PEDIA GRAND ROUNDS

Cc: Abdominal enlargement

DRE?
 Normal
 There was stool – patient had bowel movement at the ER

Interstitial densities in the perihilar area more on the right side

Distended with gas filled intestinal loops – peritoneal fluid collection
Presacral gas absent

The fluid must be distinguished whether intra-intestinal or extraintestinal before imaging –

should already be done during PE

Conclusion based on imaging: distension of the child more of fluid than solid

Every touch of abdomen, patient keeps on crying – cannot tell if irritable lang talaga or due to
tenderness

Can you distinguish guarding from tenderness?

 Guarding – contraction of muscles upon palpation
 Tenderness – elicit pain during palpation

For children during palpation:

Look for the facial expression if the patient will grimace
Can do palpation when patient is sleeping
Look for subtle signs – facial expressions, etc

Double bubble sign

 A sign of malrotation

On the basis of malrotation, why is the scout film more homogenous? Why is the patient not
incessantly vomiting? And if yes, why is the patient not hemodynamically unstable? Why is the
patient still having flatus? ANG DAMING QUESTIONS POTA

Reason of opening the patient: peritonitis

Malrotation – possible volvulus; bowel ischemia – compromised blood supply in the small
intestine

In the absence of double bubble sign but suspicious for malrotation!!!

 Inject air into stomach to produce double bubble sign
Character of OGT output?
 Bilious in small amounts <10cc
 Yellowish

Additional information about the patient:

 Abdominal ultrasound
o Look for the vessels
o According to Dr. Sio – not so sure about UTZ
 X-ray already enough

Anesthesia technique: GA
Problems:
 Septic picture of patient
 Post operative pain

Gram stain: (+) for Staph

Cox infection?
 AFB stain was done – negative
 They all look the same grossly

Immediately post-op, why the decision to extubate?

 Secondary to unremarkable intraoperative state of the patient
o No derangements aside from tachycardia
o Awaken unremarkably
 Estimated blood loss during the procedure: minimal only

Postoperative hepatic dysfunction

 Episodes of hypoalbuminemia
 Recurrence of abdominal distension
 Decided to check for liver function test
o Might be reduced hepatic blood flow, hepatic clearance maybe due to anesthetic
effect or stress from surgery or sepsis

Was an infectious specialist called in?

Patient was referred to immunology

 Considered inborn error of immunity / primary immunodeficiency
 Difficult to consider first
 Main point of this condition: recurrent infection
 Have major categories
o T cell defect – early onset, failure to thrive, viral / fungal opportunitistic
infection, T cell normal range
 o B cell defect – later in life, after 7 months after pa when antibodies are
diminished
o Complement defect – background of an autoimmune disease
 Granulocyte defect considered for this patient
o Prominent for organism growth catalase positive
o Granuloma formation
o Chronic granulomatous disease – ruled out naman for the patient
 Take away from PID – recurrent infections
 Lifelong prophylactic antibiotic needed for patients

Theoretically, saan usually yung collection?

 By gravity, towards the pelvic area

Latest follow-up:
A week ago, last follow up – baby feeding well, abdomen soft, wound is healing well, no more
episodes of fever, vomiting, abdominal distension, baby doing well

Choice of antibiotics for primary peritonitis for medical treatment:

 Piperacillin tazobactam
 Metronidazole – for better anaerobic coverage