Cushing syndrome (CS) is a constellation of findings caused by an excess of cortisol. The most common cause of CS is exogenous corticosteroid administration. Cushing disease is hypercortisolemia specifically due to excess corticotropin production by the pituitary gland. Cessation of linear growth is nearly always present in CS, whereas children who have other causes of obesity usually have normal or advanced progression of height. Diagnostic approaches include determination of likely causes by patient age and determining whether the disorder is corticotropin-dependent. Prognosis and treatment are dependent on the cause of CS.
The diagnosis of pyomyositis requires a high index of suspicion in patients with hematologic malignant neoplasms. Correct diagnosis might be delayed initially because of vague clinical presentation, overlapping symptoms, and nonspecific clinical signs. Pyomyositis should be included in the differential diagnosis when a patient develops swollen or tender muscles after chemotherapy with or without bacteremia. Prompt treatment with broad-spectrum antibiotics that cover S aureus and resistant emerging gram-negative organisms, specifically E coli, should be initiated immediately in patients with hematologic illnesses along with close monitoring and follow-up.
Unicameral bone cysts (UBCs) in children usually are asymptomatic. Most UBCs are discovered when a radiograph is performed on a child who has had accidental trauma to a limb. Symptomatic cysts typically present with pain, often the result of pathologic fracture through a large cyst or occult stress fracture within the thinned cortex around the cyst. Simple radiography is the best method for detecting such cysts, which typically are located within the long bone (femur, tibia, fibula, humerus), but can appear elsewhere. Cysts typically appear in the proximal metaphysis, but some involve the epiphysis and growth plate, thereby affecting bone growth. If clinically necessary to confirm the diagnosis, computed tomography or magnetic resonance imaging can delineate the cyst better or demonstrate an occult fracture. For the asymptomatic UBC, close follow-up is the recommended course of action. However, surgical intervention by corticosteroid or autogenous bone marrow injection or open curettage with bone grafting is recommended if the cyst is symptomatic, carries an increased risk for pathologic fracture (weight-bearing bone or dominant arm of a throwing athlete), or shows signs of an impending pathologic fracture. Clinical and radiographic follow-up is recommended after surgical intervention, because UBC recurrence after initial surgery is reported to occur in 18% to 88% of patients.
1. Ivana Kalanovic Dylag, MD*
2. Ross E. Myers, MD*
1. *Rainbow Babies and Children’s Hospital, Cleveland, OH.
An 11-year-old boy presents with a 2-week history of dry cough, chest pain, and shortness of breath. He denies fever and other constitutional symptoms. The only finding of note on his past medical history is chronic poor weight gain. Social history reveals smoke exposure and a father who has been incarcerated. He has a brother with asthma.
Findings on initial physical examination include temperature 101.5°F (38.6°C), heart rate 139 beats/min, respiratory rate 18 breaths/min, blood pressure 125/66 mm Hg (normalized with the next check to 98/69 mm Hg), oxygen saturation 96% on room air, weight 23.2 kg (<3rd percentile), and height 127 cm (<3rd percentile). He is generally alert and in mild respiratory distress. Respiratory examination demonstrates suprasternal retractions, diffuse crackles bilaterally without wheezes, and tenderness to palpation at the left lower chest. Cardiovascular examination shows tachycardia. Findings on the rest of the physical examination are normal.
The white blood cell count is 12,200/μL (12.2×109/L) with 73% neutrophils, 12.1% lymphocytes, 14.2% monocytes, 0.3% eosinophils, and 0.2% basophils. Hemoglobin is 11.2 g/dL (112 g/L), hematocrit is 33.4% (0.334), and mean corpuscular volume is 82 μm3 (82 fL). Platelet count is 377×103/μL (377×109/L). C-reactive protein measures 4.93 mg/L (46.95 nmol/L) and erythrocyte sedimentation rate is 36 mm/h. Results of a complete metabolic panel are within normal parameters. Chest radiography results are …
Children with intussusception can present with a wide variety of symptoms, including vomiting, fever,lethargy, and abdominal pain. The classic triad of abdominal pain, hematochezia, and palpable abdominal mass is seen in a few patients.• Early diagnosis of intussusception depends on a high level of clinical suspicion in any child with non specific abdominal findings followed by appropriate radiographic or ultrasonographic evaluation and confirmation with a contrast enema.• Abdominal radiography, although an appropriate component of the initial workup for gastrointestinal symptoms, lacks the sensitivity to reliably exclude the presence of intussusception.• Because ultrasonography is a safe, sensitive, and specific test for the diagnosis of intussusceptions, it should be performed early whenever there is clinical suspicion of intussusception.• Contrast enema is the gold standard for diagnosis and first-line treatment of intussusception. There is an increasing trend for pneumatic reduction of intussusception compared with hydrostatic reduction.Intravenous placement, fluid resuscitation, and notification of the pediatric surgeon should be completed before contrast enema.
Allergic contact dermatitis to nickel is extremely common and is increasing in prevalence. Nickel dermatitis is characterized by an eczematous, pruritic rash at the primary site of contact. In severe cases, direct contact nickel dermatitis is accompanied by cutaneous involvement of other sites not in contact, a development known as an id reaction. Diagnosis is often made on clinical grounds; however, a positive patch test result may be used to confirm diagnosis. The mainstays of treatment are nickel avoidance and topical corticosteroids.
Doxycycline is a classically implicated cause of phototoxic reactions. Photo-onycholysis is a rare manifestation of phototoxicity. Nail changes may typically include nail pain, subungual hemorrhages, or distal onycholysis. Self-resolution can be expected in 3 to 6 months. Patients prescribed doxycycline should be counseled about the potential for phototoxicity and the need for appropriate sun protection while taking the medication.
* CT: : computed tomography
ESR: : erythrocyte sedimentation rate
IV: : intravenous
WBC: : white blood cell
A 7-year-old girl presents to the emergency department with persistent fever and cough for 9 days. She was in her usual state of good health until she vomited twice 11 days earlier. She subsequently developed cough and fever, prompting three visits to an urgent care center in the preceding 9 days. She denies shortness of breath, chest pain, diarrhea, rash, urinary symptoms, or sore throat. A chest radiograph on the fourth day of fever was normal.
Physical examination reveals a temperature of 102.9°F, heart rate of 115 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 110/65 mm Hg, and pulse oximetry reading of 98% in room air. Generally, she appears well, with occasional coughing during the visit. On respiratory examination, there is good air movement bilaterally, and no rales or wheezes are heard. The rest of the physical findings are normal.
Her white blood cell count (WBC) is 25×103/μL with 88% neutrophils, 8% lymphocytes, and 4% monocytes; her C-reactive protein level is 16 mg/dL (normal <0.5); and an erythrocyte sedimentation rate (ESR) is 70 mm/hour. Results of her complete metabolic panel and urinalysis are normal. A blood culture and urine culture come back negative. An additional imaging study reveals the cause of her prolonged illness.
A previously healthy 14-year-old girl presents with blurred vision in the right eye of a few hours’ duration. The blurring is worse while looking at close rather than at far objects. There is no history of trauma, ingestion of toxic substances, or recent illness, including headache, nausea, vomiting, weakness or tingling of the extremities, eye pain, ptosis, diplopia, or other symptoms referable to the cranial nerves. The past, social, and family histories are noncontributory, other than the presence of asthma and dry eyes in the mother.
On physical …
• Sarcoma botryoides is an embryonal rhabdomyosarcoma that has an excellent prognosis with early diagnosis and treatment. • Clinical features of the tumor typically include an obvious and rapidly enlarging mass protruding from the genital region. • Staging of disease should include biopsy of the mass and any suspicious lymph nodes, bone scan, bilateral bone marrow biopsies, and CT scan/MRI of the chest, abdomen, and pelvis. Renal ultrasonography should be considered if urethral or bladder involvement is suspected. • Treatment of sarcoma botryoides has improved over the past 20 years, and a multimodal approach combining chemotherapy, radiation, and surgery has decreased the morbidity previously associated with treatment of this disease.
Bowel malrotation typically presents in infancy or early childhood. The condition is seen less commonly in the teenage population, in whom the diagnosis may be missed. • Among older children born with malrotation, 10% to 15% present with volvulus. The onset of symptoms usually is acute, but some children can present with a more chronic pattern of episodic vomiting and abdominal pain suggestive of intermittent volvulus. • The diagnosis may be missed or delayed, with resultant catastrophic midgut volvulus, together with sepsis or other complications. • This case illustrates that clinicians must include malrotation in the differential diagnosis when evaluating an adolescent girl experiencing chronic abdominal pain that is suggestive of menstrual pain or pain of psychogenic origin.
Neutrophils form the first line of defense against most bacterial and fungal pathogens after disruption of the skin and mucous membranes. Once tissue is invaded by microorganisms, a variety of vasoactive and chemotactic mediators are released by the involved tissue. In response to these chemotactic peptides, neutrophils, normally found in the circulation, adhere to the inflamed endothelium and migrate to the site of infection where the phagocytes ingest and kill the invading microorganisms. Neutrophils also release a variety of cytokines that may modify the neutrophils' own responses as well as interact with other elements of the immune system. Neutrophils, therefore, are both important effectors and regulators of the host defense system. Because of the complexity of this defense system and the major role played by neutrophils, both primary and acquired defects in neutrophil number or function result in persistent as well as recurrent infections.
Primary defects in neutrophil number or function are relatively rare, but they must be considered in a child who presents with recurrent infections. Early identification and management of affected children lead to decreased morbidity and mortality. Although care predominantly has been supportive in the past through the use of prophylactic and therapeutic antibiotics, specific therapies now are becoming available to reduce the frequency of infections in some diseases.
* CGD: : chronic granulomatous disease
CNS: : central nervous system
CT: : computed tomographic
ED: : emergency department
GI: : gastrointestinal
Ig: : immunoglobulin
VATS: : visually assisted thoracic surgery
A mother brings her 3-year-old son to the emergency department (ED) for 1 day of abdominal pain and subjective fever. The mother states that the boy generally is healthy. He has not had any nausea, vomiting, or diarrhea, but he has been eating less than normal and has been constipated for 3 days. He coughs occasionally but does not have shortness of breath. He was treated 3 days ago for right otitis media with high-dose amoxicillin at another ED. His immunization status does not meet the recommended standards.
On physical examination, the boy cries and actively tries to get away from the physician assistant, but he is consoled easily by his mother when the examination is finished. While crying and fighting, his temperature is 98.2°F, his heart rate is 156 beats per minute, his respirations are 24 breaths per minute, and his oxygen saturation is 97% in room air. His ear, nose, and throat examination is notable only for opaque and slightly erythematous tympanic membranes. Respiratory and cardiac findings are normal. His bowel sounds are hypoactive, his abdomen is soft, and he withdraws with right upper quadrant palpation. The findings from the rest of his examination are unremarkable. An acute abdominal radiologic series is ordered.
A 9-year-old autistic boy presents to the ED with a 3-day history of bilious emesis and one loose stool with no visible blood. His mother states that he has been increasingly irritable, and his behavior has become more erratic. He has not been wanting to eat or drink over the past few days and has had decreased urine output on the day of presentation. There is no history of fever, upper respiratory tract infections, illness contacts, or travel. He takes no medications and has not had surgery.
Physical examination results reveal a well-nourished boy who …
1. Frank A. Oski
1. Department of Pediatrics, Johns Hopkins University School of Medicine
In 1976, the Committee on Nutrition of the American Academy of Pediatrics recommended that the non-breast-fed infant receive an iron-fortified proprietary formula during the entire first year of life.1 In 1983, the Committee on Nutrition reversed the previous recommendation and concluded, "If breast-feeding has been completely discontinued and infants are consuming one third of their calories as supplemental foods consisting of a balanced mixture of cereal, vegetables, fruits, and other foods, whole cow milk may be introduced."2 The Committee, in their report, acknowledged the fact that "there are many unanswered questions concerning the use of whole cow milk in the second half year of life." I believe that we now have answers to some of these questions and that we should return to the original recommendation discouraging the use of whole cow milk (WCM) until infants have reached their first birthday.
Studies performed since the 1983 report have demonstrated that the introduction of WCM prior to the first birthday is associated with an increased risk of occult gastrointestinal bleeding3 and an increased incidence of iron deficiency anemia.4,5 In addition, iron deficiency anemia in infants less than 1 year of age has been shown to be associated with cognitive and psychomotor impairment6-8; such impairment may not be correctable with iron therapy.7-9
Phenylketonuria (PKU) has been aptly described as the "epitome of human biochemical genetics." In so distinguishing PKU among the many metabolic disorders now known, Scriver and Clow identified several categories in which this inborn error of metabolism is singularly prominent. First and foremost, PKU represents a fusion of effort between public health and genetics. It is the major genetic disorder in which treatment can prevent the clinical expression of disease and for which routine biochemical screening of newborn infants was developed. It remains the model for such screening. Second, PKU is the prime example of the importance of understanding as completely as possible the biochemical basis of a metabolic disorder. The detailed understanding of phenylalanine metabolism that arose from studies spawned by PKU led to the recognition of "new" metabolic disorders that relate to PKU in their capacity to increase the phenylalanine level but that involve a different category of metabolism and require very different treatment. Third, PKU represents an important link between obstetrics and pediatrics. The threat to the fetus from PKU in the pregnant woman (maternal PKU) must be met by special dietary care throughout the pregnancy. This is, perhaps, only the first of other maternal inborn errors that will require similar intervention during pregnancy.
1. John P. Morgan
1. Medical Professor, City University of New York, New York, NY 10031
A 1981 review of toxicity and illicit use of amphetamine noted that governmental actions had diminished the diversion of pharmaceutical amphetamine and methamphetamine. Much of the illicit market prior to 1972 had been supplied by diversion of legitimately manufactured material, chiefly through careless (or even criminal) wholesaling. Following the reduced availability of diverted amphetamine, a number of events transpired. A market of fake "look-alike" products evolved. These were produced in formulations that resembled popular amphetamine products and that contained available over-the-counter stimulants, such as ephedrine and caffeine. Between 1980 and 1982, a very popular "triple product" appeared that contained caffeine, ephedrine, and phenylpropanolamine. The look-alike problem was diminished by a series of actions taken by the federal Food and Drug Administration in 1984 that outlawed the legal marketing of any such combinations.
Illicit synthesis and marketing of methamphetamine continues. Although distribution remains limited chiefly to southern California, it has clinical importance. While a volatile version of methamphetamine ("ice") has received wide exposure in the American media, its true clinical impact apparently remains limited.
Definitions and Terminology
Amphetamine refers to a unique chemical, for which there are a number of precise terms: methylphenethylamine, phenylisopropylamine, and 2-amino-1-phenylopropane. Use of the term "amphetamines" is careless; there is no basis for using the plural term.
Despite the availability of effective antituberculosis drugs, tuberculosis remains an important cause of morbidity, mortality, and healthcare expenditures in the United States. It is estimated that more than 10 million people in the United States are infected with the tubercle bacillus. More than 26 000 new cases of clinical tuberculosis occur every year, 1600 of which occur in children. Factors that serve to sustain tuberculosis in the United States include infection with the human immunodeficiency virus (HIV), influx of foreign-born individuals at increased risk of developing tuberculosis, and poverty and poor access to medical care experienced by large segments of the population.
The Centers for Disease Control (CDC) has a goal of eliminating tuberculosis from the United States by the year 2010. If this goal is to be achieved, programs must focus on children because they are the future reservoir for the disease. Tuberculosis cases in children are important public health markers for a community insofar as they represent ongoing transmission of the disease and at least a partial failure of current tuberculosis control efforts.
Epidemiology of Childhood Tuberculosis
The incidence of tuberculosis in the United States declined steadily for a 25-y period until 1985, when it leveled off (Fig 1). More than 26 000 cases of tuberculosis were diagnosed in the United States during 1991; almost 1600 cases occurred in children <15 y.
Acute infections of the upper respiratory tract, including those of the tonsils and pharynx, are the most common affliction of humans; their tendency to occur with much greater frequency in children makes them especially important to the pediatrician. A host of microbial agents can cause these infections, but only a few are responsive to antimicrobial agents. Because of the paucity of definitive laboratory tools that allow easy recognition of the cause of most acute respiratory infections, it is important for the practicing pediatrician to have other methods to aid in the clinical management of children who have these infections. This review will discuss the etiology and epidemiology of acute respiratory infections that involve primarily the tonsils and pharynx, with emphasis on how this knowledge can guide clinicians in their management. The groundwork for this approach will be laid by suggesting a classification of upper respiratory tract infections that involve the tonsils and pharynx. Causative agents will be enumerated and put into perspective. The major factors associated with the occurrence of acute upper respiratory tract infections will be discussed. Finally, treatment of the patient who has tonsillopharyngitis will be presented.
Uncomplicated acute tonsillopharyngitis will be emphasized primarily and the role of complications only mentioned.
Palpable lymph nodes are common in children and may be a normal finding or a sign of serious disease. Because parents frequently are concerned about lymphadenopathy, the role of the primary care practitioner is to provide reassurance when appropriate and carry out a systematic evaluation when warranted. The history and physical examination frequently can elucidate the cause of the lymphadenopathy. Infectious diseases are the most common underlying cause, and antibiotics frequently are indicated if there is lymphadenitis. Generalized lymphadenopathy is less common than localized lymphadenopathy and occurs in the setting of systemic disease. Worrisome features of lymphadenopathy that should lead to additional evaluation and possible biopsy include supraclavicular location; size greater than 2 cm in a cervical lymph node; a hard, firm, or matted consistency of an enlarged lymph node; lack of associated infectious symptoms; lack of improvement over a 4-week period; and accompanying constitutional symptoms. CBC, ESR, and chest radiographs are inexpensive, useful screening tests that can aid the clinician in determining whether a biopsy should be performed.
Trasande did not disclose any financial relationships relevant to this article. Objectives After completing this article, readers should be able to: 1. Describe the sources of lead exposure and their changes over time. 2. Delineate the cognitive difficulties associated with lead exposure and uptake. 3. Describe the screening recommendations and the tests available for determining blood lead levels. 4. Discuss how to manage an increased blood lead level.
• Possible causes of a vesicular rash in an infant include the following: herpes simplex virus (HSV), varicella-zoster virus (VSV), enterovirus, neonatal scabies, tinea corporis, syphilis, contact dermatitis, and impetigo, as well as rare genetic disorders such as Langerhans cell histiocytosis and incontinentia pigmenti. History, particularly of exposures, and physical examination can point to the most likely diagnosis. • The typical course of chickenpox includes direct or droplet exposure; a 14- to 16-day latent period; a 1- to 2-day prodrome of low-grade fevers, headaches, and malaise; and the subsequent appearance of a vesicular rash, classically described as dew drops on a rose petal. • Chickenpox can be confirmed rapidly by vesicular fluid testing using either VZV polymerase chain reaction or direct fluorescent antibody. Viral culture is less sensitive than either of these methods. • The decision whether to use antiviral treatment is based on the patient's risk factors for severe disease as well as the timing of presentation. If indicated, treatment should be initiated as soon as possible. Treatment options include acyclovir for those at risk for moderate-to-severe disease as well as VZV immunoglobulin for those at risk for severe disease. • Patients are contagious from approximately the day before symptom onset until the time all the lesions are crusted over. Airborne and contact precautions are necessary for hospitalized patients. A history of exposure to individuals at risk for severe disease should be sought in any patient suspected of having chickenpox.
1. J. Alex Haller Jr
1. Professor of Pediatric Surgery, of Pediatrics, and of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Serious injuries remain the number one cause of death among American children. Major trauma is responsible for more than 50% of the mortality in children between the ages of 1 and 14 years. The majority of these life-threatening injuries result from blunt trauma rather than from penetrating injuries, which are much more common in adults. The most common causes of blunt trauma to children are: motor vehicle crashes when a child is either a pedestrian, bicycle rider, or automobile occupant; falls from windows or farm buildings and machinery; and house fires. Children die in motor vehicle crashes as a result of multiple systems injuries, of which the most serious is to the head.
Major blunt trauma to the abdomen frequently is associated with this series of injuries. This is a difficult injury to evaluate because often there are few signs of external damage to reflect the life-threatening trauma to internal abdominal organs. In addition, as noted previously, children commonly have associated head injuries and are unconscious at the time of evaluation, which makes early diagnosis and definitive treatment even more difficult, often resulting in disastrous delays in specific treatment.
The pathophysiology of blunt injuries to the abdomen results from energy transfer of compression and crush forces or from rapid deceleration/acceleration forces, which cause shearing stresses within the abdomen.
The identification of an abdominal mass in a child is a cause for concern because of the possibility of malignant disease. In addition, even benign conditions can be serious and warrant prompt evaluation and treatment. Although it is imperative that a child be referred quickly to the appropriate specialist (eg, pediatric oncologist, surgeon, nephrologist, gastroenterologist, gynecologist), evaluation by the pediatrician is of great value in deciding on initial management and in making the most appropriate referral.
The evaluation of a child with an abdominal mass involves a number of diagnostic considerations, and the possibilities considered depend to some extent on the age and sex of the patient, the location of the mass, and the presence or absence of other potentially related signs and symptoms, as well as features of the physical examination. Determination of the organ or tissue of origin of the mass can narrow down the diagnostic possibilities considerably. Thus, a completion of a careful history and physical examination, baseline laboratory studies, and limited diagnostic imaging studies can provide sufficient information to determine the diagnosis or to choose the appropriate subspecialist.
Some conditions that might produce an abdominal mass in a child are listed in Table 1 and are categorized by the organ of origin.
RAP is a broad descriptive term commonly used in pediatrics to define a heterogeneous group of patients who experience episodic attacks of abdominal pain over a period of at least 3 months. The majority of patients who seek medical attention for RAP have a functional disorder thought to be triggered by a motility or sensory disturbance of the GI tract provoked by a variety of physical and psychological stimuli. There are three distinct clinical presentations of functional abdominal pain in children and adolescents: periumbilical paroxysmal abdominal pain, dyspepsia, and irritable bowel. The medical history, physical examination, and selected laboratory, radiologic, and endoscopic evaluations allow a positive diagnosis of a functional disorder in each type of clinical presentation.
• A comprehensive review of the scientific literature reveals little evidence for the effectiveness of any specific herbal or nutritional product or the use of supplemental fiber for the treatment of RAP. • Although not the subject of this article, it should be mentioned that no evidence exists for the efficacy of any pharmaceutical product for RAP either, other than famotidine for treating dyspepsia (one small randomized, controlled trial) and pizotifen for the small subclass of children who suffer abdominal migraines (a smaller randomized, controlled trial). • There is no evidence in the literature for the effectiveness of any physical manipulations or methods in treating RAP in children. • Evidence is growing that supports the use of biobehavioral methods for the treatment of RAP. The most validated techniques are CBT and hypnotherapy, which is not surprising because RAP usually is functional. Functional refers to the cause not being organic, but rather due to a complex process that includes mind and body such as central sensitivity to pain, visceral hypersensitivity, autonomic dysfunction, and other factors still to be discovered. Mind-body or behavioral techniques help children return to normal daily activities, reinterpret their pain to lessen their suffering, and improve feelings of efficacy and self-worth. Specifically, guided imagery and hypnosis have been found to be highly effective in the treatment of nonorganic abdominal pain in children. • Much more research, perhaps combining biobehavioral techniques with other traditional and complementary/integrative methods, needs to be conducted for this common and often perplexing pediatric disorder.
1. Marshall Z. Schwartz
2. Donald B. Shaul
1. Professor, Dept of Surgery and Pediatrics, and Chief, Division of Pediatric Surgery, University of California—Davis, School of Medicine, Sacramento
2. Surgical resident, Dept of Surgery, University of California—Davis, Sacramento
The presence of an abdominal mass in the neonatal period is common, occurring in approximately 1 infant in 1000 live births. Despite this relatively high incidence, the finding of an abdominal mass in a neonate can be alarming for both parents and physicians. Until recently, the identification of an abdominal mass was made by physical signs (ie, abdominal distention, palpable mass). However, in the past decade, fetal ultrasound has become technically refined and is more widely practiced. As a result, the presence of an abdominal mass in the fetus may be known long before birth, allowing for the formation of a specific diagnosis and treatment plan. In addition to fetal ultrasonography, a wide array of sophisticated imaging techniques have become available to aid in the diagnosis of an abdominal mass. However, in the cost-conscious environment in which health care must be provided, it is the physician's responsibility to evaluate an abdominal mass as cost effectively as possible. Early consultation among the pediatrician, pediatric radiologist, pediatric surgeon, and, in the case of prenatal diagnosis, the obstetrician can expedite this process.
Many abdominal masses are of the nonsurgical variety (ie, organomegaly or bladder distention). Most masses requiring surgical intervention are benign (87%), and the prognosis for neonates with an abdominal mass is good.
1. Kelly M. Clayton, MD*
1. *University of Alabama, Birmingham, Ala.
When evaluating acute abdominal pain in children, the most important initial step is to perform a thorough history and physical examination. Only after, if necessary for diagnostic purposes, should specific laboratory and radiographic studies be obtained. Imaging can provide additional evidence to support a questionable diagnosis. A wide variety of abdominal imaging modalities is available to practitioners, although availability is highly dependent on the institution and local resources. We discuss the classic findings indicative of abdominal disorders found on plain radiography, ultrasonography (US), computed tomography (CT) scan, magnetic resonance imaging (MRI), and nuclear medicine studies.
Abdominal radiography often is a necessary preliminary study and is the most commonly requested study for a child complaining of abdominal pain. Its availability, lesser cost, and lower radiation exposure compared with other imaging modalities make it attractive. Abdominal radiography is highly sensitive (almost 100%) for diagnosing free intraperitoneal air and bowel obstruction. ( 1) It may detect abdominal calcifications and foreign body ingestions. Plain radiography for diagnosing intussusception is controversial due to a less than 50% accuracy rate. However, a right upper quadrant soft-tissue mass without right colonic gas is almost pathognomonic for intussusception. ( 2) Abdominal radiography should not be used to quantify the amount of stool, measure the liver size, or evaluate a child who has chronic vague abdominal pain. ( 3) It is important to remember that negative findings on abdominal radiography should prompt the physician to order additional, more specific studies when clinical suspicion is high.
Fluoroscopy is used with plain radiography to evaluate the pediatric abdomen. For example, upper gastrointestinal radiographic studies demonstrate both the anatomy and function of the esophagus, …
1. Chari D. Larsen, MD*
2. Marta A. King, MD, MEd†
1. *Pediatric Residency Program, University of Utah, Salt Lake City, UT.
2. †Department of Pediatrics, St Louis University School of Medicine, St Louis, MO.
A previously healthy 4-year-old boy presents to his pediatrician’s office with acute onset of abdominal pain and vomiting. Pain began suddenly the night before presentation. The pain is intermittent and severe, lasts a few seconds at a time, and prevents the child from sleeping. Nonbloody, nonbilious vomiting started approximately 3 hours after the onset of the pain. He has had more than 20 episodes of emesis and is unable to keep down fluids.
The family denies the patient had fevers, diarrhea, rashes, sick contacts, changes in diet, or recent travel. He has decreased urine output and decreased activity. The results of a review of systems are otherwise negative. The child has no significant medical or surgical history, has no known allergies, and takes no medications. The family history is unremarkable.
Vital signs are significant for tachycardia (heart rate, 130 beats per minute). Physical examination reveals a tired and non–toxic-appearing boy, who is fussy but easily consoled by his parents. He has slightly dry mucous membranes and an erythematous oropharynx without exudates. The abdomen is mildly distended, soft, diffusely tender, and without guarding or rebound tenderness. There is no organomegaly and no masses can be felt. Bowel sounds are …