Abdominopelvic Emergencies

This section covers the following abdominopelvic emergencies:

• Appendicitis

• Intussusception

• Malrotation of the Bowel with Volvulus

• Urinary Tract Infection

• Testicular Torsion

• Gynecologic Emergencies

Other related topics are discussed in the following section in the Pediatric Emergency Medicine rotation guide:

• Pyloric Stenosis (Emergencies in the Neonate and Young Infant)

Appendicitis

Acute appendicitis is the most common nontraumatic surgical emergency in children. Clinical goals and outcomes for patients with suspected appendicitis in the emergency department (ED) include early diagnosis, limiting radiation exposure and unnecessary testing, and minimizing the number of negative appendectomies.

Clinical Presentation

• classical presentation: periumbilical pain that migrates to right lower quadrant (RLQ)

• additional symptoms: abdominal pain, fever, anorexia, nausea, and vomiting

• physical exam: periumbilical or RLQ tenderness, rebound tenderness, guarding, Rovsing sign (increased tenderness in the RLQ upon palpation of the left lower quadrant [LLQ]), psoas sign (pain increases with extension of the right leg at the hip when the patient is lying on left side)

Examination Techniques for Acute Appendicitis

Obturator sign: Pain in the right side of the abdomen is elicited by passive flexion of the right hip and knee and internal rotation of the leg at the hip. (Source: An Unusual Case of Abdominal Pain. N Engl J Med 2013.)

Psoas sign: Pain increases with the extension of the right leg at the hip when the patient is in the left lateral decubitus position. The psoas sign is associated with a retrocecal appendix. (Source: An Unusual Case of Abdominal Pain. N Engl J Med 2013.)

Rovsing sign: Pain in the right lower quadrant (red circle) is elicited in response to the application of deep pressure (arrow) in the left lower quadrant and to the sudden release of pressure. This sign is indicative of peritoneal irritation. (Source: An Unusual Case of Abdominal Pain. N Engl J Med 2013.)

Diagnosis

• initial: physical exam, complete blood count (CBC) with differential, C-reactive protein (CRP), application of clinical prediction rule to guide imaging

• imaging: RLQ ultrasound; if unable to visualize appendix by ultrasound, then CT of abdomen or MRI (per center availability)

  • Note: Not all children require imaging, as outlined below.

Clinical Prediction Rules

Fewer than 50% of children present with the “classic” presentation described above, and definitive cross-sectional imaging (CT in most centers) is not without radiation-exposure risk. As a result, clinical prediction rules have been developed to aid in risk stratification for children with suspected appendicitis and to determine the need for cross-sectional imaging.

The Pediatric Appendicitis Score and Alvarado Score are the most widely used clinical prediction rules for acute appendicitis.

The Low-Risk Appendicitis Rule further identifies children at low risk for appendicitis. This rule was validated by the AAP’s Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC) in a prospective, multicenter, cross-sectional study of more than 2000 children. Children meeting the following low-risk criteria can be safely observed or undergo ultrasound rather than immediate imaging with CT.

Management

• Patients with definitive appendicitis and those at intermediate and high risk should be designated NPO (no food or fluids), and their pain should be adequately treated.

• Patients at intermediate and high risk merit imaging to assess for appendicitis as outlined above.

• Patients with definitive appendicitis on exam or imaging warrant surgical consultation and appendectomy. Antibiotics may be initiated in consultation with the surgical team.

• Patients without a definitive diagnosis can be observed in the hospital or discharged home based on clinical index of suspicion and surgical consultation.

Intussusception

Intussusception occurs when a segment of proximal intestine invaginates into a distal segment of intestine and results in bowel obstruction. The most frequent type of intussusception is ileocolic and is most common in children ages 3 months to 5 years, with peak incidence between ages 5 and 9 months. More than 90% of cases are idiopathic; however, about 5% are caused by pathologic lead points, including lymphoid hyperplasia, Meckel diverticulum, and polyps.

Image demonstrating ileocecal intussusception. Although this location is not classic, the image visually demonstrates the concept of intussusception. (Source: Case 12-2012: An Infant with Vomiting. N Engl J Med 2012.)

Clinical Presentation

• sudden, intermittent, colicky abdominal pain and/or mental-status changes punctuated by episodes of baseline mental status and activity level

• irritability, crying during periods of obstruction

• “classic” triad of bilious emesis, abdominal mass, and blood per rectum (“currant jelly” stool) is uncommon (approximately 20% of cases)

Diagnosis

• Initial and definitive diagnosis is abdominal ultrasound with “crescent-in-doughnut” or “target” sign.

• Consider plain abdominal radiographs if there is concern for perforation with free air.

Ultrasound demonstrating classic “target sign” found in intussusception. (Photograph courtesy of Dr. Sathyaseelan Subramaniam, MD, Faculty/Director of Ultrasound, The Valley Health System.)

Management

• Air insufflation enema is first-line treatment and is successful in 70% to 95% of cases.

  • It should be performed at a center with pediatric surgery available; unsuccessful air enema will require surgical reduction.

• Patients with recurrent intussusception merit surgical consultation for further care.

Malrotation of the Bowel with Volvulus

Malrotation of the bowel is characterized by the abnormal placement and fixation of the mesentery of the bowel during embryologic development. Malrotated bowel tends to volvulize and cause intestinal obstruction at the point(s) of abnormal fixation. Unrepaired, volvulized bowel becomes ischemic, leading to intestinal necrosis, perforation, and sepsis. Most cases of malrotation with volvulus occur in infants younger than one year, but it can occur throughout childhood. Goals of care for malrotation in the ED include early recognition, surgical consultation, and immediate operative management.

Clinical Presentation

• classic: newborn with bilious emesis in the first month of life

• older infants/children: nonspecific symptoms including abdominal pain, bilious or nonbilious vomiting, irritability, abdominal distention

Diagnosis

• two-view abdominal radiographs (flat and upright) to assess for obstruction (look for dilated, gas-filled loops of bowel)

• abdominal ultrasound to assess the relative orientation of the superior mesenteric artery and vein to each other; transposed orientation of these vessels may signal malrotation

• upper-gastrointestinal imaging series (considered the gold standard) showing absent ligament of Treitz (malrotation)

Management

• designate the patient NPO if not already; consider placement of a nasogastric (NG) sump for relief of gastric distension

• immediate surgical consultation and operative management

Urinary Tract Infection

The urinary tract is the most common site of serious bacterial infections in children. However, diagnosis of urinary tract infection (UTI) in children can be difficult given its nonspecific physical exam findings and symptoms. Most often, fever is the only finding in young children. Children with suspected UTI are screened in the ED with urinalysis (UA); however, screening for UTI in children is not without consequence, as false-positive tests can lead to unnecessary interventions, including bladder catheterization, antibiotic administration, and imaging. Therefore, the AAP has developed guidelines to help clinicians choose which children to screen for UTI. UTICalc is a tool to estimate the probability of UTI in children ages 2 to 23 months based on clinical characteristics.

UTI Prediction Rule

Gorelick and Shaw Clinical Prediction Rule: This rule helps determine which patients should be screened with UA by predicting the pretest probability of UTI in febrile infant girls and boys.

Urinalysis

In all but the youngest infants (<6 months), obtaining an initial UA with a bagged urine specimen has been shown to reduce unnecessary catheterization and to perform as well as UA via catherization as an initial screen. The AAP recommends the following screening algorithm:

• children aged <6 months, catheterize for urinalysis and culture

• children aged 6 to 24 months, urine bag with point-of-care dipstick; if positive (leukocyte esterase >2 or positive for nitrites), catheterize for urine culture specimen

For more information on UTI, see the Pediatric Nephrology rotation guide.

Testicular Torsion

Testicular torsion is caused by twisting of the spermatic cord, resulting in obstruction of blood flow to the testis leading ultimately to ischemia. Testicular torsion is a true urologic emergency. Goals of management in the ED include prompt diagnosis and early surgical consultation for operative management.

Clinical Presentation

• history

  • sudden onset, relentless scrotal pain not improved by positional change (often severe enough to wake the child from sleep)

  • unexplained abdominal pain in young children; maintain a high index of suspicion for torsion in boys with abdominal concerns and extremely fussy infants

  • nausea/vomiting

• physical exam

  • enlarged, swollen hemiscrotum (often the only sign in the neonatal period)

  • significant tenderness of scrotum

  • loss of cremasteric reflex on the affected side

  • horizontal lie of affected testis

Diagnosis

• emergent ultrasound with Doppler of testicle

• prompt surgical consultation

Management

• surgical reduction and fixation (orchiopexy)

• preservation of testicular viability is most likely when surgery occurs within 6 hours of onset of pain

Gynecologic Emergencies

This section provides an overview of gynecologic emergencies that should always be considered in young women presenting to the ED with abdominal/genitourinary chief concerns. For more on gynecologic emergencies, see Abdominopelvic Emergencies in the Adult Emergency Medicine rotation guide.

Ectopic Pregnancy

• implantation of fertilized ovum in a location other than the endometrial lining of the uterus

• low overall incidence of ectopic pregnancy in teenagers

• higher mortality in teens relative to adults due to delayed presentation

• symptoms: vaginal bleeding, lower abdominal pain, missed menstrual period

Diagnosis:

• positive urine or serum human chorionic gonadotropin (hCG) test and visualization on ultrasound of a gestational sac outside the uterus

• in patients for whom there is not a priori concern for ectopic pregnancy, a positive hCG test without sonographic evidence of an intrauterine pregnancy should prompt concern (and sonographic search) for an ectopic pregnancy

Management: hemodynamic stabilization followed by immediate transfer/referral for obstetric/gynecologic evaluation and further management (see Abdominopelvic Emergencies in the Adult Emergency Medicine rotation guide).

Adnexal Torsion

• twisting of the ovary, fallopian tube, or both on the axis between the infundibulopelvic ligament and the utero-ovarian ligament

• left untreated, leads to ovarian ischemia and necrosis

• rare in children (0.3 to 5.0 cases reported annually in large pediatric centers)

• more common in postmenarchal patients, but can occur in prepubescent girls

• symptoms: acute-onset (nearly always unilateral) lower abdominal pain, nausea, and vomiting

• diagnosis: pelvic ultrasound with Doppler; consider MRI if ultrasound is negative and there is still high level of clinical concern

• management: surgical consultation and intervention