3-Year-Old Female with a 12-Hour Onset of Abdominal Pain, Vomiting, and Fever of 38.5°C (Case 47)

Chapter 66 3-Year-Old Female with a 12-Hour Onset of Abdominal Pain, Vomiting, and Fever of 38.5°C (Case 47)



Ruth D. Mayforth, MD, PhD



Differential Diagnosis











Appendicitis Intussusception
Mesenteric lymphadenitis Gastroenteritis



Speaking Intelligently


My primary goal in evaluating a child with abdominal pain is to determine whether the child has a cause of pain that will require surgical therapy. If not, then I reassure the family and the referring physician that the pain will resolve, and carefully follow the patient to be certain that it does resolve. In some patients, additional testing is required, and I make certain that these tests are obtained in a timely fashion. If the patient has a condition requiring acute surgical therapy, I educate the family about the nature of the proposed procedure and assure that the patient is properly prepared for the procedure.



PATIENT CARE



Clinical Thinking



• It is important to recognize quickly the conditions that require emergent surgery to prevent major morbidity or death.

• A careful hx and physical examination remain the cornerstone of surgical assessment of the acute abdomen. When the patient is too young to provide a hx, it is obtained from parents or adult caregivers.

• An important first step is to reassure the patient and family that the examination will be performed gently. Distracting the patient during the physical examination may also be useful.

• If the patient has systemic manifestations of his or her illness, then dx may have to occur while management is initiated. For example, the hx can be obtained while IV fluid resuscitation is under way.

• The use of CT to evaluate patients with abdominal pain has become quite prevalent in adults (see Chapter 11, Right Lower Quadrant Pain). This may not, however, be the best practice in pediatrics. There is a risk for cancer secondary to the radiation of CT in children, especially if adult protocols are used.


History



• Determine the location, onset, duration, severity, and type of pain. Is it constant or episodic? Has the pain shifted in location?

• Fever, anorexia, and behavioral changes, including lethargy, should be noted.

• Ask about emesis, diarrhea, constipation, passage of flatus, or blood in the stools.

• Note any previous abdominal surgery.

• In adolescent girls, note menstrual and sexual hx.


Physical Examination



• A complete examination is performed looking for signs and symptoms of inflammation and hypovolemia (e.g., prolonged capillary refill). The examination should also include attention to nonabdominal conditions that can present as abdominal pain (e.g., streptococcal pharyngitis).

• A detailed abdominal examination includes identifying the point of maximal tenderness. When palpating, the surgeon’s examination should begin away from the point of maximal tenderness and work toward tender areas. Focal peritoneal findings (tenderness to percussion, guarding, and rebound) may be present. Generalized peritonitis may present with more diffuse abdominal pain. In advanced peritonitis the abdomen is rigid.


Tests for Consideration












• CBC: A leukocytosis, especially with a left shift, suggests an inflammatory process.
 $40

• U/A: To r/o urinary tract infection, nephrolithiasis, or pyelonephritis.
 $50



IMAGING CONSIDERATIONS














→ Obstruction series: Chest and abdominal x-rays infrequently show appendicolith (20%). Look for obstruction or free air, kidney, or gallstones.
 $200

→ Ultrasonography: No radiation or oral contrast needed. False negatives occur. Also evaluate for kidney or gallstones, ovarian anthology.
 $250

→ CT: Used rarely and judiciously in small children. Substantial radiation dose and long delay filling GI tract.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on 3-Year-Old Female with a 12-Hour Onset of Abdominal Pain, Vomiting, and Fever of 38.5°C (Case 47)

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