Pediatric Examination and Board Review (138 page)

(D) ultrasonography offers 100% sensitivity and specificity to accurately exclude the possibility of appendicitis as a cause of acute abdominal pain in children as long as either a normal appendix is visualized or the appendix is not visualized at all

(E) all of the above statements are true

10.
Which of the following statements is false?

(A) appendicitis is the most common surgical abdominal emergency in children

(B) missed appendicitis is one of the top reasons for malpractice claims in the emergency department

(C) in cases involving appendicitis in children, a well-documented chart will not prevent a lawsuit

(D) all children with acute onset of abdominal pain should have an imaging study regardless of the clinical diagnosis

(E) males have a higher lifetime risk of suffering from appendicitis than females

11.
A delay in diagnosing acute appendicitis in children can have serious consequences. Which of the following is least likely to occur as a direct result of a delayed diagnosis?

(A) death

(B) bowel obstruction

(C) perforation

(D) peritonitis

(E) pancreatitis

12.
A 5-year-old boy presents to the pediatric emergency department early in the morning. You find him lying on his side with his knees curled up. His mother tells you he fell off his bike last night. He is now complaining of worsening periumbilical abdominal pain and also midback pain. On examination, the child has hypoactive bowel sounds, guarding, and right upper quadrant tenderness. All of the following statements are true regarding your suspected diagnosis except

(A) a complete blood count might demonstrate a leukocytosis with a bandemia

(B) abnormal liver function tests as well as an elevated lipase and amylase might be present

(C) a sentinel loop of small bowel seen best on a plain radiograph is often diagnostic

(D) ultrasonography is the cornerstone of diagnosis for the suspected condition

(E) blunt abdominal trauma is a relatively rare cause of this condition

13.
Which of the following is least likely to be a potential cause of acute pancreatitis in a 5-year-old?

(A) trauma

(B) cholelithiasis

(C) viral infection

(D) cystic fibrosis

(E) urolithiasis

14.
You are asked to evaluate a 2-year-old African American girl who presents with a history of sudden, intermittent, crampy abdominal pain for 1 day and decreased oral intake. Your physical examination reveals no reproducible abdominal tenderness; however, a guaiac-positive soft mucous-like stool on rectal examination is noted. Which of the following abdominal imaging studies would diagnose and treat your suspected diagnosis?

(A) a plain radiograph

(B) ultrasonography

(C) CT

(D) barium enema

(E) MRI

15.
A 1-year-old presents with bilious vomiting, abdominal distention, tenderness, and guarding. Which of the following diagnoses would be most likely?

(A) midgut volvulus

(B) mesenteric adenitis

(C) peritonitis

(D) gastroenteritis

(E) Meckel diverticulum

16.
In any infant or toddler who presents with acute abdominal pain, bilious emesis, and guarding, which of the following imaging studies is the initial study of choice most likely to confirm your suspicions?

(A) MRI

(B) ultrasonography

(C) CT

(D) barium enema

(E) upper gastrointestinal (GI) series

17.
A 6-week-old infant with postprandial emesis worsening over the past 4 days presents to the emergency department. The mother describes the vomit as projectile and nonbilious. On examination, the child appears hungry and slightly dehydrated. In preparation for your discussion with the surgeons, you order some basic laboratory tests. You suspect the child will have

(A) normal laboratory values

(B) hyperkalemia, hyperchloremia metabolic alkalosis

(C) hypokalemia, hypochloremia metabolic alkalosis

(D) hyperkalemia, hyperchloremia metabolic acidosis

(E) hypokalemia, hypochloremia metabolic acidosis

ANSWERS

1.
(D)
Acute appendicitis is the most likely etiology of this patient’s illness. Although the presentation could initially be confused with gastroenteritis, the presence of hypoactive bowel sounds, anorexia, pain preceding the onset of any other symptoms, and reproducible tenderness have a higher likelihood of appendicitis than any of the other diseases listed.

2.
(C)
The placement of a nasogastric tube should be reserved for patients who need gastric decompression. This would include patients with suspected pancreatitis, some forms of bowel obstruction such as a volvulus, or a patient with bilious emesis.

3.
(A)
Serum electrolytes, BUN, and creatinine may be helpful for assessing a patient’s renal and hydration status but otherwise add little to the diagnostic evaluation of abdominal pain. The urinalysis is useful to exclude the diagnosis of a urinary tract infection; amylase and lipase are useful in differentiating pancreatitis from other causes of abdominal pain such as appendicitis. Lastly, the combination of an increased leukocyte count with an increased blood CRP level can be suggestive of appendicitis in the setting of acute abdominal pain.

4.
(C)
A psoas abscess usually requires surgical drainage.

5.
(E)
All of the conditions can present with abdominal pain in children and must be included in the differential diagnosis.

6.
(A)
In children, diarrhea can be associated with the presence of appendicitis up to 30% of the time. Many of the clinical features of acute appendicitis are nonspecific; however, pain as the initial symptom and pain associated with movement—that is, jumping up and down, riding in a bumpy car, or tapping on the patient’s heel—raise clinical suspicion.

7.
(B)
Bluish discoloration around the umbilicus describes Cullen sign that, when coupled with Grey Turner sign (bluish discoloration around the flank), is suggestive of acute hemorrhagic pancreatitis (see
Figure 81-1
). Rovsing sign refers to referred pain from the LLQ to RLQ. McBurney point is the classic RLQ appendiceal location for pain. Choices “D” and “E” refer to the classic psoas and obturator signs, respectively, that if present, nonspecifically support the diagnosis of acute appendicitis.

FIGURE 81-1.
Grey Turner and Cullen Signs. This patient has both flank and periumbilical ecchymoses characteristic of Grey Turner and Cullen signs. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AS, et al. Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010:166. Photo contributor: Michael Ritter, MD.)

8.
(C)
All suspected cases of acute appendicitis should have early surgical evaluation because some children will be spared further diagnostic evaluations once the decision for surgical treatment has been made. In the absence of a perforation or peritonitis, antibiotics are not always necessary, although most experts recommend them. Often the diagnosis of appendicitis can be made clinically and imaging is not necessary. Pain medication should not be withheld. The examination of a surgical abdomen will not be masked by giving adequate pain control to a child.

9.
(C)
Abdominal radiographs are traditionally not useful in the diagnostic evaluation of appendicitis except in the presence of a fecalith (calcified appendix). The disadvantage of CT is radiation exposure compared with ultrasound imaging associated with a high degree of operator dependency and variation. The presence of a normal appendix on an ultrasound effectively excludes appendicitis as a diagnosis; however, the inability to visualize the appendix renders the study inconclusive.

10.
(D)
Not all patients with acute abdominal pain need an imaging study, but a prompt surgical consultation is recommended.

11.
(E)
Pancreatitis is not a complication of acute appendicitis. Rather, it must be differentiated from appendicitis in the setting of acute abdominal pain.

12.
(E)
All of the choices are true in the setting of suspected acute pancreatitis except that blunt abdominal trauma is actually a common cause. In fact, it is the most common cause of acute pancreatitis and accounts for 13-33% of cases.

13.
(E)
Blunt trauma to the midepigastric area of the abdomen such as being struck with bicycle handlebars is the most common cause of acute pancreatitis in children. Viruses such as coxsackie B, cytomegalovirus, varicella, hepatitis A and B, influenza A and B, and Epstein-Barr virus have also been implicated in addition to bacterial and parasitic causes. Gallstones can cause pancreatitis but are usually only seen in this age range in the presence of a hereditary hemolytic anemia such as hereditary spherocytosis or sickle cell disease. Cystic fibrosis can cause acute pancreatitis, but the incidence is relatively low among African Americans. Renal stones should not cause pancreatitis.

14.
(D)
A barium enema continues to be the gold standard for the diagnosis (100% sensitivity and specificity) and has a 70% successful reduction rate of intussusception. However, recent practice reflects increasing use of ultrasonography with pneumatic reduction by an air enema. Success rates approach 90% with fewer complications than barium enemas.

15.
(A)
The presence of bilious emesis should prompt a thorough evaluation for bowel obstruction. Malrotation with intermittent volvulus is one cause in the toddler to preschool-age child (see
Figure 81-2
).

FIGURE 81-2.
Abdominal radiograph of a 10-day-old infant with bilious emesis. Note the dilated proximal bowel and the paucity of distal bowel gas, characteristic of a volvulus. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 9th ed. New York: McGraw-Hill; 2010: Fig. 39-16.)