Hot Seat #48: 5 yo M abd pain transfer

Posted on: December 4, 2014, by :

by Rosemary Thomas-Mohtat, Children’s National
with Moh Saidinejad, Children’s National

The Case
Sunday morning 3am:
You receive signout on a 5 yr old male transferred from OSH for abd pain.

He has had 48hrs of abd pain- awakening “shrieking” in the night 2 nights ago. Pain was described as periumbilical. Had 3 episodes of NBNB emesis on day 1. He went to PCP that day, WBC per report 15. Dad had had gastroenteritis 24 hours earlier, so his symptoms were attributed to that. On morning of presentation, the pain was more constant, especially on the left side of his abdomen, flank and back. He refused to get out of bed and urinated on himself. Had very poor po, but no further emesis x24h. At times also complained of groin/testicular pain and mom notes “difficulty emptying bladder”.

ROS: Pain seems to be mostly left sided, worse on left flank/LLQ. Mom mentions that he has complained about back pain intermittently every few months, but self resolves. Seen by PCP for this, however no further w/u initiated because pain resolved. No constipation. No known trauma (though rough houses with sibs). No fever, URI, sore throat, hematuria, dysuria, urinary frequency, urgency.

Seen at OSH this evening, US: appendix not visualized. AXR showed significant stool burden, so got an enema, however had no result. He continued to have severe abdominal pain requiring narcotics. WBC 20. Got ertapenem and transferred for further care. At CNMC, he is up in US now (so defer exam till he returns).

Vitals: T 37.5, P 101, BP: 111/57, 99% RA
Labs: Wbc 13.69, Hgb 10.2, hct 29.7, plt 325 %n 80
CMP: Na+137, K+3.6, Cl-101, CO2 19, glu 79, bun 11, cr 0.5. LFTs nl
UA: neg.

Questions for you:

Re-examination after return form US at 05:00.
Vitals: T: 38.3, HR 133, BP: 104/43, R: 25, 99% RA
Significant tachycardia- HR 140s. This is his first fever.
Exam: Diaphoretic, pale, looks unwell. Cap refill 3secs. Lungs: CTA, no WOB. Abd: hyperactive bs. Significant guarding. No rebound. No organomegaly. Significant tenderness LLQ more than RLQ. + left flank pain. GU nl: circumcised, testes descended and nontender.

Gets bolus NS and morphine 2mg.
Unfortunately, 2nd US has not visualized appendix either, but prelim commented on+ shotty LNs and small amount of free fluid in abdomen, and left mild pelviectasis. Also comment on area of heterogenous material of soft tissue echogenicity, with intermixed fluid, possibly consistent with stool in fluid filled colon.

How would you approach this case? Please share your opinions by clicking on “What do you think?” below.

2 thoughts on “Hot Seat #48: 5 yo M abd pain transfer


  1. If the patient looks unwell with poor perfusion, sounds like we need more information and more aggressive treatment.

    I don’t like getting surgeons involved in these cases. I think the era of having a surgeon touch the belly and add any clinically meaningful decision is gone. This prolongs ED LOS and is procastinating, especially if you don’t have a likely surgical cause.

    So you have mild acidosis, leukocytosis, fever, anemia, left-sided abd. pain, and “looks unwell”

    Some things i think about:
    –ileal-ileal intussusception, Those kids usually don’t follow signs of “gastro” like the younger ileal-colic ones and they often resolve spontaneously depending on the lead-point etiology
    –UPJ obstruction is a cause of vomiting and flank pain
    –Mesenteric adenitis is associated with fever and leukocytosis
    –Outside the box: pleural effusion, pericardial effusion, IBD, confluence of factors (constipation+viral syndrome), something oncologic, diffuse inflammatory process, omental infarction, etc.

    What i would do:
    –CXR, abd CT, additional labs (albumin, ESR, retic), fluid resuscitation, re-eval perfusion, consider adding vanco if concern for sepsis. I think our job is to r/o something surgical or potentially shocky. But most of these kids will have a negative CT and need admission to floor for pain control, serial belly exams, and further testing.

    Remember that you don’t need PO contrast for abd CT (per our protocol) if onset of pain is within 72 hrs….this expedites a helpful imaging modality. I think the anemia is the biggest read flag for me because it implies a longer standing process or acute loss….so i might inquire more about that.

    We are moving towards MR for abd. pain NOS….it is great for looking at signs of colitis as well as appy, pancreatitis, etc.


  2. So, this is a 5 year old male with progressive symptoms, which began with apparently sharp, intermittent abdominal pain 2 days ago, and now the pain is becoming more constant. Looks like the location of pain also moved from peri-umbilical, to more left sided pain with flank and back pain. Not much in the way of gastroenteritis symptoms (vomiting or diarrhea), and no report of fever, poor appetite, or urinary symptoms. One piece of information that I want to keep in the back of my mind as I work this out is the intermittent back pain. It makes me think something potentially pressing or squeezing on the spine, and given the stool burden findings, I wonder if part of the dialated colon may be responsible.

    On my differentials are:
    – GI causes [appendicitis (might be retrocecal, given the left sided complaints or ruptured although no peritonitis signs at this time), GI bleeding, mesenteric adenitis, partial bowel obstruction (less likely given only one NBNB vomiting), though not clear from this case, I also agree with Dave on possible ileo-ilal and or even ileocecal intussusception (Enlarged lymph nodes seen on US can be lead point, and explains the initial intermittent pain 2 days earlier
    – Renal cause (urolithiasis, UPJ obstruction as Dave mentioned, given pelviectasis), given the flank pain and radiation of pain to the groin and back. No hematuria is a reassuring sign against this, however.
    – Oncologic cause – Solid tumor in the abdomen – maybe what is responsible for excessive stool burden, also explains the low H and H. Renal or suprarenal mass (Neuroblastoma, Wilms Tumor)
    – Other GU cause (testicular torsion, obstruction in the bladder/ureters
    – Other differentals may emerge as more work-up is conducted

    My approach to this case:
    – Patient looks unwell, and has now developed a fever and has a slight acidosis. I will keep patient NPO, start fluid resuscitation with NS bolus over 30 minutes and reassess to see how this affected the patient in case we want to do further fluid boluses, grab a blood culture, and start on broad spectrum antibiotics. I think something like ceftraixone would be a good start. Somehow, I lean more towards gram negative organisms given the location and type of symptoms.
    – I would get inflammatory markers (ESR, CRP), and LDH + uric acid, LFTs, and protein/albumin at this point. I would also see if pathology lab can get me a peripheral smear study.
    – I definitely would like a better imaging modality. I would get an abdominal CT with IV contrast. As Dave also mentioned, not having PO contrast is fine. Chest x-ray is lower on my list, but I can see how we might end up ordering that also.

    ** Do I want to focus on renal source more? (Don’t know, but this is a Rosemary case and she definitely knows the ins and outs of renal pathology better than I do, so I should consider this 🙂

    While I wait for my CT results, my focus is on timely and frequent reassessment of clinical presentation, and continuing to check perfusion, and evidence of hemodynamic stability. Depending on what the CT abdomen shows, I will consider a renal US looking for size of the kidneys and ureter. The normal BUN and Cr is a good sign, though.

    Finally, I also agree with Dave, that at this point, I have nothing to bring surgeons in for.

    I look forward to hearing what the outcome was.

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