely ill and are dehydrated and
require resuscitation
➔ Managed either opertiely or nonoperatively
➔ Immediate surgery is necessary in patients that
appear septic associated with higher complication
include abscess and enterocutaneous fistula-dense
adhesions and inflammation
➔ Resuscitation And IV antibiotics
➔ Logns tanding perforated appendicitis are better
treated with image guided percutaneous drainage
and is successful in 79% of patients with complete
resolution
➔ Operative intervention is performed in patient who fail
conservative management
➔ Conservative treatment
◆ If patient is placed on nothing by mouth (NPO) diet
◆ IV fluid resuscitation
◆ IV antibiotics (2nd or 3rd gen cephalosporins,
metronidazole or gentamicin)
◆ If patient has abscess and extractable
percutaneous drain is performed
Complications
➔ Wound infection and dehiscence
➔ Bowel obstruction
➔ Perforation → peritonitis
➔ abdominal/ pelvic abscess
➔ Portal pyaemia (pylephlebitis)
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 [SISS] EVALUATION OF PEDIATRIC ABDOMINAL PAIN PLUS IMAGING Dr. Isabedra

➔ Stump appendicitis #keepsafe

Prognosis
➔ Excellent
◆ Time of dx, the rate of appendiceal perforation is
20-25%
➔ Rate of perforation is 80-100% for children younger
than 3 years compared with 10-20% in children 10-17
y/o
➔ Children with ruptures appendicitis are at risk for
intra-abdominal abscess formation and small bowel
obstruction
➔ Can have prolonged hospital stay (several weeks or
more)
➔ The mortality rate for children with appendicitis is
0.1-1%

ASSIGNMENT :(

➔ NAME, DATE, SECTION, ROTATION

➔ LABEL WHAT ABNORMAL FINDINGS YOU CAN

FIND - encircle, arrow, underline, etc. Also put your
initial impression
◆ Example: Barium Enema: Distended in the rectum
(in this slide)
➔ To be submitted: when you want (decide na lang daw)

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References:

Trifectafam

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