2 thoughts on “Hot Seat #58: 12 yo with abd pain and vomiting”

1. 
   

   One other “outside the box” [of the abdomen] thing to consider is getting a CXR to rule out a lower lobe pneumonia irritating the diaphragm, given the child’s fever, cough, upper abdominal pain, and 96% O2 Sat in triage. I’d hate to make a diagnosis of lower lobe pneumonia on abdominal CT — but have done it more than once in my career (and will probably do it again!).

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2. 
   

   Abdominal pain in a male…

   I’m going to use SPIT (http://www.pemfellows.com/blog/the-med-ed-toolbox-spit/) to review the DDx. I often use this in the ED with trainees and it helps to have a discussion around the DDx.

   S Serious
   P Probable
   I Interesting
   T Treatable

   DDX:

   S: Serious

   Testicular Torsion- Our clinical exam is very reassuring and essentially helps to move this off the list. It is very important to document a normal testicular exam in males presenting with abdominal pain (especially lower abdominal pain with vomiting).

   Appendicitis– Although the location of the pain is not focal RLQ and with upper> lower as described, in a patient with low-grade fevers, tachycardia and persistent pain I would consider a dedicated US appendix. A normal WBC count does not rule out appendicitis (especially on day one of illness). If the appendix was not visualized and…
   • If he had more focal RLQ pain: I would consider CT
   • If still in pain but generalized would observe with serial abdominal exams
   • If pain improved/resolved I would consider discharge home with strict return precautions

   Volvulus – Emesis was not reported as bilious and abdominal exam was not consistent with an exam in someone who is demonstrating intestinal obstruction. If exam worsened would consider a plain film or go straight to CT.

   Perforated gastric/duodenal ulcer – could cause pain and tachycardia; would be worried about perforation but we have no concern for GI bleed and our patient’s abdominal exam is improving. With a gastric ulcer eating usually makes the pain worse (compared to better with a duodenal ulcer). Would be good to know if he was on NSAIDs.

   P: Probable

   Infectious colitis – Our patient has only one day of symptoms with vomiting, low grade fevers and more generalized (though it is unusual to have repeated exams with right sided pain). This could still be early gastroenteritis. Also, given he is coming from Korea…we should consider stool cultures if he does have diarrhea.

   Constipation – Although he reports normal stools – pain could be right sided and migrate with peristalsis. Also this is so common. At times I consider a diagnostic/therapeutic enema in the ED is a possibility. In our patient though fever and tachycardia make me more concerned.

   I: Interesting

   Typhoid – In this patient who recently came from Korea…and looking at the yellow book CDC website below, 21 days is still technically within the incubation period for typhoid. And perhaps the tachycardia with a drop in temperature is the temperature/HR dissociation often reported (nah….) We also do not have HSM (though not always present), no progressive increase in temperature. Of note intestinal hemorrhage or perforation is a serious complication of typhoid.

   “The incubation period of typhoid and paratyphoid infections is 6–30 days. The onset of illness is insidious, with gradually increasing fatigue and a fever that increases daily from low-grade to as high as 102°F–104°F (38°C–40°C) by the third to fourth day of illness. Headache, malaise, and anorexia are nearly universal. Hepatosplenomegaly can often be detected. A transient, macular rash of rose-colored spots can occasionally be seen on the trunk. Fever is commonly lowest in the morning, reaching a peak in late afternoon or evening. Untreated, the disease can last for a month. The serious complications of typhoid fever generally occur after 2–3 weeks of illness and may include intestinal hemorrhage or perforation, which can be life threatening.”

   Spontaneous Rupture of the Spleen – This would be in a patient whom you suspect to have had mononucleosis. Labs reported are not consistent with this (no pharyngitis, body aches or malaise). Also, this patient does not have documented splenomegaly (though I guess it could be so large that one misses it on exam), however for this patient we have a normal ultrasound.

   At the end of our case we are left with tachycardia in the setting of improvement in pain and temperature reduction…this is concerning. Could it be dehydration, yes – so I agree – lets give fluids. However abdominal pain, fever and tachycardia – should also make you consider myocarditis (but we are reminded to not think of this as a typical hot seat case…so perhaps not ☺)…practically speaking though, I would not discharge this patient tachycardic…at minimum he warrants observation.

   Pneumonia – This could very well be a presentation of a RLL pneumonia. Though would expect a higher WBC count.

   DKA – Not our child….though important to consider in any child with vomiting and abdominal pain—especially if they look dry and are tachypneic without respiratory distress (compensatory for metabolic acidosis). I had a child who looked very dry, complained of right flank pain (screaming in pain) with repeated episodes of vomiting at home…and we did a VBG as he was tachypneic….turned out he had DKA.

   MERS – Just for fun…..given Dr. Debiasi’s email and the cases in Korea.. I included this:

   Who should be evaluated for MERS?
   •Healthcare providers should be alert for and evaluate the patients who develop fever and symptoms of severe acute respiratory illness (SARI) with the following characteristics for possible MERS-CoV infection; termed Persons Under Investigation or PUI:

   •Fever AND pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence) AND EITHER:
   o a history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, OR
   o close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula, OR
   o a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments.

   OR
   •Fever AND symptoms of respiratory illness (not necessarily pneumonia; e.g. cough, shortness of breath) AND being in a healthcare facility (as a patient, worker, or visitor) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula in which recent healthcare-associated cases of MERS have been identified.

   OR
   •Fever OR symptoms of respiratory illness (not necessarily pneumonia; e.g. cough, shortness of breath) AND close contact with a confirmed MERS case while the case was ill.

   Take home points:

   1. Although still relatively rare among all comers to the ED with abdominal pain, appendicitis is the most common surgically correctable cause of abdominal pain in children.
   2. As Dewesh nicely pointed out – pneumonia. Sadly, I have also have diagnosed pneumonia on CT before – embarrassing…but think of pneumonia in any child with upper quadrant abdominal pain, vomiting, fever and cough (cough may not be the primary complaint).
   3. Try to avoid discharge diagnoses of gastroenteritis or constipation when the etiology is unclear.
   4. Document serial abdominal examinations in the ED.

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