Pediatric emergency medicine trisk 2059 2059
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Management/Diagnostic Testing. Abdominal radiography, including an
upright view, is indicated in cases of suspected partial or full obstruction, toxic
megacolon, or perforation. Abdominal ultrasound is the preferred initial
modality to evaluate for an abscess, and has a sensitivity approaching 90%
and specificity approaching 100% to identify bowel inflammation. Computed
tomographic (CT) imaging should be used sparingly and only if urgent
information related to inflammation or a possible extraenteric complication is
needed, as children with IBD have been identified as having moderately
increased exposure to radiation over the course of their chronic disease. MRI
enterography has gained favor as an alternative imaging technique when
delineation beyond ultrasound is desired. It may be completed once the child
is admitted or in the outpatient setting.
Laboratory Testing. Laboratory evaluation should include a CBC with
differential, chemistry panel (chem 10, especially in those with chronic
diarrhea or vomiting), liver panel (albumin, protein, aminotransferases,
bilirubin), erythrocyte sedimentation rate (ESR), C-reactive protein, amylase,
and lipase. ESR is elevated in up to 80% of patients with newly diagnosed
Crohn disease and in 60% of those with newly diagnosed UC. It may also be
used to assess the efficacy of therapies in those with previously diagnosed
IBD. A blood type and crossmatch is indicated in cases of suspected or
confirmed severe anemia. Stool testing for C. difficile, stool culture, as well as
ova and parasites should be obtained. Increasingly, fecal calprotectin, a protein
produced by neutrophils, is being used to help diagnose IBD and monitor the
severity of inflammation in those with established disease.
Management. Management is guided by the history, physical, and diagnostic
testing. The role of the ED provider is to provide supportive care while
ensuring a significant medical complication (e.g., significant dehydration,
electrolyte imbalance, severe anemia, superinfection) or potential
complication requiring surgical intervention (e.g., toxic megacolon, intraabdominal or perirectal abscess, perforation) is identified and addressed if
present.
Initial supportive medical care includes rehydration with crystalloid per
established protocols. Blood transfusions may be required in those with severe
anemia. If toxic megacolon or perforation is suspected, arrangements should
be made for admission to an intensive care unit (ICU) and for surgical
