Pediatric appy

[chasingdaylight]

Question for the attendings regarding pediatric abdominal pain:

What is your criteria for sending labs for a kid with complaint of abdominal pain?

I've been sending these kids with cc: abdominal pain +/- vomiting home with no labs and just 12-24 hr follow up if they have no tenderness to palpation, jumps, coughs and has normal exam on arrival.

A lot of my colleagues seem to insist on doing labs, for these kids, then getting u/s if there is a white count elevation or CRP elevation.

I know the PAS score takes WBC elevation into consideration, and so does the alvarado score.

Curious what your criteria is for sending labs on kids complaining of abdominal pain?

Thanks!

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[GeneralVeers]

Depends on age and abdominal exam. If the kid is old enough/verbal enough for me to get any kind of decent exam, then if it's not appendicitis I would discharge with 12-hour followup. If the kid is too young, then I treat it like a veterinary case and get labs/US.

 

[dotcb]

Rarely do any work-up for peds abd pain. Key point: you want a specific test, not a sensitive test. The only 2 tests I do w/ any regularity for peds abd pain are UA'S and RLQ US, which is usually nondiagnostic and leads to a CT. If I order the US, I order a BMP and CBC, and often a UA.

 

[Rendar5]

First off WBC is bs in apply. Sure it's high in most, but I've had plenty of pts with rlq ttp and no wbc, fever, nause, anorexia, or vomiting have clear cut appy.

Abdominal pain and fever are also bs as complaints. All that matters is physical exam EXCEPT in the case of a recently ruptured appy, in which case history is everything.

If they are ttp in the rlq, they get imaging, period. The only thing that might dissuade me is more than 50 wbcs in urine.
If they are non tender, unless they just had their pain drop from 10 to 2 a couple hours prior, there is essentially no role for imaging (and yes their hr of 120 was a giveaway.)

 

[Rendar5]

My criteria for labs in these kids? If I am imaging them, if I am worried about dka, maaaaybe if the vomiting is bilious, though in that I usually just image without labs. I also check urinalysis if there is some suggestion of uti

 

[bougiecric]

The only thing that might dissuade me is more than 50 wbcs in urine.

This doesn't necessarily dissuade me because they may have aseptic pyuria secondary to appendicitis.

That said, I try to minimize sticking kids as it's almost never fruitful. Agree with above that I do it if I'm already suspicious enough image. I don't agree with the practice of deciding on imaging based on lab results in these cases given the poor sensitivity and specificity of WBCs.

 

[dchristismi]

The single most helpful diagnostic test in a kid with abdominal pain is a zofran challenge.
Zofran ODT > feel better > PO challenge > home

If Zofran make the "pain" go away, chances are it was just nausea, and pain and nausea are hard to differentiate under the umbrella of "my tummy hurts."

I very rarely do labs in kids, especially if they are moving fluidly and are nontender. Bloodwork is never diagnostic and CTs are a ton of radiation. Urine? If fever.

Now a kid who very gingerly moves onto the stretcher and refuses to jump up and down? That kid may very well get a workup after still feeling puny after zofran. I certainly couldn't walk upright when my own appendix (which HAD read the textbook, thankfully) decided to mutiny.

 

[Birdstrike]

Can any of you actually get your radiologists to commit to a positive or negative US scan for appy, without the classic, "correlate clinically and follow up CT if indicated"?

 

[Apollyon]

Can any of you actually get your radiologists to commit to a positive or negative US scan for appy, without the classic, "correlate clinically and follow up CT if indicated"?

I did just last weekend. 6y/o went to the OR. Acute suppurative appy, afebrile, 15.5K WBC, able to jump up and down, vomit x1, U/S positive for appy.

 

[chasingdaylight]

Thanks for your replies! All very helpful.

 

[Perrotfish]

As a pediatric resident it seems like the standard of care for the two Peds EDs I have rotated through is to get labs on almost everyone. The problem is that with the Pediatric Appendicitis Score basically anyone who shows any clinical signs of appendicitis (just RLQ pain, just anorexia and vomiting, etc) can meet criteria for screening with US if they have leukocytosis and a left shift.

PAS 2014 prospective trial: http://pediatrics.aappublications.org/content/133/1/e88.full.pdf html?sid=8855d2ed-f36d-44cb-9f2b-404eb758fa31

At the Peds ED we rotate through anyone under 14 with anything that looks remotely like appendicitis (including belly pain of unknown source) gets a CBC. Almost everyone gets a CRP too, but that's not actually part of the PAS so I'm still not sure why. Everyone with a PAS score of > 3 gets an US. If the US can't visualize the appendix or if the read is equivocal they then get an MRI.

CT is now completely out of the equation at that ED, BTW. Unless you're really in the middle of nowhere, maybe transfer to a Peds ED if you have a PAS>3, equivocal US, and no available MRI on site?

 

[WilcoWorld]

Tangentially related - the Pediatrician who I diagnosed with appendicitis a couple weeks back had a WBC = 8. It was curious, but would've been amusing had the doc been a surgeon.