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PEDIATRIC GI EMERGENCIES. Kevin Levere Jan 16, 2003. Objectives. To appreciate differences from adults in GI bleeds Pancreatitis Liver disease To review common pediatric abdominal emergencies IBD, toxic megacolon, metabolic disease, constipation, colic, and jaundice are not discussed.

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pediatric gi emergencies

PEDIATRIC GI EMERGENCIES

Kevin Levere

Jan 16, 2003

objectives
Objectives
  • To appreciate differences from adults in
    • GI bleeds
    • Pancreatitis
    • Liver disease
  • To review common pediatric abdominal emergencies
  • IBD, toxic megacolon, metabolic disease, constipation, colic, and jaundice are not discussed
pediatric gi bleeds
Pediatric GI Bleeds
  • Many etiologies similar to adult
    • Frequency differs significantly
    • Some uniquely pediatric causes
  • Mortality lower than adult counterparts
    • Fewer comorbidities
    • Relatively greater physiological flexibility
  • Division between upper and lower
    • Ligament of Treitz
slide4
Case
  • 4wo ex35wker girl, breast feeding. Spat up a shot-glass worth of red blood.
  • Apart from oral thrush, her exam is normal.
    • Hx: Got Vit K. No meds. Growing. No BRBPR.
    • FHx: No bleeding diatheses. Mom not on meds, but has mastitis.
    • Apt test turns yellow-brown
slide5
Case
  • 2yo boy passing several fairly large maroon coloured BMs, x12hrs. Painless. Normal BM Hx until then.
  • 37, 140, 90/70, 24, pale but playful. OB+. Hgb 60, rest of CBC normal.
  • Which is best course of action?
    • A) cross-match, radionuclide scan, IV bolus, surgery
    • B) cross-match, IV bolus, scan, surgery
    • C) cross-match, IV bolus, surgery, scan
    • D) IV bolus, 0- transfusion, surgery, forget the scan
pediatric gi bleeds7
Pediatric GI Bleeds
  • Hemorrhagic disease of the newborn
    • Early (<1wk)
      • Vitamin K deficiency
        • Rare now administration of vitamin K shortly after birth has become routine
      • Maternal anticoagulant and intrapartum antiepileptic drug use
    • Late onset (2-6mos)
      • Fat malabsorption
pediatric gi bleeds8
Pediatric GI Bleeds
  • Ingestion of maternal blood
    • Apt Downey test
      • 1:1 stool with tap water, spin
      • 5:1 supernatant with 1% NaOH
      • After 2 mins
        • Pink = fetal Hgb
        • Yellow = maternal Hgb
pediatric ugi bleeds
Pediatric UGI Bleeds
  • Upper GI Bleeds
    • No good epidemiologic data outside PICU
      • 6-25%, depending on prophylactic therapy
      • 0.4% considered significant
    • Commonest endoscopic findings
      • Gastritis
      • Esophagitis
      • Varices
      • Ulcers
      • Mallory-Weiss tears
pediatric ugi bleeds10
Pediatric UGI Bleeds
  • Ulcers and Gastritis
    • Gastric acid production begins shortly after birth
    • Ulcers relatively rare
      • Most are associated with NSAIDs and stress
    • H. pylori infection
      • Diffuse nodular gastritis commonest presentation
      • Infection increases with age
        • <5yo rare
        • ~20-50% by 10yo (SES dependent)
        • 40-80% adults (SES dependent)
pediatric ugi bleeds11
Pediatric UGI Bleeds
  • Esophagitis
    • Severe GERD
    • FB or chemical injury
    • Infection
  • Vascular anomalies
    • Hemangiomas
    • Hereditary telangiectasia
    • Aortoenteric fistulas
  • Congenital malformations
    • Duplications, obstructions
      • Predisposed to mechanical injury
pediatric ugi bleeds12
Pediatric UGI Bleeds
  • Management
    • Similar to adults
      • ABC’s, history and physical
      • NG
        • Same dilemma as in adults, but no pediatric data
        • No longer use ice cold lavages
      • Diagnostics
        • CBC, PTT/INR, LFT’s, cross-match
        • Limited roles for imaging – CXR, U/S, angiography
      • Medications
        • Acid-suppressive +/- visceral vasoconstrictive
        • Limited but supportive data; dosing is the key difference
pediatric ugi bleeds13
Pediatric UGI Bleeds
  • Management
    • Endoscopy
      • Indications less standardized than in adults
        • For severe or persistent/recurrent bleeding
      • Diagnostic
        • No data on risk of rebleeding based on findings
      • Interventional as in adults
        • Size the limiting factor for techniques
      • Safety similar to adult data
        • Complication rate 0.3% in retrospective study of 2026
pediatric ugi bleeds14
Pediatric UGI Bleeds
  • Management
    • Surgery as back-up
      • Failed endoscopic therapy
      • Surgical lesion, e.g. Dieulafoy’s lesion
  • Take home point
    • Non-GI sources as common as GI sources in “pediatric UGI bleeds”
pediatric lgi bleeds
Pediatric LGI Bleeds
  • Lower GI Bleeds
    • 0.3% of ED visits
    • 50% <1yo
      • Allergic colitis, fissures commonest
    • >1yo
      • Infectious GE, fissure, polyps commonest
        • Ann Emerg Med, 1994
pediatric lgi bleeds16
Pediatric LGI Bleeds
  • Diagnosis
    • Nature of bleeding helps localize origin
      • N.B. hematochezia unreliable in infants, with their faster GI transit times
    • History and physical
    • If doubt bleeding, or suspect false-pos guaiac
      • Immunodiffusion of fecal Hgb
        • Sensitivity and specificity ~70% each, as with guaiac
      • Fecal alpha-1-AT measurement
        • Sensitivity 88%, specificity 90%
        • Also elevated in protein-losing enteropathy???
pediatric lgi bleeds17
Pediatric LGI Bleeds
  • Numerous laboratory and imaging options
    • Blood
    • Stool
    • Urine
    • Plain films, nuclear scans, endoscopy
      • Commonly used in painless bleeding
    • Non-barium contrast studies, U/S, CT, MRI, angiography
      • Dependent on suspected etiology
pediatric lgi bleeds18
Pediatric LGI Bleeds
  • Management
    • Similar to adults
      • ABC’s, history and physical
      • NG
        • Aspirate can help identify if blood from UGI source
      • Diagnostics
        • CBC, PTT/INR, LFT’s, cross-match, etc
      • Medications
        • Visceral vasoconstrictive
        • Supportive data for role in LGI bleeds
      • Treat underlying cause
pediatric lgi bleeds19
Pediatric LGI Bleeds
  • Neonatal
    • NEC
      • Risk factors
        • Prematurity (87% of cases)
        • Hypoxia
        • Sepsis
        • Acidosis
        • Early enteral feeds
        • Umbilical vascular catheter
        • PDA
      • Epidemics support infectious component
pediatric lgi bleeds20
Pediatric LGI Bleeds
  • Neonatal
    • NEC
      • Onset
        • Typically <4wks of age; can be late as 3mos
      • Manifestation
        • Abdominal distention, gastric retention
        • Poor feeding, V/D, lethargy, apnea
        • Gross blood in stools in only 25%
        • Severe cases lead to SIRS
pediatric lgi bleeds21
Pediatric LGI Bleeds
  • Pneumatosis intestinalis in 50-75% at diagnosis
  • Portal venous gas in severe disease
pediatric lgi bleeds22
Pediatric LGI Bleeds
  • Neonatal
    • NEC
      • Complications
        • Mortality up to 5%
        • Strictures in 10%
      • Treatment
        • Supportive
        • Antibiotics, gut rest
        • Surgical back-up
pediatric lgi bleeds23
Pediatric LGI Bleeds
  • Neonatal
    • Hirschsprung disease
      • Congenital aganglionic megacolon
        • Delayed (>48hr) passage of meconiom
        • History of (often progressive) constipation
        • 25% have blood in stool
      • Diagnosis
        • Contrast enema – proximal dilation = normal bowel
        • Rectal manometry
        • Biopsy with absent ganglion cells
      • Treatment is surgical resection
pediatric lgi bleeds24
Pediatric LGI Bleeds
  • Infants
    • “Allergic” colitis
      • Intolerance to cow’s milk protein
        • 0.2-7.5% prevalence
        • Soy protein intolerance in 14-25% of these
        • Typically not IgE mediated
        • Resolves in most by 2yo
      • Treatment is dietary restriction
    • Volvulus
    • Intussusception
pediatric lgi bleeds25
Pediatric LGI Bleeds
  • Children
    • Infectious enterocolitis
    • HUS, HSP, pseudomembranous colitis
    • IBD
    • Vascular malformations
      • Hemangiomas, telangiectias, varices, hemorrhoids
    • Polyps
      • Other tumors, e.g. colon cancer, are rare
    • Trauma
      • FB, NAT
pediatric lgi bleeds26
Pediatric LGI Bleeds
  • Meckel’s diverticulum
    • Vitellointestinal duct remnant
      • 50% have gastric mucosa
    • Most important source of small bowel bleeding
      • Gastric mucosal ulceration vs intussusception
    • Rule of 2’s
      • 2% of population
      • 2:1 male:female
      • 2 feet from IC valve
      • Under 2yo commonest
    • Diagnosed by radionuclide scan
    • Treatment is surgical resection
pediatric lgi bleeds27
Pediatric LGI Bleeds
  • Take home point
    • Think of NEC and Meckel’s
      • Both relatively common
      • Both potentially serious
slide28
Case
  • 13yo girl with 3days fever, despite Tylenol used round the clock. Also c/o N/V, anorexia, moderate epigastric pain. Today a bit jaundiced. Denies EtOH or other drug use. Her boyfriend has Mono.
  • 38.7, 100, 120/85, 22. Abdo tender, a bit distended, else exam normal.
pancreatitis
Pancreatitis
  • Differential
    • Gastroenteritis
    • Ulcer
    • Hepatitis
    • Pneumonia
    • Biliary tract obstruction
pancreatitis30
Pancreatitis
  • Much less common than in adults
  • Pathogenesis
    • Cell injury (toxin or otherwise) sets off pancreatic autodigestion and inflammatory response
pancreatitis31
Pancreatitis
  • Acute
    • Interstitial edema
      • Usually resolves within 2-7 days – mortality 5%
    • Complications – rare
      • Pseudocyst – slow to mature and resolve (weeks)
      • Phlegmon, necrosis +/- hemorrhage
      • SIRS – 50-80%+ mortality
  • Chronic/recurring
    • Endocrine and exocrine insufficiencies
    • Calcification
pancreatitis32
Pancreatitis
  • Etiology – the key difference in pediatrics
    • Trauma
      • Blunt injury – commonest cause; think of NAT
    • Infection
      • Viral (not just mumps), et al
    • Multisystem disease
      • CF, collagen vascular disease, vasculitits, metabolic
    • Obstructive
      • Congenital anomalies, biliary microlithiasis
    • Drugs and Toxins
      • EtOH, acetaminophen
    • Hereditary – autosomal dominant
    • Idiopathic (25%)
pancreatitis33
Pancreatitis
  • Clinical Picture
    • Abdominal pain
      • Steady, epigastric, with tenderness, distention
    • Persistent vomiting
      • Proportional to abdominal pain
    • Fever
    • Associations in complicated picture
      • Mass, e.g. in 50% of cases with pseudocyst
      • Asictes, pleural effusions, hypocalcemia, hyperglycemia, jaundice
      • Grey Turner (flank) and Cullen (periumbilical) signs
      • MSOF and shock
pancreatitis34
Pancreatitis
  • Diagnosis
    • Serum lipase
      • sensitivity 86% to 99%; specificity of 50% to 99%
      • Elevated 1-2 weeks longer than amylase
    • Serum amylase
      • sensitivity 75% to 92%; specificity 20% to 60%
    • General lab evaluation
    • Urinary trypsin activation peptide (TAP)
      • Investigational prognosticator
    • Ranson and APACHE-II criteria
      • Not reliable in pediatrics
pancreatitis35
Pancreatitis
  • Diagnosis
    • Diagnostic imaging – 20% normal at first
      • Plain films
        • Pleural effusions, “sentinel loop”, “cut-off sign”
      • U/S
        • Biliary tract evaluation, or follow-up of cysts/abcesses
      • CT
        • Usually only if poor U/S visualization
      • ERCP/MRCP
        • Considered if recurrent/undiagnosed problems
        • For suspected stones
pancreatitis36
Acute pancreatitis

Pseudocyst 5 months after acute episode

Pancreatitis
pancreatitis37
Pancreatitis
  • Management
    • “Pancreatic rest”
      • NPO +/- NG
    • Pain control
      • Meperidine – opioid causing least enterobiliary pressure by contraction of Sphincter of Oddi
    • Fluid and electrolyte homeostasis
    • Surgical and antibiotic interventions rare
      • Abcess, infected pseudocyst, necrosis, hemorrhage
    • Address underlying cause if able
pancreatitis38
Pancreatitis
  • Take home point
    • Trauma, including non-accidental, is the commonest cause
liver failure
Liver Failure
  • Fulminant hepatic failure
    • Acutely impaired hepatocyte function with
      • Encephalopathy within 8 weeks of initial symptoms, with a previously healthy liver, or
      • Encephalopathy within 2 weeks of jaundice, even if previously underlying liver dysfunction
liver failure40
Liver Failure
  • Cirrhosis
    • End-stage of acute or chronic disease
      • Fibrosis following injury from hepatitis, necrosis, or biliary obstruction
      • Restricts blood flow, creating portal hypertension, and ischemia further impairing heptocyte function
    • Biliary atresia
      • Commonest cause of liver failure in pediatrics
fulminant hepatic failure
Fulminant Hepatic Failure
  • Etiology
    • Viral
      • HBV likely the commonest of these
      • TORCH
    • Toxins
      • Acetaminophen the most common toxin
      • Amanita phalloides, EtOH, PHT, VPA…
    • Vascular
      • Veno-occlusive disease, ischemia, thrombosis
fulminant hepatic failure42
Fulminant Hepatic Failure
  • Etiology
    • Metabolic
      • Wilson’s, neonatal iron storage disease, tyrosinemia, galactosemia, fatty acid oxidation defects, mitochondrial disease
      • Reye’s syndrome
    • Others
      • Malignancy, autoimmune, idiopathic (20-40%)
fulminant hepatic failure43
Fulminant Hepatic Failure
  • Clinical Picture
    • Jaundice
    • Fetor hepaticus
    • Fever
    • Anorexia
    • Vomiting
    • Abdominal pain
    • Encephalopathy
      • Grades I-IV = mild confusion to coma
fulminant hepatic failure44
Fulminant Hepatic Failure
  • Note about ALT
    • Most specific for hepatocellular toxicity, BUT…
    • Falls as exhaust hepatocyte supply
  • Markers of function
    • Bilirubin, albumin, INR, glucose, NH3
fulminant hepatic failure45
Fulminant Hepatic Failure
  • Complications
    • Cerebral edema
    • Renal failure
    • Coagulopathy
      • GIT commonest site of bleeding
    • Hypoglycemia
    • Metabolic instability
    • Infection
    • MSOF
fulminant hepatic failure46
Fulminant Hepatic Failure
  • Treatment in ED
    • Eliminate or treat cause if able
      • N-acetylcysteine, charcoal
    • Supportive therapy
      • ABC’s, then
        • Increased ICP
          • Mannitol or hyperventilation; no Dexamethasone
        • Bleeding
          • FFP; FVIIa being studied
          • H2 blocker > sucralfate; PPI role being studied
fulminant hepatic failure47
Fulminant Hepatic Failure
  • Treatment thereafter
    • Ongoing supportive care
      • Corticosteroids shown to worsen outcome
    • For encephalopathy
      • Lactulose
      • Neomycin
      • Low protein diet
      • Plasmapheresis
    • Specific therapies
      • Antivirals, TIPS, thrombolysis, transplant
fulminant hepatic failure48
Fulminant Hepatic Failure
  • Prognosis
    • 50% experience serious infection
    • Mortality with medical care ~70%
      • Worse prognosis if <10yo or >40yo
    • Transplant survival 50-80%
    • Spontaneous recovery
      • More likely with low grade encephalopathy
      • Viral and acetaminophen 50-60%
      • Wilson’s and some idiosyncratic reactions 10-20%
liver failure49
Liver Failure
  • Take home point
    • Infants with fulminant hepatic failure typically have congenital problems, i.e. underlying liver disease
      • They don’t strictly fit the definition for fulminance
slide50
Case
  • 5yo with 1day of vomiting and occasional diarrhea. Severe abdo pain on and off every 15 mins or so. No sick contacts.
  • 37.9, 120, 110/75, 22. Abdo diffusely tender, no peritonitis, no mass. CBC normal, OB+.
intussusception
Intussusception
  • Differential Diagnosis
    • GE
    • Formula intolerance
    • Volvulus
    • Incarcerated hernia
      • inguinal>internal
intussusception52
Intussusception
  • Definition
    • Invagination of proximal intussusceptum into distal intussuscipiens
      • Ileocolic>cecocolic>ileoileal
  • Epidemiology
    • 1-4/1,000 live births
    • 50% by 1yr,80% by 2yrs, 90% by 5yrs
    • Peak incidence 10mos (2mos-2yrs)
    • 2-4:1 male:female
intussusception53
Intussusception
  • Etiology
    • 90-95% idiopathic in <2yo’s
      • Peyer patches’ hypothetical role
    • Pathologic lead points commoner in >5yo’s
      • Meckel’s diverticulum commonest
      • Polyps, HSP lesions, lymphomas, appendix, HUS, parasite, hemangiomas, metastases, CF, fecolith
    • Entrapped mesentery, bowel edema cause ischemia
intussusception54
Intussusception
  • Clinical Picture
    • Classic triad seen in <20%
        • 13% have less than or equal to 1 of these features
      • Intermittent abdominal pain (50-90%)
      • Vomiting (60-80%)
      • Blood and mucous in stools (20-60%)
        • Currant jelly stools are a late sign (20%)
intussusception55
Intussusception
  • Clinical Picture
    • Nonspecifics
      • Fever
      • Poor feeding
      • Lethargy
    • Physical Exam
      • “Dance’s sign” = sausage in RLQ (up to 70%)
      • Abdominal mass in 25-85%
intussusception56
Intussusception
  • Diagnosis
    • Plain films
      • Normal in <30%; suspect mass in 70%; obstruction
    • Barium or H2O-soluble enema
      • Gold standard for diagnosis and therapy
      • Misses ileoileal cases, e.g. Meckel’s
    • U/S
      • High accuracy
      • Adjunct to enemas, to monitor therapeutic effect
intussusception57
Intussusception
  • Plain film
intussusception59
Intussusception
  • Therapy
    • Barium or H2O-soluble enema
      • Successful reduction in 80% <48hrs, 50% >48hrs
    • Air-contrast enema
      • Studies suggest at least as effective as barium
      • Bowel perforation in 0.1-0.2% vs 0.5-2.5% with Ba
    • Surgical
      • Reduction vs resection
    • Dexamethasone
      • Hypothesis that it might reduce recurrence
intussusception60
Intussusception
  • Initial misdiagnosis in up to 60%
    • GE commonest
    • Consider in differential of lethargy
  • Spontaneous resolution rare
  • Mortality increases after 24-48hrs
  • Recurrence rate 5-8%
    • Higher if pathologic lead point
    • Less after surgery
intussusception61
Intussusception
  • Take home points
    • Be suspicious of this diagnosis
    • Add it to your differential for lethargy
volvulus
Volvulus
  • Definition
    • Closed loop obstruction from twist in GIT from a predisposing embryonic malrotation
  • Epidemiology
    • Malrotation in 1/500 births
    • 70% experience volvulus
    • 2/3 of volvulus occurs by 1mo, 75% by 12mo
volvulus63
Volvulus
  • Clinical Picture
    • Bilious emesis (80-100%)
    • Abdominal pain
      • Peritonitis, shock as ischemia progresses
      • Necrosis can occur within 2hrs
    • Feeding intolerance
    • Normal abdominal examination in 50%
      • Since obstruction is usually high and proximal
volvulus64
Volvulus
  • Differential Diagnosis
    • Small bowel obstruction (most are duodenal)
      • Web
      • Stenosis
      • Atresia
      • Hernia
    • Large bowel obstruction
    • Adynamic ileus
volvulus65
Volvulus
  • Diagnosis
    • Plain films
      • Variable: normal, SBO, LBO
    • UGI
      • Taper/beak of contrast; Ligament of Trietz abnormally located
    • Malrotation can be suspected by U/S
      • Abnormal position of superior mesenteric vessels
    • Malrotation work-up includes contrast enema
      • Cecum most common element of malrotation
volvulus66
Volvulus
  • Management
    • Volvulus is a surgical emergency
  • Take home point
    • Bilious emesis is volvulus until proven otherwise
appendicitis
Appendicitis
  • Definition
    • Appendicitis!
  • Pathophysiology
    • Luminal obstruction vs mucosal ulceration leads to inflammation or infection, edema and ischemia, then perforation, and subsequent peritonitis or abcess formation
appendicitis68
Appendicitis
  • Epidemiology
    • Incidence: 2/10,000 <4yo, 25/10,000 teens
      • 1/10th incidence where high fiber diets
    • Seasonal variability
    • Family history has RR of 3.5-10
    • Lifetime risk: 9% males, 7% females
    • 1-8% of ED Diagnoses of abdominal pain
    • Perforation: ~90% <3yo, <15% teens
appendicitis69
Appendicitis
  • Pathophysiology Encore
    • Appendix’s function - ? immunologic
    • Funnel shaped tube in infants
      • Less likely to obstruct
    • Maximal lymphoid hyperplasia in teens
      • Corresponds to peak incidence
    • More mobile than in adult population
      • Hence more confounding clinical features
appendicitis70
Appendicitis
  • Clinical Picture – age dependent
    • Classic progression
      • Periumbilical pain – N/V – RLQ pain
      • Occurs in 50% of adult cases, less in pediatric
      • Hence initial misdiagnosis 28-57%
    • Neonates (~80% mortality)
      • Features are nonspecific
        • Lethargy, irritability (20%)
        • Vomiting (60%)
        • Abdominal distention (60-90%)
        • Mass (20-40%), abdominal cellulitis, dyspnea, shock
appendicitis71
Appendicitis
  • Clinical Picture
    • Infants – misdiagnosis 70-100%
      • Commonest features
        • Vomiting (85-90%)
        • Pain and diffuse tenderness (35-92%)
        • Fever (50%)
        • Diarrhea (18-46%)
      • Right hip complaints (3-23%)
appendicitis72
Appendicitis
  • Clinical Picture
    • Pre-schoolers – misdiagnosis 19-57%
      • Vomiting often noted before pain
      • RLQ pain and tenderness become more prominent than diffuse pain
      • Rebound and guarding evident
appendicitis73
Appendicitis
  • Clinical Picture
    • School-aged kids – misdiagnosis 12-28%
      • Clearer communication of features
      • Non-classic features
        • Vomiting prior to pain (18%)
        • Dysuria (up to 20%)
        • Constipation or diarrhea (~20% each)
    • Adolescents – misdiagnosis <15%
      • Challenge in female population
        • Pelvic pathology
appendicitis74
Appendicitis
  • Clinical Picture
    • Rebound most sensitive (83%) and (with percussion) most specific (82%) for peritonitis (adult data)
    • No pediatric data on psoas, obturator, cough, and Rovsing’s signs, or cat’s-eye symptoms
    • Rectal exam adds little outside of infant population (except legal fodder in the USA)
    • Alvarado’s MANTRELS scoring system not accurate in pediatrics
appendicitis75
Appendicitis
  • Differential Diagnosis
    • GE
    • Mesenteric adenitis
    • Tubo-overian pathology
    • UTI
    • Intussusception
    • Meckel’s diverticulitis
    • Testicular pathology
    • RLL pneumonia
    • Sepsis
appendicitis76
Appendicitis
  • Diagnostic Studies – limited role, nothing 100%
    • WBC
      • Non-specific, non-sensitive – might alter suspiscions >48hrs
    • Neutrophilia
      • More sensitive at <24hrs of symptoms than WBC
    • CRP
      • Studies suggest more sensitive than WBC if perforation
    • Beta-HCG
      • The only “mandatory” test, in teen girls
    • U/A
      • 7-25% abnormal due to appendicitis
appendicitis77
Appendicitis
  • Radiology
    • Plain films
      • Fecolith in 13-20% (1-2% without appendicitis)
      • Role if suspect free air, obstruction, or mass
    • WBC scans
      • Variable results, therefore not recommended
    • U/S
      • Sensitivity 80-92%, specificity 86-98%
      • Don’t visualize appendix in 10% with appendicitis
    • CT (+/- contrast)
      • Sensitivity 87-100%, specificity 83-97%
      • Sometimes used to follow-up negative U/S
appendicitis78
Appendicitis
  • Management
    • Controversy over use of “prophylactic” antibiotics in uncomplicated appendicitis
      • Often decision deferred to surgeon
    • Fluid resuscitation and broad-spectrum antibiotics if suspect perforation
    • Observation in equivocal cases
  • Rare cases sound like recurrent appendicitis
    • Think IBD!
appendicitis79
Appendicitis
  • Take home points
    • Young children and adolescent girls are hardest to diagnose
    • In the CT vs U/S debate
      • U/S is often better in thin patients
      • CT is often better in fat patients
      • Utilization is centre and resource dependent
incarcerated inguinal hernia
Incarcerated Inguinal Hernia
  • Hernias
    • Indirect in >99% of pediatric cases
  • Epidemiology
    • 1-2 inguinal hernias/100 live births
      • Up to 30% in prems
      • Most right-sided; 10% bilateral (more in girls!)
    • 10% complicated by incarceration
      • Commonest cause of obstruction in infants
      • 70% of these by 1yo
    • 4-6:1 male:female
incarcerated inguinal hernia81
Incarcerated Inguinal Hernia
  • Hernia vs Hydrocele
incarcerated inguinal hernia82
Incarcerated Inguinal Hernia
  • Clinical picture
    • Bulge in groin
    • Progresses to off-colour, firm, tender mass
    • Symptoms and signs of intestinal obstruction
    • Unlike hydrocele, can feel neck of mass at distal inguinal ring
    • Transillumination suggests hydrocele
incarcerated inguinal hernia83
Incarcerated Inguinal Hernia
  • Differential Diagnosis
    • Hydrocele
    • Undescended or retractile testes
    • Lymphadenopathy
  • Management
    • Manual reduction
      • 95% success, less if ovary entrapped
    • Surgery for all hernias
      • Emergent if not reducible
slide84
Case
  • 6 wk old boy with 2/52 forceful non-bilious vomiting after feeds. Responsive, feeds hungrily.
  • 36.5, 150, 28, 90/50. CRT>2secs, AF depressed. Abdo soft, non-tender.Skin turgor diminished. Na 125, K 3.8, Cl 85, CO2 30.
  • Which of these is correct?
    • A) Congenital adrenal hyperplasia
    • B) Hypertrophic pyloric stenosis
    • C) Malrotation with volvulus
    • D) Milk allergy
pyloric stenosis
Pyloric Stenosis
  • Differential Diagnosis
    • GERD
    • Milk allergy
    • Infection (e.g. GE, sepsis)
    • Hydrocephalus
    • Metabolic disorders
    • Surgical causes
      • Malrotation, webs, duplications, atresias, annular pancreas
pyloric stenosis86
Pyloric Stenosis
  • Definition
    • Idiopathic hypertrophy of pyloric muscle
  • Epidemiology
    • 1-4/1,000 live births
    • 2-5:1 male:female
    • Family history; genetic syndromes
  • Etiology
    • Poor innervation of pyloric musculature
    • Presumed molecular cause (e.g. NO, GrwthF)
pyloric stenosis87
Pyloric Stenosis
  • Clinical Picture
    • Presents 1-10wks
    • Peak incidence 3-5wks
    • Progressive nonbilious projectile emesis post feeds
      • Earlier onset but slower progression in prems
    • Hungry until too dehydrated
pyloric stenosis88
Pyloric Stenosis
  • Physical Examination
      • Up to 90% specific, but <50% sensitive
    • RUQ “Olive”
      • 60-80% found “by an experienced examiner”
    • LUQ peristalsis
      • Saw it at last!
pyloric stenosis89
Pyloric Stenosis
  • Diagnosis
    • Hypochloremic metabolic alkalosis
      • +/- hypokalemia
      • +/- hyponatremia
      • +/- paradoxical aciduria
    • Imaging
      • U/S vs UGI
        • Both >90% sensitive
pyloric stenosis90
Pyloric Stenosis
  • Management
    • Correct hydration and electrolyte disorders
      • Focus on chloride replacement else alkalosis resistant to therapy
      • Severe alkalosis and hyponatremia need slow correction to decrease risk of pontine myelinolysis
pyloric stenosis91
Pyloric Stenosis
  • Management
    • Pyloromyotomy commonest choice
    • Natural history
      • spontaneous resolution over weeks to months
        • Controversial option – long-term TPN
        • Atropine has reportedly hastened this resolution
          • No good trials to date for this option
    • No long-term differences in gastric emptying
pyloric stenosis92
Pyloric Stenosis
  • Take home point
    • This is a medical, not a surgical emergency
dehydration in pediatrics

DEHYDRATION IN PEDIATRICS

Kevin Levere

Jan 16, 2003

definition
Definition
  • Loss of H2O and salt from ECF
    • Isonatremic – 70-80%
    • Hyponatremic – 10-20%
    • Hypernatremic – 10-20%
question
Question
  • Which of the following is associated with greater fluid loss per KG for a given severity of clinical manifestations of dehydration?
    • A) Fever
    • B) Hypernatremia
    • C) Male gender
    • D) Obesity
    • E) Older age
etiology
Etiology
  • Infectious gastroenteritis
    • Commonest by far (>1 episode/yr/pediatric patient)
    • Compounded by malnutrition
  • Pyloric stenosis
  • DKA or DI
  • Starvation
pathophysiology
Pathophysiology
  • Lean Body Mass (LBM) is 65-80% H2O
      • Infants
        • 25% ECF, 45% ICF
      • Children by 5yo (equivalent to adults)
        • 20% ECF, 50% ICF
      • Plasma is within ECF
        • 6% of LBM at all ages
    • Total Body Weight is ~10% fat in older children and adults
      • So Total Body Water is ~60% of Total Body Mass
pathophysiology99
Pathophysiology
  • Renal and hormonal homeostasis
    • Preserve H2O, regulate Na
  • Losses
    • Insensible, GI, renal
  • Intake
    • Deficient
    • Hypoosmolar vs hyperosmolar
clinical picture
Clinical Picture
  • Isonatremic
    • Isoosmolar state, no fluid compartment gradient
    • ICF preserved
  • Hyponatremic
    • Further H2O loss as shifts from ECF into ICF
    • Exacerbates circulatory depletion, enhancing signs
  • Hypernatremic
    • ECF preserved by shifts from ICF
    • Attenuates circulatory signs; doughy skin; lethargy
clinical picture101
Clinical Picture
  • Signs arise at 3% - Lancet, 1989
    • Clinical overestimation is common
  • Clinical Physician estimates ~70% sensitive
    • Pediatr Emerg Care, 1997
  • Tachycardia presents early
    • Not specific, and surprisingly not sensitive
  • Decreased U/O occurs by 5%
    • Therefore poor predictor of severity
clinical picture103
Clinical Picture
  • Validity and Reliability of Clinical Signs
        • Pediatrics, 1997
    • Individual findings lack sensitivity
      • Included capillary refill time and tachycardia
    • For dehydration of 5% or more
      • 3 or more findings 87% sensitive and 82% specific
    • For dehydration of 10% or more
      • 7 or more findings 82% sensitive and 90% specific
clinical picture104
Clinical Picture
  • Validity and Reliability of Clinical Signs
        • Pediatrics, 1997
    • Factors independently associated with dehydration (in logistic regression)
      • Capillary refill >2 sec
      • Dry mucous membranes
      • Absent tears
      • Ill appearance
    • For dehydration of 5% or more
      • 2 of 4 findings 79% sensitive and 87% specific
lablablab
lablablab
  • Common lab tests
      • Recommended in moderate to severe cases
      • Not sensitive or specific for degree of dehydration
    • Na
      • Reflects relative losses of H2O and salts
    • K
      • Low if lost in diarrhea or if alkalotic (vomiting)
      • High if renal compromise or acidosis
    • HCO3
      • Lost in renal compromise or stool losses
      • Might replace if renal compromise and acidosis
more labs
More Labs
  • Cl
    • Alkalosis resistant to therapy if not replaced
  • Urea
    • Estimates degree of renal compromise
  • Ca
    • Reduced if phosphate retention or hypernatremia
    • Rarely significant
  • U/A
    • Specific gravity
fluid therapy
Fluid Therapy
  • “Coconut Water!”
fluid therapy108
Fluid Therapy
  • 150 years of History
      • Parenteral concoctions assayed with varying success
      • Early theories were that ICF was dehydrated because of excess K in diarrhea – 1915
      • Principle of cellular homeostatic limits led to maintenance and deficit therapy, IV therapy as mainstay – NEJM, 1953
      • Greater success after realized ECF dehydration was the greater contributor, with potassium restored during maintenance – Pediatrics, 1956
      • Affect of net Na and glucose relationship on reabsorption appreciated, oral rehydration therapy (ORT) success realized – NEJM, 1968
      • Free water and concentrated ORT solutions found to have increased mortality, hence reduced osmolar questions
fluid therapy110
Fluid Therapy
  • Rice-based oral solution with WHO’s electrolyte balance:
    • More effective than the WHO ORS in reducing stool output in people with cholera. This effect was not apparent in infants and children with non-cholera diarrhea
        • Cochrane Database Syst Rev, 2000
    • Starch and small proteins as Na cotransport, with less osmolar effect on diarrhea
fluid therapy111
Fluid Therapy
  • Reduced osmolarity solutions
      • ~270mOsm/L, Na ~60-75mEq/L
    • 33% fewer IV infusions
    • Decreased stool losses
    • Less vomiting
    • No additional risk of hyponatremia
        • Cochrane Database Syst Rev, 2001
      • Only significant incidence of hyponatremia found in adults with cholera, but none were symptomatic
        • CHOICE Study Group, 1999
fluid therapy112
Fluid Therapy
  • For severe dehydration (~10% or 100ml/kg)
    • Rapid intravenous ECF restoration
      • Over 2-6hrs
      • Improves renal perfusion and function
      • Reduces vomiting
      • Earlier resumption of oral intake, including food
      • Food and milk might shorten duration of diarrhea despite transient lactase deficiency
      • Avoid fatty food and simple sugars
fluid therapy113
Fluid Therapy
  • For severe dehydration
    • IV restoration followed by ORT to replace K, restore ICF status
      • For maintenance and ongoing losses
    • Deficit calculations in isonatremic situations not found to improve care
fluid therapy114
Fluid Therapy
  • For hypernatremic dehydration
    • Restore circulation (treat shock)
    • Deliver maintenance and deficit over 48hrs to avoid cerebral sequelae
    • Hyperglycemia often accompanies hypernatremia
    • Slower restoration increases risk of hypocalcemia, especially in young infants
fluid therapy115
Fluid Therapy
  • For mild to moderate dehydration (5-9%)
    • ORT is 90-95% effective
    • Oral fluid challenge only if moderate (i.e. borderline for IV therapy)
fluid therapy116
Fluid Therapy
  • NG vs IV
        • Pediatrics, 2002
    • 93 patients prospectively enrolled
      • Moderate dehydration, failed oral fluid challenge
    • Randomized to rapid NG vs IV hydration
      • 50ml/kg over 3hrs of Pedialyte vs NS
    • Both found to be safe and efficacious
      • Significantly more emesis in NG group
      • Significantly less cost
      • Improved acidosis in NG vs worsened in IV
        • Not clinically significant; no other lab variance
fluid therapy117
Fluid Therapy
  • NG vs IV vs ORT
    • Failure meant getting admitted
      • 1 of the 47 NG arm failed (~2%)
      • 2 of the 46 IV arm failed (~5%)
    • ORT is 90-95% successful, and cheapest
      • Still the first line therapy in moderate dehydration
      • Oral fluid challenge poorly defined
        • Only useful if borderline for IV/NG intervention
medications
Medications
  • Antidiarrheals
    • None recommended in younger children
        • AAP Guidelines, 1996
      • Loperamide and other opiate derivatives
        • Limited efficacy vs high rate of side effects
      • Anticholinergics
        • No clear efficacy, high rate of side effects
      • Bismuth compounds
        • Limited benefit vs lack of data on rates of side effects
      • Adsorbents and lactobacillus
        • No clear benefit, though little concern of toxicity
medications119
Medications
  • Antiemetics
    • Concensus opinion – they aren’t needed
      • Little efficacy vs side effects
        • CHMC Guidelines, 1997
    • Ondansetron effective in reducing emesis from GE, increasing success of ORT
        • Ann Emerg Med, 2002
medications120
Medications
  • Zinc
    • Role in the malnourished
      • Reduced duration and severity of diarrhea
      • Independent of Vitamin A supplementation
        • Pediatrics, 2002
      • Regular Zn supplementation reduced frequency of diarrheal illnesses (and pneumonias)
        • J Pediatrics, 2002
ad sub mission
Ad(sub)mission
  • Significant dehydration and…
    • Persistent and/or prolonged ongoing losses
    • Care-givers far from help, or unable to help
  • Ill despite fluids – consider other diagnoses
    • i.e. back to the beginning
liver disease
Liver Disease
  • Chronic manifestations
    • Hepatomegaly
    • Jaundice
    • Pruritis
    • Spider hemangiomas
    • Palmar erythema
    • Ascites
    • Portal hypertension
    • Xanthomas
    • Encephalopathy
    • Renal dysfunction
    • Endocrinopathies (rarer than in adults)
liver disease124
Liver Disease
  • Hepatomegaly
    • Inflammation
      • Infections, toxins, autoimmune disease
    • Storage
      • Glycogen, lipids, Wilson’s, iron
    • Infiltration
      • Primary and secondary neoplasia
    • Congestion
      • CHF, veno-occlusive disease, post-hepatic obstruction
liver disease125
Liver disease
  • Jaundice (aka icterus)
    • In neonates at 80-100micromol/L
      • Occurs at lower levels in children and adults
    • Unconjugated bilirubin
      • Lipid soluble; unbound crosses BBB
    • Conjugated bilirubin
      • Unbound is renally excreted
      • Increased if >20% total bilirubin
unconjugated hyperbilirubinemia
Unconjugated Hyperbilirubinemia
  • Hemolytic disease
    • Hereditary or acquired
    • Sepsis, UTI
  • Decreased hepatic conjugation
    • Decrease hepatic intake
      • Breast milk, hypothyroidism
    • Decreased hepatocellular function
      • Hepatitis
      • Physiologic, Crigler-Najjar, Gilbert
  • Enterohepatic recirculation
neonatal cholestasis
Neonatal Cholestasis
  • Infectious
    • Sepsis, hepatitis, TORCH
  • Toxin
    • TPN, sepsis, drugs
  • Metabolic
    • Galactosemia, tyrosinemia, alpha-1 AT defiency, CF
  • Intrahepatic diseases
    • Alagille, bile duct paucity, congenital fibrosis
  • Extrahepatic biliary diseases
extrahepatic biliary diseases
Extrahepatic biliary diseases
  • Biliary atresia
    • Commonest cause of liver failure in pediatrics
  • Sclerosing cholangitis
    • Association with IBD
  • Bile duct stenosis
  • Choledochal-pancreaticoductal junction anomaly
  • Spontaneous perforation of the bile duct
  • Choledochal cyst
  • Mass (neoplasia, stone)
  • Bile/mucous plug ("inspissated bile")
liver disease130
Liver Disease
  • Evaluation
    • ALT most specific for hepatocellular toxicity
      • AST might have role in evaluation of EtOH etiology, not a typical pediatric concern
    • 5’ nucleotidase and GGT sensitive markers of biliary obstruction or inflammation
      • Alk phosphatase not so specific
    • Bilirubin, albumin, INR, glucose, NH3
      • Markers of function
liver disease131
Liver Disease
  • Evaluation
    • Metabolic survey
      • Electrolytes, Ca, Mg, PO4
      • Renal function, U/A (ketones)
      • Glucose, U reducing substances
      • NH3, lactate, urate
      • Blood gas
      • Serum AA’s, urine AA’s and OA’s
liver disease132
Liver Disease
  • Evaluation
    • Imaging
      • U/S, CT, MRI, ERCP
        • Masses, gall bladder, biliary tree
      • Nuclear med studies now very rarely used
    • Liver biopsy