Non-Traumatic Abdominal Pain Abdominal PowerPoint Presentation

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown

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Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown

Slide 27 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown

Slide 28 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown

Slide 29 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29

Slide 30 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30

Slide 31 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31

Slide 32 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32

Slide 33 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33

Slide 34 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34

Slide 35 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35

Slide 36 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36

Slide 37 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown

Slide 38 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown

Slide 39 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39

Slide 40 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40

Slide 41 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41

Slide 42 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42

Slide 43 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown

Slide 44 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44

Slide 45 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown

Slide 46 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown

Slide 47 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown

Slide 48 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48

Slide 49 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown

Slide 50 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown

Slide 51 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51

Slide 52 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52

Slide 53 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown

Slide 54 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown 54 Source unknown

Slide 55 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown 54 Source unknown Constipation Defined as delayed or difficulty passing stool for >2wks Functional Organic 55

Slide 56 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown 54 Source unknown Constipation Defined as delayed or difficulty passing stool for >2wks Functional Organic 55 Treatment Enema vs. no enema Single site 121 enrolled X-rays 69.4% Did not receive rectal 75.2% 33% had enema 56

Slide 57 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown 54 Source unknown Constipation Defined as delayed or difficulty passing stool for >2wks Functional Organic 55 Treatment Enema vs. no enema Single site 121 enrolled X-rays 69.4% Did not receive rectal 75.2% 33% had enema 56 27.3% had follow-up visit (42.4% to ED) 70.2% found visit helpful No difference if had enema, x-ray, or laxatives 63.4% reported child upset or very upset if they received an enema 57

Slide 58 -

Project: Ghana Emergency Medicine Collaborative Document Title: Non-Traumatic Abdominal Pain/Abdominal Emergencies Author(s): Joseph House (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2 Case 1 CC: vomiting HPI: 2 day old female, discharged home yesterday from outside facility 3 Case 1 Vitals: Temp 36.9 rectally, HR 135, RR 36, pulse-ox 98%, wt is 3.2 kg PE: awake, alert, well hydrated, normal exam Abd: soft, non-distended hyperactive BS 4 Case 1 Source unknown 5 Case 1 Source unknown 6 Case 1 Source unknown 7 8 Source unknown 9 Source unknown Vomit DDx 10 Source unknown Most Common Cause Vomiting Newborn (birth to 2wks) Nml “spitting up” GERD Obstruction NEC Infection Infant (2wks to 1yr) Nml “spitting up” GERD Obstruction Gastroenteritis Infection Post-tussive Drug OD 11 Most Common Cause Children (>1yr) GI Obstruction Other GI cause Infection Post-tussive Metabolic Toxins/Drugs Pregnancy 12 Life Threatening Anatomic abn NEC Neurologic Renal Infections Metabolic Drugs 13 Work-Up Based on H&P First few days of life: delayed passage of meconium? Bilious? Suspect obstruction Febrile? Sepsis, meningitis Signs of increased ICP? 14 Malrotation 15 St Bartholomew's Hospital Archives & Museum, London, UK, Wellcome Images Malrotation with Volvulus Bilious vomiting Can occur in utero Distention depends on site of volvulus May develop ischemia within hour May have h/o intermittent abd pain, failure to thrive Can have malrotation w/o volvulus 16 Treatment OR Fluids Electrolytes 17 Case 2 CC: vomiting 2wk old Was feeding normally 4 days ago, but then started having increasing frequency and quantity of vomiting Non-bilious 18 Case 2 0.384 cm 1.4 cm 19 Source unknown Pyloric Stenosis Hypertrophy of pylorus 1 in 250 births Male : female of 4:1 First born males highest risk Onset 2 to 5 wks Infant is hungry and will eat, but vomit w/in 30 min 20 Pyloric Stenosis Electrolytes Na:139 K:3.4, Cl:84, BiCarb>40, BUN:21, Cr:0.3 Measurements: >1.4cm length, >0.3cm thickness Other studies Upper GI 21 Pyloric Stenosis Treatment Atropine Reversible disorder of muscarinic receptors Start treatment 0.2mg/kg/day divided 5min prior to feeds When tolerated po transitioned to 2x dose orally Average length of treatment 52 days OR 22 Case 3 CC: abdominal pain 9yo male History of abdominal migraines 23 Case 3 24 Source unknown 2yo same diagnosis 25 Source unknown 2yo same diagnosis 26 Source unknown 2yo same diagnosis 27 Source unknown 2yo same diagnosis 28 Source unknown Intussusception Leading cause of obstruction in infants Most commonly between 3 and 12 months Can have ileo-colic, ileo-ileo, or colo-colic Small bowel prolapses through ileo-cecal valve May have lead point 29 Intussusception COLICKY pain May have currant jelly stool 50-75% have heme + stool 30 Intussusception Work-up X-ray Early may be normal After 6 to 8hrs, may show obstructive pattern U/S 98-100% sensitivity 31 Intussusception Treatment Air enema Perf rate up to 3% Lower success rate and higher perf rate: <3 months or >5yrs, >48hrs of symptoms, hematochezia, dehydration, SBO OR 32 Intussusception Antibiotics prior to reduction? Have heard prior peds surgeon requested it Only reference can find is use if suspect peritonitis Surgeon needs to evaluate prior to reduction? 33 Recurrence 1 to 3% Can retry air enema More common in older May have lead point 34 Case 4 CC: Abdominal pain 3yo male Pain, vomiting, constipation x3d 35 Case 4 VS: HR 148, RR 22, T 36.7, wt 16.1kg Gen: mildly ill appearing HEENT, Neck, CV, Resp: neg Abd: tense, distended, tympanitic 36 Case 4 37 Source unknown Case 4 38 Source unknown Case 4 Peds surg consulted Going to take to OR Delayed decided to do conservative treatment Became CV unstable to OR Final diagnosis: perforated Meckel’s Diverticulum 39 Meckel’s Diverticulum Remnant of embryonic yolk sac Omphalo-mesenteric duct connects yolk sac to the gut and provides nutrition until the placenta is established Between the 5th and 7th wk of gestation, separates from the intestine Epithelium of the yolk sac develops a lining similar to stomach 40 2% of population Male to female: 2 to 1 Within 2 feet of ileo-cecal valve 2 inches long 2% develop problems 41 Painless rectal bleeding Ulceration within gastric mucosa 50% do not have gastric mucosa 42 How do you find it? Accidentally Meckel’s Scan 99m technetium scan 43 Source unknown Appendicitis Still most common requiring emergent surgery Peak incidents 12-18yrs, uncommon <5yrs, rare <3yrs Perforation rates as high as 20% 44 Pediatric Appendicitis Score 45 Source unknown 46 Source unknown Results 47 Source unknown Ultrasound Operator dependent: sensitivity and specificity as high as 90% Limited by extreme tenderness and guarding weight? Excess of fatty tissue/bowel gas Lack of cooperation 48 Weight limited 49 Source unknown Weight limited 50 Source unknown Don’t Forget Genital Exam Hernias Scrotal pain often radiates to the abdomen Ovarian Torsion 51 Case 5 CC: Abdominal pain, fullness, and vomiting 17 yo male H/O constipation + weight loss 52 53 Source unknown 54 Source unknown Constipation Defined as delayed or difficulty passing stool for >2wks Functional Organic 55 Treatment Enema vs. no enema Single site 121 enrolled X-rays 69.4% Did not receive rectal 75.2% 33% had enema 56 27.3% had follow-up visit (42.4% to ED) 70.2% found visit helpful No difference if had enema, x-ray, or laxatives 63.4% reported child upset or very upset if they received an enema 57 Hirschsprung’s Disease Parasympathetic ganglion cells of Auerbach’s plexus are absent History of chronic constipation May not be stool without assistance Work-up Biopsy Barium enema Anorectal manometry 58