Transcript Pediatric Case Discussion

Pediatric Case Presentation
2007. 1. 30
R1 邱垂祥
Supervisor: 吳孟書醫師
李X珍 4326659
 Age: 8y/o, Gender: female
 基隆急診, 就診時間:2007/1/2 04:25
Vital signs: TPR:36.1C/ 125/ 20, BP:
115/53mmHg
GCS: E4V5M6, SaO2:99%
 檢傷主訴: 腹痛
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Chief complaint
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Abdomimal pain since tonight (1/1 night)
Present illness
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12/28.29: fever, watery diarrhea for 2-3 times/day, abd pain
 visited LMD: Rx: antipyretics, antidiarrhea (drug unknown)
 no improve
 diarrhea 7-8 times/day x 2 days
1/1: LMD Rx: antidiarrhea (different drug, 2-3 pills in one
package, unknown)
took one package in the morning  no diarrhea or abd pain
 at the night: abd distension, abd pain with cold sweating,
fever, N/V
Past history
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no known drug allergies
no other systemic diseases
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Physical examination:
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Appearance: ill-looking
HEENT: neck supple
Chest: coarse breathing sound
Heart: RHB
Abdomen: muscle guarding, diffuse tenderness
McBurney tender(+)
Extremities: freely movable
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Initial impression:
Peritonitis, r/o appendicitis ruptured
Initial order (04:31)
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CBC/DC
CRP
SUGAR
B/C
U/A
KUB
NPO, IV D5.225S keep 80ML/HR
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K.U.B. shows :
Negative finding of the
abdomen.
Lab
Glucose: 136
CRP: 112.23
WBC: 12500
Seg: 77.4% Lym: 17.4
Hb: 12.5
PLT: 287K
Further
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05:51:
CT OF ABDOMEN C+/GENTA 80MG STAT
METRONIDAZOLE 400MG STAT
CT report
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MSCT study for the abdomen and pelvic cavity, mainly for the ,
without and with IV contrast study shows:
1.Evidence of normal size of the apendix, However,its wall is
thickened, compatible with early changes of acute appendicitis. No
strandings to be noted in the ileocecal region
2.The liver, spleen, pancreas, kidneys and adrenal glands are normal.
No definite intraabdominal lymphadenopathy.
3.The stomach, duodenum, small intestine and the colon are seen to be
unremarkable except feces in the colon.
4.There is no abnormal lesion in the pelvic cavity. The uterus and
ovaries are normal in size.
5.There are no enlargement of the paraaortic, pelvic and inguinal
nodes.
6.No ascites in the abdomen and pelvic cavity.
Imp.:Compatible with acute appendicitis.
Others are unremarkable in the abdomen.
Further
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06:37:
Consult GS
-- peritonitis, suggest operation
OP record
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Post OP Dx: cecum perforation, peritonitis
OP method: right hemicolecotmy with end to
side anastomsis
Toxic megacolon
Def: total or segmental nonobstructive colonic
dilatation plus systemic toxicity
Up to date~ Toxic megacolon
Up to date~ Toxic megacolon
Toxic megacolon
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Precipitating factors:
Hypokalemia
antimotility agents
Opiates
Anticholinergics
barium enema
colonoscopy
Up to date~ Toxic megacolon
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The most widely used criteria for the clinical diagnosis of
toxic megacolon are :
Radiographic evidence of colonic distension (frequently >
6cm)
PLUS at least three of the following:
Fever >38ºC
Heart rate >120 beats/min
Neutrophilic leukocytosis >10,500/mm3
Anemia
PLUS at least one of the following:
Dehydration
Altered sensorium
Electrolyte disturbances
Hypotension
Up to date~ Toxic megacolon
Up to date~ Toxic megacolon
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Inadequate early hydration: urine <2ml/kg/h in
the first 8 hrs on admission
Factors associated with intestinal perforation in children's non-typhi
Salmonella toxic megacolon. Pediatric Infectious Disease Journal.
19(12):1158-1162, December 2000.
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Gender, high frequency of defecation,
peripheral leukocytosis, electrolyte imbalance
and positive results of stool analysis including
OB, mucus and pus  no statistically
significant correlation with intestinal
perforation.
proper and effective antibiotic therapy  still
risk of intestinal perforation.
Factors associated with intestinal perforation in children's non-typhi
Salmonella toxic megacolon. Pediatric Infectious Disease Journal.
19(12):1158-1162, December 2000.
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aggressive intravenous hydration and close
monitoring of the effect of fluid resuscitation
 may reduce the risk for intestinal
perforation
appropriate rectal tube placement is very
effective for the prevention of bowel
perforation in children with non-typhi
Salmonella toxic megacolon.
Factors associated with intestinal perforation in children's non-typhi
Salmonella toxic megacolon. Pediatric Infectious Disease Journal.
19(12):1158-1162, December 2000.
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Predilection for 3 areas: T colon near splenic
flexure, lower sigmoid, ileocecal region
(anatomically watershed areas)
Ischemic injuries may result from vascular
shunting in response to dehydration
Adequate rehydration as a means of prevention
of bowel perforation
Spontaneous Bowel Perforation in Infants and Young Children: A
Clinicopathologic Analysis of Pathogenesis. Journal of Pediatric
Gastroenterology & Nutrition. 30(4):432-435, April 2000.
Key points
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AGE treatment: Hydration is the most
important! Not antidiarrhea!
Antimotility agents are not suitable in children.
D/D of viral gastroenteritis and bacterial
gastroenteritis
Ref
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Up to date “Toxic megacolon”
Chen, Jeng-Chang; Chen, Chiu-Chiang +; Liang, Jin-Tung +; Huang, ShiuFeng * Spontaneous Bowel Perforation in Infants and Young Children:
A Clinicopathologic Analysis of Pathogenesis. Journal of Pediatric
Gastroenterology & Nutrition. 30(4):432-435, April 2000.
CHAO, HSUN-CHIN MD; CHIU, CHENG-HSUN MD; KONG, MANSHAN MD, MD; CHANG, LUAN-YIN MD; HUANG, YHU-CHERING MD;
LIN, TZOU-YIEN MD; LOU, CHIH-CHEN MD Factors associated with
intestinal perforation in children's non-typhi Salmonella toxic megacolon.
Pediatric Infectious Disease Journal. 19(12):1158-1162, December 2000.
Sheth, S G. LaMont, J T.
Toxic megacolon. [Review] [17 refs]
Lancet. 351(9101):509-13, 1998 Feb 14.
Thank your for
your attention!!!