Pediatric AP

[PAGuy77]

We've been seeing a lot of gastro in our pediatric population recently, and some of our attendings are heavy handed with scans. What is the cocensus out there for scanning vs waiting vs US in peds with N/V/D abd pain/fever to r/o AP? Do you find that if pt improves with IV bolus, zofran, and motrin/tylenol are more likely to have gastro alone? Thoughts?

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[Socrates25]

We've been seeing a lot of gastro in our pediatric population recently, and some of our attendings are heavy handed with scans. What is the cocensus out there for scanning vs waiting vs US in peds with N/V/D abd pain/fever to r/o AP? Do you find that if pt improves with IV bolus, zofran, and motrin/tylenol are more likely to have gastro alone? Thoughts?

I dont think you can use improvement with IVF, zofran, NSAIDs as a gauge for appendicitis.

I go by the physical exam, particularly serial physical exams. I think they are a much more useful tool than whatever response they might have to things you listed above.

Appendicitis should give you fairly consistent physical exam findings that are replicable if you know how to examine kids properly.

Intussusseption is a different story. They can have either a completely normal abdominal exam or severe TTP in all quadrants depending on when you look at them. Conversely they can be squirming in pain or happy/playful on mom's lap. For intussusseption I go by the history as the main determination of when to image or not. If the parent gives you a history of intermittent colicky abdominal pain then I would image.

 

[RustedFox]

Serial physical exams (documented), the alvarado appendicitis score, and "clear and precise" discharge instructions to return within (specifically) 12 hours if not resolved. I hate CT scanning a pedi.abdomen. Hate.

 

[Zanegray]

Serial physical exams (documented), the alvarado appendicitis score, and "clear and precise" discharge instructions to return within (specifically) 12 hours if not resolved. I hate CT scanning a pedi.abdomen. Hate.

If I am quite suspicious based on the above I transfer to the kiddos hospital for ultrasound - as we can not operate on them at any rate. If I am not convinced I OFFER transfer (discussion with parents) and discharge with 12 hour follow up if they decline. Of course, family has to be reliable for discharge, and fortunately most of our families are.

You can also do bedside ultrasound if you have a good one. I wouldn't rule someone out with it, but I might rule someone in.

Also, I did a rotation at Phoenix Children's during residency and for some reason they have a lot more appendicitis there than many places in the country (I felt like I saw a lot of kids and someone confirmed it was true - so I have no actual data to support this.)
Anyway, they also use CRP to help them rule someone in. May be useful - again, I would caution you not to rule someone out with this.

 

[deleted109597]

There is some data (mostly in adults) that you can rule out (100% sensitivity!) with a normal CBC and normal CRP. I include normal US in that as well. If any of them are abnormal, or the US does not identify the organ, then I explain to the family the risks, benefits, and help them come to a decision of discharge with return visit, imaging, or admission for serial exams. Thankfully our pediatric surgeons would rather keep them in the hospital overnight than image them. Since the hospital is rarely at capacity, we can do this fairly easily.
I haven't CT'd a kid for appendicitis in probably a year.

 

[Rendar5]

If there's no consistent reproducible tenderness, they go home and are told to go to the kid's hospital if the pain gets worse. nausea, vomiting, diarrhea I don't care about, nor do I care about abdominal pain. all I care about is abdominal tenderness. It's either there or it isn't. If it's there and consistent, I send them to the local peds hospital so they can get an u/s by an experienced technician. My tech's are absolutely fantastic where I work, but unless you are well-trained in appy exams and do them regularly, one's ability to successfully find the appendix is very low.

That said, that applies to appy's. Intussusception I always hate. If I'm very concerned I send them to the local peds ED, but if the kid who's having colicky pains every half hour comes into my ER with a normal belly, negative guaiac, and sits there for 3 hours without crying once with mom in the room, they're probably going home.