Pediatric emergency medicine trisk 93
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FIGURE 12.2 Fluid (ascitic, blood). PLE, protein-losing enteropathy; TB, tuberculosis; CHF,
congestive heart failure. a Right upper quadrant tenderness. b Newborn period only or primarily.
FIGURE 12.3 Extreme hepatomegaly.
FIGURE 12.4 Extreme splenomegaly.
FIGURE 12.5 Mass.
Often, after the initial history, physical examination, and laboratory evaluation,
further imaging studies will be necessary. Ultrasound is an excellent first step
since it is portable, has no ionizing radiation, is inexpensive, and can usually
determine the presence and characteristics of a mass, organomegaly, and ascites
(see Chapter 131 Ultrasound ). It is also fairly accurate in the diagnosis of GI
obstruction, malrotation, and intussusception. POCUS can be used as an
extension of the clinical examination because physical examination findings (site
of maximal tenderness and/or distension) can be correlated with ultrasound
findings. An abdominal CT scan is the preferred study in the evaluation of
abdominal distension if an ultrasound is inconclusive or unable to be obtained
(i.e., obesity). Focused abdominal sonography for trauma (FAST) is a useful
screening tool in the initial evaluation of abdominal trauma in pediatrics (see
Chapter 103 Abdominal Trauma ).
Management
Abdominal distension by itself may represent a medical emergency. First, this
occurs when the distension is so severe that diaphragmatic excursion is
compromised. For example, gastric and bowel distension secondary to aerophagia
and ileus post trauma may significantly impair a child’s respiratory status.
Massive ascites and free peritoneal air may also compromise respiration.
Therefore, the first step in management is to assess and stabilize the child’s
respiratory status, including the use of positive-pressure ventilation and/or
emergent relief of distension, if needed. Passage of a nasogastric or orogastric
tube may also result in dramatic improvement in the child’s respiratory status.
The second, far less common situation in which abdominal distension may
represent an emergent situation in itself is compression of the inferior vena cava
(IVC), resulting in a compromised cardiovascular status. For example,
occasionally, a child with severe obstipation may present with weak pulses and
cool extremities. In this situation, rapid infusion of intravenous fluids, as well as
disimpaction, will improve the patient’s perfusion status rapidly. Managing the
child in the lateral decubitus position may relieve pressure on the IVC.
Progressive increase in intra-abdominal pressure may lead to abdominal
compartment syndrome (ACS) that results in end-organ damage of the gut, in
addition to affecting the renal, pulmonary, and cardiovascular systems. ACS has
an extremely high morbidity and mortality and should be considered in any child
with abdominal distension and shock. ACS may be seen in the setting of trauma
(massive hemorrhage or volume resuscitation) or in conditions that result in
massive ascites or bowel wall edema. If ACS is suspected, immediate abdominal
decompression with nasogastric and rectal tubes should be performed as well as
surgical consultation. CT or MRI findings in children with ACS include IVC
compression, basal lung atelectasis, compromised renal perfusion, and ascites.
When the airway, breathing, and circulation have been stabilized, the diagnostic
evaluation can proceed with laboratory and imaging studies as discussed
previously.
Suggested Readings and Key References
Abu-Zidan FM, Cevik AA. Diagnostic point-of-care ultrasound (POCUS) for
gastrointestinal pathology: state of the art from basics to advanced. World J
Emerg Surg 2018;13:47.
Devanarayana NM, Rajindrajith S. Irritable bowel syndrome in children: current
knowledge, challenges and opportunities. World J Gastroenterol
2018;24(21):2211–2235.
Jain A. Pediatric fatty liver disease. Mo Med 2019;116(2):123–128.
Je B, Kim H, Horn P. Abdominal compartment syndrome in children: clinical and
imaging features. AJR Am J Roentgenol 2019;212:655–664.
Nowak-We grzyn A, Konstantinou G. Non-IgE-mediated food allergy: FPIES.
Curr Pediatr Rep 2014;2:135–143.
