Pediatric emergency medicine trisk 935
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CHAPTER 116 ■ ABDOMINAL EMERGENCIES
SUSAN C. LIPSETT, RICHARD G. BACHUR
GOALS OF EMERGENCY CARE
Pediatric abdominal complaints are common, and ED physicians are challenged
to distinguish common, innocent gastrointestinal complaints from surgical
emergencies. Logical diagnostic strategies and prompt recognition of surgical
emergencies should be the goal of the evaluation. For abdominal surgical
emergencies, the clinical evaluation should focus on timely recognition of a
surgical condition and early involvement of a surgeon. Ideal care would limit
complications such as peritonitis and ischemic bowel.
KEY POINTS
Bilious emesis in a young infant is a surgical emergency
Young children with appendicitis often have atypical presentations
Intussusception can present with profound altered mental status
Bloody stool or blood per rectum may represent ischemic bowel
RELATED CHAPTERS
Signs and Symptoms
Abdominal Distension: Chapter 12
Constipation: Chapter 18
Gastrointestinal Bleeding: Chapter 33
Pain: Abdomen: Chapter 53
Medical, Surgical, Trauma
Gastrointestinal Emergencies: Chapter 91
Gynecology Emergencies: Chapter 92
Abdominal Trauma: Chapter 103
ACUTE NONPERFORATED APPENDICITIS
CLINICAL PEARLS AND PITFALLS
Young children often have nonclassic presentations of appendicitis
Pain and tenderness will vary based on exact location of the appendix
Rapid improvement in pain in a child with high suspicion of appendicitis
may occur at the time of perforation
Diagnostic algorithms should incorporate a clinical risk score and
ultrasound as the first-line imaging modality
Current Evidence
Acute appendicitis is the most common nontraumatic surgical emergency in
children. Anatomic characteristics may influence the incidence and presentation
of appendicitis throughout childhood. Lymphoid hyperplasia within the appendix
is maximal in adolescence and might be related to the peak incidence in this age
group. Generally, obstruction of the appendix (by fecal material, an appendicolith,
or simply lymphoid hyperplasia) is believed to be a key step in the development
of appendicitis. Once obstructed, bacterial overgrowth and invasion into the
mucosal barrier lead to progressive inflammation and dilation. Localized pain and
tenderness develops. Perforation rarely develops before 12 hours of pain but is
common after 72 hours. Perforation can lead to generalized peritonitis or focal
abscesses. Since younger children have a relatively underdeveloped omentum,
they are much more likely to present with diffuse peritonitis.
Goals of Treatment
Early recognition and treatment prior to perforation is ideal. Ultrasound (US)
should be used as the first-line imaging modality in stable patients, with advanced
imaging reserved for children with nondiagnostic US and a persistent clinical
concern for appendicitis. Clinical outcomes for patients with suspected
appendicitis include accurate identification of appendicitis over medical
etiologies of focal abdominal tenderness, limiting the use of computed
tomography among patients with uncomplicated acute appendicitis, minimizing
the number of negative appendectomies, definitive treatment prior to perforation,
and the consideration of serial examinations over advanced imaging for patients
considered low risk for appendicitis.
Clinical Considerations
Clinical Recognition
The peak incidence of appendicitis in children occurs between 9 and 12 years of
age. Although neonatal cases have been reported, appendicitis rarely occurs in
children younger than 2 years of age. Predictably, the diagnosis is very difficult in
children younger than 5 years of age. The emergency physician must accurately
evaluate the child and promptly consult a surgeon when the diagnosis is clear or
when appendicitis cannot be safely ruled out. Such consultation is especially
urgent in younger children, in whom perforation can occur within 8 to 24 hours of
the onset of symptoms. Usually the child with appendicitis initially complains of
poorly defined and poorly localized midabdominal or periumbilical pain.
Unfortunately, this symptom is common to many other nonsurgical intraabdominal problems. In the young and, to a lesser extent, the older child,
vomiting and a low-grade fever often occur. Characteristically, the pain then
migrates to the right lower quadrant ( Table 116.1 ).
TABLE 116.1
PROGRESSION OF SYMPTOMS AND SIGNS OF APPENDICITIS
Nonperforated appendicitis
Poorly defined midabdominal or periumbilical pain
Low-grade fever
Anorexia
Vomiting
Migration of pain to right lower quadrant
Localization depends on position of appendix
Appendix in gutter → lateral abdominal tenderness
Appendix pointing toward pelvis → tenderness near pubis may cause
diarrhea or bladder irritation
Retrocecal appendix → tenderness elicited by deep palpation
Pain on coughing, hopping, or to percussion
Rectal examination: pain on palpation of right rectal wall
WBC count: 10,000–15,000/mm3
Urinalysis: ketosis, few WBCs
Perforated appendicitis
Increasing signs of toxicity
Rigid abdomen with extreme tenderness
Absent bowel sounds
Dyspnea and grunting; tachycardia
Fever: 39°C–41°C (102.2°F–105.8°F)
WBC count: >15,000/mm3 with left shift
Eventual overwhelming sepsis and shock
WBC, white blood cell.
Triage Considerations
Children with abdominal pain and localized right lower quadrant tenderness or
guarding should be evaluated promptly for appendicitis. Associated fever,
extreme pain, and ill appearance may imply perforation and demand emergent
treatment and surgical consultation. Shock related to peritonitis, sepsis, or severe
dehydration is rare.
Clinical Assessment
