QUESTIONS & ANSWERS Jo a n L . G r e e n e , M S N , R N , C P N P
1. What is the differential diagnosis of an eight-year-old boy with abdominal pain? The differential diagnosis of acute abdominal pain is extensive and includes: gastroenteritis, urinary tract infection, constipation, appendicitis, gastroesophageal reflux, diabetic ketoacidosis, rightlower-lobe pneumonia, inflammatory bowel disease, primary peritonitis, Meckel’s diverticulitis, intestinal adhesions, Henoch-Schonlein purpura, hemolytic-uremic syndrome, Rocky Mountain spotted fever, peptic ulcer disease, hepatitis, strangulated inguinal hernia, lactose intolerance, mesenteric lymphadenitis, and parasites (Hoekelman, 2001; Burns, Brady, & Dunn, 1997.) 2. What lab studies would you order? Initially, in the office, a urinalysis and a complete blood count were ordered. The UA was normal except for a trace amount of occult blood. The CBC revealed a white blood cell count of 14,600 with 87% granulocytes and 13% lymphocytes; platelets 221,000; and a hematocrit of 38.9%. Additional laboratory tests that could have been ordered include stool guaic; stool collection to test for ova and parasites; stool culture; and sedimentation rate and/or C reactive protein. The history, physical exam, and lab tests seem to rule out urinary tract infection, constipation, diabetic ketoacidosis, right-lower-lobe pneumonia, inflammatory bowel disease, Henoch-Schonlein purpura, hemolytic-uremic syndrome, Rocky Mountain spotted fever, and strangulated inguinal hernia. 3. What imaging studies would you order? The three most common radiological studies ordered to investigate acute abdominal pain in a school-aged boy include a conventional X-ray (“plain film”) of the abdomen, an ultrasound of
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the abdomen, or computed tomography (CT) of the abdomen. A plain film is relatively inexpensive, quick, painless, and readily available. It has a relatively low radiation dose
he three most
common radiological studies ordered to investigate acute abdominal pain in a school-aged boy include a conventional X-ray (“plain film”) of the abdomen, an ultrasound of the abdomen, or computed tomography (CT) of the abdomen.
and requires no preparation. The study may reveal intra-abdominal disease, including a calcified fecalith, air-filled appendix, or free intraperitoneal air. Its disadvantage is that it provides basic anatomic information for only a few tissue densities.
An ultrasound is more expensive, painless, widely available, and has no radiation exposure or preparation. The sonographer can evaluate most pediatric abdominal processes. The disadvantage of this modality is that it is very operator-dependent. CT is a fast exam, widely available, and has excellent depiction of anatomic detail. With intravenous contrast, CT can examine organ enhancement and blood vessels. Disadvantages of this imaging technique are that it has a higher radiation dose, requires preparation, and is relatively expensive (Paterson, Donnelly, & Frush, 2001.) Magnetic resonance imaging (MRI), an excellent mode of imaging in depicting organ and tissue structures, is not ordered as a firstline study because it is expensive and usually requires sedation and monitoring with pediatric patients. It is infrequently available for same-day studies. The nurse practitioner and consulting pediatrician chose to obtain imaging studies of the abdomen. L. G. did not have severe abdominal pain and was not toxic-appearing, but his reproducible right-lower-quadrant abdominal pain was a concern. A CT was ordered. The radiologist called to relate that the CT revealed findings consistent with acute appendicitis. In the rightlower-quadrant of the abdomen, the appendix showed intravenous contrast enhancement and appeared thickwalled. There was mild edema of the mesentery. There was no free air or free fluid shown on the scan. A surgeon was consulted, and L. G. had his appendix removed laparoscop-
Joan L. Greene, MSN, RN, CPNP, 200 Forbes St., Annapolis, MD 21401; e-mail: [email protected]
J Pediatr Health Care. (2004). 18, 111-112. 0891-5245/$30.00 Copyright © 2004 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2003.12.004
PH CASE STUDIES C ically, confirming appendicitis without perforation. He experienced no complications and went home from the hospital within 48 hours. 4. What is known about the diagnosis? Appendicitis is the most common cause of abdominal surgery in children. It is rare in the young child but becomes more common after the age of ten. The peak incidence of acute appendicitis is between the ages of fifteen and thirty. The inflammation of the appendix, a wormlike (vermiform) appendage at the end of the cecum, is caused by an obstruction of the lumen. It can be blocked by a fecalith or by lymphoid hyperplasia. Uncommonly, the blockage can be caused by tumor, parasite, or foreign body. The appendix becomes distended and subject to ischemia and necrosis, which in turn irritates the surrounding peritoneum and causes the characteristic symptoms (Hoekelman, 2001; Burns et al., 1997.) Historically, the child complains of periumbilical pain. This may last for up to twelve hours, accompanied by anorexia, nausea, vomiting, and lowgrade fever. The pain usually shifts to the right-lower-quadrant of the abdomen. On physical exam, the patient
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often has guarding, rebound tenderness, and pain over McBurney’s point (two-thirds of the distance from the umbilicus to the right iliac crest). There may be a positive psoas sign (pain elicited by extending the right hip with the patient in the left decubitus position) or positive obturator sign (pain
owever, it is typical
that young children are often unable to describe and localize their pain accurately.
diagnosis. Without surgical intervention, the appendix may rupture, causing peritonitis. Delaying surgery more than thirty-six hours after the patient’s initial symptoms results in at least a 65% incidence of perforation (Hoekelman, 2001; Burns et al., 1997). L. G. did not have a classic presentation of acute appendicitis. He was afebrile, had diarrhea (usually bowel habits do not change), had mild abdominal pain, and could jump without discomfort. However, it is typical that young children are often unable to describe and localize their pain accurately. The physical examination was key to this case, as both clinicians were correctly concerned about the child’s definite right-lower-quadrant pain. The clinician is reminded that, contrary to what many mothers believe, not all bellyaches can be blamed on fast food!
REFERENCES elicited by internal rotation of the flexed right hip with the patient supine). If the child can jump, he usually does not have appendicitis. The laboratory tests usually show a mild leukocytosis (10,00020,000/mm3). Radiological studies (plain film, ultrasound, and CT) can aid in the
Burns, C. E., Brady, M. A., Dunn, A. M., & Starr, N. B. (2nd ed.). (1997). Pediatric Primary Care, A Handbook for Nurse Practitioners. St. Louis: Saunders, pp. 904-913. Hoekelman, R. Primary Pediatric Care. (4th ed.). (2001). St Louis: Mosby, pp. 1327-1328. Paterson, A., Donnelly, L.F., & Frush, D. The pros and cons of imaging options. Contemporary Pediatrics, 18(4): 73-94.
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