Abdominal Pain

(Everyones favorite!)
Laura Williams, MD MPH, PGY3
Morning report 5/11/2015

HPI
17 yo male with TOF s/p repair and psoriasis
Epigastric abdominal pain x 1 mo
Usually 1-2 hours after he eats

Vomiting episodes 2-3 times daily x 1 mo

Vomits several times over 1-2 hours
NB/NB, with whitish foam
Vomiting seems to be worse after eating

HPI
Decreased appetite x 1 mo
Thinks hes lost about 20 lbs

Bloating
Stooling daily or QOD, no diarrhea
Denies heartburn, reflux, chest pain
Has had some cough and intermittent fever

History contd
PMH:
TOF s/p repair as infant (has had multiple RV to PA conduit revisions,
bovine valve in pulmonary valve position in 2008)
Psoriasis dx in 2013: has been using clobetasol

Meds: ASA 81mg daily, clobetasol

PRNs: 1 excedrin almost daily, 1 aleve almost daily, pepto-bismol
several times a day

NKDA
Imms: UTD
Fam Hx: MGM, mother, brother, and cousin with cholecystectomy
Soc Hx: Lives with grandparents who are his guardians. Senior in
high school. Denies drug use.

Exam:
T: 38, HR: 100, BP: 99/45, RR: 24, SpO2: 99% RA
Weight 56 kg, Height 160 cm, BMI 21.9

GEN: awake, alert, oriented, interactive. Strikes you as somewhat

anxious.

HEENT: WNL
NECK: WNL
CV: RRR, III/VI systolic mid-high pitched murmur at LUSB, nml distal
pulses

RESP: WNL
ABD: TTP in epigastric region, soft, non-distended, no HSM
NEURO: WNL
SKIN: psoriasis worse on chest and back

DDx
GI
Functional dyspepsia
Delayed gastric emptying
GERD
Gastric/duodenal ulcer
Irritable bowel syndrome
Abdominal migraine
Inflammatory bowel disease
Cholecystitis
Pancreatitis
Celiac disease
Hepatitis

ID
Viral gastroenteritis
Post-viral ileus
Endocarditis

Onc
Solid tumor
Hepatic
Burkitt lymphoma
Soft tissue sarcoma

Leukemia/lymphoma w involvement of liver, spleen, or retroperitoneal lymph nodes

Urologic
Nephrolithiasis

Other
Lead poisoning
Porphyria
Functional/psych

Work Up
Outside EGD/colonoscopy reportedly normal
Outside HIDA scan with gallbladder disease?
CBC: wbc 15.9 (16B, 78N, 3L), hgb 11.6, hct 34.3, plt 132
CRP 8.9, ESR 25
CMP: WNL
Amylase 17, lipase<4
UA: 2+ ketones, 1+ protein
VRP negative

Blood culture from outside ED with GPCs

Pediatric Endocarditis
Epidemiology
Congenital heart disease 45-60% of IE have CHD
Indwelling CVC major risk factor for pediatric patients

Pathogenesis
Endocardial surface is injured by shear forces from
turbulent flow or indwelling catheter
Fibrin, platelets form non-infected thrombus
Transient bacteremia or fungemia results in
adherence
Subsequent fibrin, platelets from protective sheath
that isolates organisms from host defenses

Pediatric Endocarditis
Microbiology
Staph and Strep are most common organisms
Gram negative bacterial endocarditis is rare due to
poor ability of gram neg to adhere to endocardium
HACEK
Haemophilus aphrophilus (now called
Aggregatibacter aprophilus)
Aggregatibacter (used to be called Actinobacillus)

Cardiobacterium
Eikenella
Kingella

Pediatric Endocarditis
Modified Dukes Criteria
Pathologic Criteria (one of following two):
Direct evidence of endocarditis on histological
findings

Positive gram stain or culture of surgical/autopsy

specimen

Clinical Criteria
two major
one major and three minor
five minor

Infective endocarditis in
children.
See Modified Duke Criteria (Table B) in UpToDate titled article
above.

Endocarditis ppx
Recommended in:
Prosthetic valves/prosthetic material for valve repair
Prior history of IE
Unrepaired cyanotic heart disease (shunts and conduits)
Completely repaired hearts with prosthetic material during the first 6 mo after
procedure
Valvulopathy in a transplanted heart

NOT in
bicuspid aortic valve
acquired mitral or aortic valve disease (including mitral valve prolapse with
regurgitation)
hypertrophic cardiomyopathy

When
Dental procedures
Incision/biopsy of respiratory tract mucosa (T&A, bronch)

References
UpTpDate. Infective endocarditis in children.
UpToDate. Antimicrobial prophylaxis for bacterial
endocarditis.