EMERGENCY MEDICINE: Top 4 abdominal emergencies

Part of Contemporary Pediatrics’ coverage of the 2015 AAP Annual Conference. For more coverage, click here.

Avoiding misconceptions and practice gaps are keys to recognizing the most common abdominal emergencies in community pediatrics, said Joan E Shook, MD, MBA, FAAP. She made the following important points in her presentation “Abdominal Emergencies: Recognition and Management of Four Common Abdominal Complaints”:

·      Appendicitis – The pediatric appendicitis score and the Alvarado score, when filled out completely, can help pediatricians decide in the hospital or office if they need to call surgery or order additional testing. High scores on either scale should prompt a call to surgery. A mid-level score indicates insufficient information; imaging could be indicated. Assuming high-quality pediatric ultrasound is available, it is the modality of choice. As backups, computed tomography scan, and rapid magnetic resonance imaging have proven effective.

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·      Intussusception – Here, too, ultrasound, if available, is the imaging modality of choice. It offers 100% sensitivity and specificity while sparing patients from needless ionizing radiation. If a child has intussusception, a misconception that we still give barium enemas persists. Barium is almost never used now as a contrast agent. Among newer approaches, enema reduction using ultrasound alone has proven highly effective.

·      Pyloric stenosis – This diagnosis is changing over time because ultrasound is allowing clinicians to catch it much earlier than before; in the last 2 decades, mean age at hospital admission has dropped from 5.9 weeks to 5.4 weeks.¹ Before ultrasound, patients often did not reach emergency care until they were extremely ill. That has changed, however, as ultrasound has proven very helpful in identifying pyloric stenosis when the child’s only symptom might be a couple of vomiting episodes. Recent research also has confirmed that the mutations responsible for pyloric stenosis gravitate toward genetic loci on chromosomes 3 and 5.²

·      Malrotation with volvulus – Although community pediatricians rarely see it, none should forget that volvulus represents a surgical emergency and that delaying surgery can result in significant loss of gut tissue. In volvulus malrotation, the gut twists on itself, cutting off its own blood supply. In emergency medicine, we see not infrequently that providers do not understand or remember the urgency of this particular problem.

References

1. Taylor ND, Cass DT, Holland AJ. Infantile hypertrophic pyloric stenosis: has anything changed? J Paediatr Child Health. 2013;49(1):33-37.

2. Everett KV, Chung EM. Confirmation of two novel loci for infantile hypertrophic pyloric stenosis on chromosomes 3 and 5. J Hum Genet. 2013;58(4):236-237.

Joan E Shook, MD, MBA, FAAP, is chief safety officer, Texas Children’s Hospital, and professor of pediatrics, Baylor College of Medicine, Houston.