Leybie AngPEM FellowAug 6 2009

ObjectivesApproach to GI Bleed

DDxCommon CausesLife threatening Causes

Approach to Abdominal Pain

Case Presentations

Approach to GI BleedA B C

Severity of the bleeding

Site of the bleed

Common cause of UGI in neonatal period?

Common cause of UGI in preschool age?

Common cause of LGI during neonatal period?

Common cause of LGI during infancy?

Approach to Abdominal Pain

Causes of Acute Abdomen Pain

Causes of Acute Abdomen Pain

Life-Threatening Cause

Life Threatening Cause

Case Presentation #12 week old male presented with abdominal

distension At triage, noted to have bilious vomitingFormer 37 weeker SVD SCN stay x 48hr for ?TTNNo sick contact

Afebrile HR 200 RR 65 O2 sat 98% RAFussy but consolableGI exam revealed distended abdomen

Case Presentation #1 (con’t)Management priorities?

Likely diagnosis?

Malrotation With Midgut VolvulusCongenital malrotation of the midgut

During 5th-8th embryonic week, intestine projects out of cavity, rotates 270 degree and then returns

If incomplete rotation, intestine does not anchor at the mesentry

Volvulus is twisting of a loop of bowel about the mesentric attachment

Malrotation with VolvulusIncidence 1 in 500Male-to-female ratio 2:1Usually presents in the first year of life

Bilious vomitingAbdominal distension Hematochezia

ImagingAbdominal films – Classic double bubble sign

Upper GI (GOLD STD) – “cork-screwing”, spiraling of SB around SMA

US – distended, fluid filled duodenum, with dilated loops of bowel to the right of the spinal column

TreatmentSURGICAL CONSULT!!!IV hydrationCorrection of electrolytesNG tube

Case Presentation 21 yo female presents with vomiting, and

intermittent abdominal crampingNoted to be lethargic

PE revealed palpable mass in RUQHeme positive stools

Most likely diagnosis???

Management???

IntussusceptionTelescoping of a segment of bowel into an

adjacent segment

Mesentery and venous supply obstruct mucosal edema and increased pressure arterial flow obstruction

Incidence: 6mo to 2 yo

IntussusceptionMost common location ???

Most common reported symptoms ???

IntussuceptionIdiopathic Meckel’s DiverticulumHSPPolypsTumorsLymphoma

IntussusceptionIntermittent, colickly abdominal pain Currant jelly stools => late finding+/- RUQ massEmesis -> biliousHeme positive stools

Intussusception - DxAXR – may normal initially, but then may see

signs of obstruction, paucity of air and dilated loops of bowel

US – “target” or “donut” sign = single hypoechoic ring with hyperechoic center

“pseudokidney” sign = superimposed hypo- and hyperechoic rings of edematous bowel and compressed mucosal layers

What is crescent sign?

Please show it in the imaging below….

Air Enema vs Contrast EnemaPROS

InertRapidLess radiation Air perforation better than contrast perforationEasier to administer

CONSMay miss the lead point Poorer visualisation

Absolute contraindication???

Case Presentation 36 yo male presents with diffuse abdo pain,

decreased appetite, fever, vomiting, increased pain with motion

T38 HR 120 bp 108/58 RR22 In moderate discomfortAbdo exam revealed tenderness over

periumbilical pain with rebound tenderness

Differential diagnosis?

AppendicitisMost common etiology for surgical abdomen

in children

Third leading cause of pediatric hospitalisation

Incidence 4 cases per 1000 children

Male to female ratio 2:1

AppendicitisMortality in children 0.1-1%

False positive rate 15-20%

Perforation rate 15-40% in younger children due to delayed in diagnosis

In younger children <5 yo, ,perforation rate 50-85%

Morbidity in children treated with appendicitis results either from late diagnosis or negative appendectomy

PathophysiologyBlockage of lumen with stool, barium, food or

parasitesSwollen lymph glandsHyperplastic lymphoid tissueEdematous appendical mucosaIncrease intraluminal pressurePersistence inflammationExudate drainage

Pathophysiology (con’t)Exudate touches parietal peritoneum Pain (diffuse)Fecal bacteria grown within the obstructing

materialWorsening inflammation responseFurther increase intraluminal pressureperforation

Pathophysiology (con’t)Peritonitis developsIn adult, the omentum can wall off inflamed

or perforated appendixIn child, less well developed omentum, hence

decrease the ability to wall off perforationMore likely to have peritonitisSevere blunt abdo trauma

HistoryClassic history

Anorexia, pain migrated from periumbilical to RLQ and vomiting

Less than 60% patients

Pain precedes vomitingAfebrile or low grade fever

High grade – after perforation

Appendicitis – Signs & SymptomsAm Emerg Med, 1986; 15:557-561

M – Migration of pain A – AnorexiaN – Nausea/Vomiting T – TendernessR – ReboundE – Elevated temperatureL – LeukocytosisS – Shift (Bandemia)

Pain Meds???Green R et al. Pediatrics 2005

5 – 16 yo with acute abdominal pain requiring surgical consult

52 – IV morphine56 – IV placeboStandardised form used to document clinical

data and physician confidence in dx and 15 min after meds

Surgeon see pt w/i 1 hr and same data collected

Pt monitored for 2 weeks after enrollment

Conclusion Green R et al. Pediatrics 2005

No difference in MD confidence – ED or surgeon’s after morphine

No difference in significant decrease in pain No difference in diagnosis

ManagementEmergency appendectomy (operation within

6hr) in children has no advantages over urgent appendectomy (operation with 12 h) wrt gangrene and perforation rates, readmissions, postoperative complications, hospital stay, or hospital charges.

ObjectivesApproach to hematuria

DDx for testicular mass

Approach To HematuriaDetermine if the pigment in urine is from

blood or other source. Are red blood cells present?

Determine the source of bleeding, i.e., kidney, bladder, urethra.

Select those who will require referral versus those who simply require follow-up.

Case Presentation #510 yo male presented with 24 hour of scrotal pain. Mom noted that patient was walking “funny”

Afebrile HR 120 bp 120/75 RR 18 O2 sat 97% RAPE exam revealed patient in moderate discomfortGI revealed benign exam GU revealed erythema, swollen right testes. High

riding testes with absent cremasteric reflex on the right

Differential diagnosisPAINFUL SCROTAL PAINTorsion of spermatic cordTorsion of testicular appendageEpididymitisOrchitisIncarcerated herniaHematocele

Differential diagnosisPAINLESS SCROTAL SWELLINGHydroceleVariocele Testicular cancer Nonincarcerated inguinal herniaSpermatoceleLocalised edema from insect bitesNephrotic syndrome

Testicular TorsionMost dramatic and potentially serious

acute process affecting the scrotum

Associated with anatomic anomaly of the tunica vaginalis

Normally the tunica vaginalis inserts at the lower pole of testis (gubernaculum testes)

Testes lack of the normal attachment to tunica vaginalis and rest transverse w/i scrotum

Bell Clapper Deformity

Testicular TorsionDeformity permits xs mobility of testis,

increasing likelihood of torsion on its spermatic cord and compromise blood flow

If bell clapper deformity, usually bilateral

Twisting of spermatic cord w/i tunica vaginalis causes venous compression and subsequent edema of testicle and cord -> arterial occulsion ischemia

Testicular TorsionCan occur at any age

Two peak incidence: neonatal period and puberty

1:4000 in males <25yo

65% cases in boys 12-18yo

Increased incidence during adolescent - secondary to increase of weight of testes during puberty

Clinical PresentationAbrupt onset of severe scrotal pain

Typical presentation: awaken from sleep with scrotal pain in the

middle of night

+/- radiation to lower abdomen

Nausea/vomiting

Physical ExamTender and firm+/- edematous Abn transverse lieAbsence of cremasteric reflexUnilat elevation of testis

Retracted upward in hemiscrotumUsually negative Prehn sign

Positive Prehn sign where elevation of scrotal contents relieves pain

Usually true in epididymitisUnreliable distinguishing feature

Intermittent Testicular TorsionAcute and intermittent sharp testicular

pain and scrotal swellingRapid resolution (w/i secs to mins)Long period symptom-freeHence clinical and radiographic eval (US)

maybe normalIntermittent pain with nml evaluation – f/u

w/i 7D and sooner if pain recursIf high suspicious, referral to urology

Testicular TorsionDoppler US or nuclear scan

Decreased testicular perfusionCan be positive in pt with large hydrocele,

abscess, hematoma or scrotal herniaCan be negative in intermittent torsion or

spontaneous detorsion

Sensitivity and specificity of US in detecting testicular torsion 69-100% and 77-100% respectively

Limited usefulness in doppler US in prepubertal pt due to lower blood flow

Nuclear scan sensitivity and specificity 100 and 97% respectively

Management of Testicular TorsionSURGICAL EMERGENCY!!!Increased time in a state of torsion is

inversely proportional to testis survival rates

Urology/surgery consultSurgical detorsion of affected testesOrchiopexy of both testes

Bell clapper deformity bilateral

If nonviable orchiectomy

What is the viability if detorsion happens after 12hr???

Viability & FertilityStudies have shown:

Detorsion w/i 4-6 hr 100% viabilityDetorsion after 12 hr 20% viabilityDetorsion after 24 hr 0% viability

Fertility controversial issuesDecreased fertility after unilat torsion (immune-mediated

damage)No evidence of decreased fertility or anti-sperm antibodies

Heindel et al The effect of unilateral spermatic cord torsion on fertility in the rat JUrol 1990 Aug;144:366-9 If torsion >720 degree or more causes a significant

reduction of subsequent fertility

Manual DetorsionManual detorsion if experienced clinician

available, definitive care hours away and appropriate sedation and analgesics

Textbook teaching: Testes rotates medially normally

To detorse, rotate outward towards the thigh.Retrospective study showed pt with surgical detorsion,

1/3 has lateral rotationSuccessful detorsion if pain relief, lower position

of testes and return of normal arterial pulsations (US)

Still need to have orchiopexy

Torsion of Appendix TestesSudden onset pain

Less severe pain Usually tender localised palpable mass at

superior/inferior poleTiny, localised swelling pain localised to upper portion of testisBlue dot sign

gangrenous/black appendix through scortal skin (esp in lightly pigmented skin pt)

Torsion of Appendix TestesNearly always able to elicit cremasteric reflex+/- Reactive hydroceleUS showed nml or increased blood flow to

affected testis (2nd to inflammation)Lesion of low echogenicity with central

hypoechogenic areaUnable to visible involved appendageIn prepubertal, US unreliable (low baseline

testicular perfusion)

ManagementSupportive managementAnalgesicsBed restPain resolve in 5-10DIf persistent pain -> surgery to remove

testicular appendixContralateral hemiscrotum need not to be

explored

EpididymitisInflammation of epididymisCommon among adolescentsOften caused by infections

Sexually active – Chlamydia, N. gonorrhea and viruses

Less commonly - Ureaplasma, Mycobacterium, CMV/Cryptococcus in pt with HIV

Normal Scrotal Anatomy

EpididymitisOccur in younger boys who deny sexual

activity

Other causes: heavy physical exertion, bicycle/motorcycle riding, structural anomalies of UT

Noninfectious – chemical inflammation swelling ductal obstruction reflux of sterile urine through ejaculatory ducts and vas into epididymis

Multiple etiologies of epididymitis

Clinical FeaturesAcute/subacute pain and swelling Urinary frequency, dysuria, urethral

discharge, feverNml vertical lie of testes+/- erythema scrotum and parchment-like

scrotal edema+/- inflammatory nodule is felt with soft,

NT epididymisNml cremastric reflex

EpididymitisPain relief with elevation of testes (Prehn

sign) – unreliable marker for epididymitis+/- leukocytosis and pyuria+/- UA nml with urine culture (still need

to get UA/UCx)US – increased blood flowIf suspect STD induced epididymitis -> GS

smear and culture of urethral/intraurethral, NAA test for NG and CT, syphilis and HIV testing

Management of EpididymitisAntibiotics if ST epididymitis

CTX 250mg IM x1 and doxycycline 100mg PO bid x10D

If allergic to cephalosporins, ofloxacin 300mg PO bid x10D or levofloxacin 500 mg PO daily x10D

AnalgesicsScrotal supportElevation Bed rest

OrchitisAcute inflammation reaction of the testes

Mostly associated with viral infection

Bacterial Orchitisrare

usually associated with a concurrent epididymitis (epididymo-orchitis)

occur in sexually active males > 15yo

Unilateral testicular edema occurs in 90% of cases

Bugs in immunocompromised pt?

Clinical featuresTesticular pain and swelling

course variable and ranges from mild discomfort to severe pain.

FatigueMalaiseMyalgiasFever and chillsNauseaHeadacheMumps orchitis follows the development of

parotitis by 4-7 days.complicated by a reactive hydrocele or pyocele

Physical examTesticular enlargement and tendernessInduration of the testisErythematous scrotal skinEdematous scrotal skinEnlarged epididymis

If associated with epididymo-orchitisRectal examination

Soft boggy prostate (prostatitis) often associated with epididymo-orchitis

Parotitis

Diagnosisbased on history and physical examination

if concerns for epididymo-orchitisUA and cultureurethral cultures

serum immunofluorescence antibody testing

Color Doppler ultrasound to rule out testicular torsion.inflammation of the testis or the epididymis

ManagementRule out testicular torsion Supportive treatment (viral)

AnalgesicsBed restHot or cold packs

If highly suspicious for epididymo-orchitis, treat appropriately.

If a significant hydrocele or pyocele is detected or suspected surgical tapping

Bacterial orchitis or epididymo-orchitis requires appropriate antibiotic coverage

Complications~60% with orchitis Unilateral testicular

atrophy

Sterility is rarely a consequence of unilateral orchitis.

little evidence supports an increased likelihood of developing a testicular tumor after an episode of orchitis.

HydroceleCollection of peritoneal fluid between the

parietal and visceral layers of tunica vaginalis

Communicating vs noncommunicatingCommunicating result of failure of the processus vaginalis

to close during developmentfluid around testes is peritoneal fluid

HydroceleNoncommunicating no connection to the peritoneum; the fluid

comes from the mesothelial lining of tunica vaginalis

Common in newborns and majority spontaneously resolve

In older children and adolescentsIdiopathicsecondary to epididymitis, orchitis, testicular

torsion, torsion of the appendix testes/epididymis, trauma or tumor (reactive hydrocele)

Communicating usually cystic scrotal massReducibleincrease mass in size during the day or with

valsalva maneuverNon communicating

not reducibleno change in size or shape with

crying/straining Transillumination of scrotum

cystic fluid collectionUS of testes

to r/o primary causes

In newborns – spontaneously resolution by 1 year of age

If communicating, rarely resolve and risk of incarcerated inguinal hernia

If tense scrotum – concerns for reduce circulation to testessurgical repair at time of diagnosis

If secondary causes, treat underlying condition

VaricoceleCollection of dilated and tortuous veins in the

pampiniform plexus surrounding the spermatic cord in scrotum

Result from increased venous pressure and incompetent valves

Commonly on left side (85-95%)Left spermatic vein entering left renal vein to a 90

degree angleRight spermatic vein drains more obtuse angle directly

in IVC – more continuous flow10-15% varicoceles - infertility

VaricoceleAsymptomaticc/o dull ache in scrotum upon standing

Gr I (small) – palpable only with valsalva maneuver

Gr II (mod) – nonvisivible on inspection, but palpable upon standing

Gr III (large) - Visible distention around spermatic cord

Palpable varicocele – texture of “a bag of worms”

VaricoceleExamined in both supine and standing

positionIf idiopathic – prominent when upright

and disappears in supineIf secondary – no change in size with

change of positionUS

r/o IVC thrombus, right renal vein thrombosis with clot propagation down IVC and abdo mass

VaricoceleConservative management

Observation

Surgical ligation / Testicular vein embolizationAffected testicular vol < unaffected testicle

(diff in size of >10-15% or >2mL by US)Presence of bilat varicocelesLarge varicoceles (Gr III)Presence of scrotal pain

ParaphimosisSURGICAL EMERGENCY

occurs when a phimotic ring of foreskin is retracted, becoming trapped proximal to the coronal sulcus

Significant edema of the glans penis

Ischemic injury to the glans

Paraphimosis - ManagementReduction of the foreskin

Manually after applying gentle constant pressure to the edematous foreskin with or without local anesthesia

Surgically by division of the phimotic ring.

Circumcision is advisable at some point after the occurrence

Hair Tourniquet Syndrome SURGICAL EMERGENCY

Circumferential strangulation of an appendages or genitalia by human hairs or fibers

Ischemic injury to the glans may occur if not relieved promptly by division and removal of the hair strand

Hair-Thread Tourniquet Syndrome in an Infant with Bony Erosion- a Case Report, Lit

Review, and Meta-analysisSaad et al. Ann Plast Surg 2006; 57: 447–452

210 reported cases Penile - 44.2%Toes - 40.4%Fingers - 8.57%Others (female external genitalia, uvula, and

neck) - 6.83% Penile tourniquet is more common in patients

around 2 years old.

What product would you use to remove hair torniquet on finger/toe non-operatively???

Post-Circumcision BleedBleeding remains the commonest

complication encountered during and after circumcision

Reported incidence ranges from 0·1 to 35 per cent

Majority is minor bleedRequired to achieve haemostasis is gentle

pressure

Post-Circumcision BleedExcessive bleeding

Anomalous vesselsBleeding disorder

13 000 circumcisions reported in two large series, no patient required blood transfusion for bleeding

In the event of a bleeding disorder, appropriate clotting factors may have to be administered.

Circumferential bandage may be used to aid haemostasis

May cause a degree of urethral obstruction which in severe cases, leads to urinary retention and may dispose thus dispose to urinary tract infection