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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
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ANSWERS
30.1 B. This patient’s BP falls within the definition of hypertension (it is not
normal, as answer A states) but outside the need for immediate pharmacologic intervention. The first treatment is to implement lifestyle modifications, such as the DASH diet and exercise. The AHA/ACC consensus
statement recommends that, if the patient has maximized lifestyle therapy
and her 10-year risk is > 10%, she should start antihypertensive medications
(answers C and D).
30.2 D. In the JNC 8 guidelines, calcium channel blockers, thiazides, ARBs and
ACE inhibitors are first-line treatments in nonblack patients over age 60.
In this case, beta-blockers (answer B) may worsen the depression. Thiazide
diuretics such as chlorthalidone may improve osteoporosis and reduce hypercalciuria, which can reduce nephrolithiasis. Nevertheless, both lisinopril
(answer A) and losartan (answer E) would be effective as first-line agents but
would not have the secondary goal of helping with the osteopenia. Answer C
(Amlodipine), a calcium channel blocking agent, may be considered a firstline agent as well and especially may be helpful in black patients; however,
calcium channel blocking agents again do not have a secondary added benefit
of helping with osteopenia.
30.3 C. Because of his diabetes, the BP goal for this patient is less than
140/90mm Hg. He is above the BP goal, so an ACE inhibitor or ARB is
first-line therapy regardless of BMI or hemoglobin A1c. The dose of the medication can be maximized if BP is not controlled after 1 month or another
agent can be added (answer D). A DASH diet (answer A) may be considered,
although a diabetic diet is likely more important; nevertheless, beginning
pharmacological therapy is important to prevent cardiovascular complications. Answer B (thiazide diuretic alone) is not preferable since these agents
would likely elevate the blood sugar.
30.4 C. The most common cause of hypertension is renal parenchymal disease, and
a urinalysis, urine culture, and renal ultrasonography should be ordered for
all children presenting with hypertension. Essential hypertension (answerA)
is rarely found in children less than 10 years of age and should be a diagnosis
of exclusion. Hyperthyroidism (answer B) or pheochromocytoma (answer E) is
possible in children but is more common in adults, and there are no findings
in the scenario suggesting either condition. A BP of 150 systolic in a child
is markedly elevated and outside of the range of white coat hypertension
(answer D).
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CLINICAL PEARLS
» Patients with BPs > 160/90 mm Hg will most likely need two or more
agents to achieve JNC 8 recommended control.
» Thiazide diuretics or calcium channel blockers should be the first-line
drug treatment in black patients with hypertension.
» Diuretics, calcium channel blockers, ACE inhibitors, or ARBs are the first-
line agents for nonblack patients. Choice of first-line medication can be
tailored to mitigate other comorbidities.
» Goal BP for patients greater than age 60 is < 150/90 mm Hg if they do not
have diabetes or kidney disease. Patients under the age of 60 or patients
of any age with diabetes and/or chronic kidney disease have a BP goal of
< 140/90 mm Hg.
» All patients with chronic kidney disease should have ACE inhibitors or
ARBs as first-line agents or add-on treatment.
» All patients with hypertension are at risk for cardiovascular and cerebro-
vascular disease. Be sure to address their other significant risks for these
diseases, including lipids, smoking, diabetes, and obesity.
REFERENCES
James P, Opani S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood
pressure in adults: report from the panel members appointed to the Eighth Joint National Committee
(JNC 8). JAMA. 2014;311(5):507-520.
Kotchen TA. Hypertensive vascular disease. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J,
Loscalzo J, eds. Harrison’s Principles of Internal Medicine., 20th ed. New York, NY: McGraw Hill;
2018: Chap. 298. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid
=79743947
Langan R, Jones, K. Common questions about the initial management of hypertension. Am Fam
Physician. 2015;91(3):172-177.
Riley M, Bluhm B. High blood pressure in children and adolescents. Am Fam Physician. 2012;
85(7):693-700.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/
AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation,
and management of high blood pressure in adults: a report of the American College of Cardiology/
American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;
71(6):e13-e115.
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CASE 31
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The mother of a 12-month-old infant boy calls at midnight stating that her son
has been crying incessantly for the last 6 hours. His bouts of crying last for about
20 minutes, then completely disappear for 15 minutes at a time. Since early
afternoon, the child has not been eating much, and he has started to vomit the
small amounts of juice and milk he had ingested. She decided to call you because
the vomitus is now green, and the bouts of crying seem to be getting worse. The
mother is advised to bring the child to the emergency department.
In the emergency department, you recall that the patient does not have any
significant past medical history, was born at term without complications, and is up
to date on immunizations. On examination, his temperature is 100°F (37.7°C), his
respiratory rate is 40 breaths/min, his pulse is 155 beats/min, his blood pressure
is 109/60 mm Hg, and his weight is 22 lb. He cries inconsolably for 15minutes,
drawing his legs up to his chest, and then becomes quiet. You notice he still
produces tears, and his mucosae are moist. Heart and lung examinations are
normal; abdominal examination reveals markedly decreased bowel sounds with
generalized tenderness to palpation. You feel a sausage-like mass in the right
side of the abdomen. His diaper holds some amount of bloody stool mixed with
mucus. The rest of the examination is normal.
▶ What is the most likely diagnosis?
▶ What is the next diagnostic step?
▶ What are the possible complications?
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ANSWERS TO CASE 31:
Abdominal Pain and Vomiting in a Child
Summary: A 12-month-old infant boy presents with
Sudden onset of intermittent crying that progressed with the day, each bout lasting
about 20 minutes
Vomiting that later became bilious
No signs of hypovolemia, sepsis, or shock
Generalized tenderness of the abdomen and a sausage-like mass on the right side
A small amount of bloody-mucus stool
Most likely diagnosis: Intestinal obstruction caused by intussusception.
Next diagnostic step: Abdominal plain x-rays to rule out perforation.
Possible complications: If perforation occurs, rapid deterioration as a consequence
of shock/sepsis.
ANALYSIS
Objectives
1. Be able to state the most likely causes of intestinal obstruction in the pediatric
population. (EPA 1, 2)
2. State the differentiating features between life-threatening abdominal emergencies and urgent conditions. (EPA 1, 10)
3. Explain the diagnostic approach to the pediatric patient presenting with
abdominal pain and vomiting. (EPA 3)
Considerations
This 12-month-old infant boy presented with vomiting and intermittent abdominal
pain. His vomitus was initially the gastric contents of what he had ingested, but
later became bilious, which is suggestive of intestinal obstruction. The description
of his abdominal pain reveals the pathophysiologic nature of intussusception. The
intermittency and “pain-free” intervals correlate with the gradual and slow telescoping of the intussusceptum (proximal or leading part of the intestine) into the intussuscipiens (distal or receiving end of the intestine). As the “telescoping” progresses,
the portions of bowel that are trapped within the lumen of the intestine become
edematous, which will ultimately lead to obstruction, ischemia, and perforation of
the bowel wall. The sausage-shaped mass felt on examination will not be present
in all cases. It represents the portions of bowel that are involved and have become
edematous. “Currant jelly” stools are basically a mixture of blood and mucus that
has sloughed from the affected bowel wall. While common, this is not present in
all cases.
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Before proceeding to diagnostics, the patient should be stabilized with intravenous fluid hydration, and surgery consultation should not be delayed. A nasogastric
tube may need to be placed if obstruction is suspected. A plain film of the abdomen
is done to rule out perforation. If perforation has occurred, surgical intervention is
required. If no perforation is evidenced, an ultrasound of the abdomen may reveal
a “target” lesion or “donut sign” that reflects the layers of intestine within the lumen
of a different portion of intestine. Fluoroscopic guided air contrast enema is the
first-line treatment and may be both diagnostic and therapeutic. The therapeutic
value of the enema is a result of the constant application of hydrostatic pressure
on the bowel, mechanically forcing it to telescope back. Air reduction may also be
achieved. Air reduction is effective in 75% to 90% of cases, after which a 12- to
24-hour observation period is needed until bowel function is adequate and a bowel
movement has been produced. The risk of recurrence in this patient with idiopathic intussusception is approximately 10%.
APPROACH TO:
Pediatric Abdominal Pain With Vomiting
DEFINITIONS
HYPERTROPHIC PYLORIC STENOSIS: Condition of hypertrophy of the
pylorus leading to gastric outlet obstruction, commonly manifesting in infants at
about 1 month of age.
INTUSSUSCEPTION: A telescoping of the intestine within itself, leading to
abdominal pain, fever, vomiting, and ultimately bowel necrosis if not resolved.
MALROTATION WITH VOLVULUS: Condition in which the small bowel
twists around the superior mesenteric artery and results in vascular compromise to
large portions of the midgut, commonly before 1 month of age.
CLINICAL APPROACH
Pathophysiology
The most important aspect of a diagnostic approach in these cases is to differentiate between emergent and nonemergent causes. Although the case presented is that
of the most common cause of intestinal obstruction in children, it is by no means
the only cause. Among the diagnoses that have to be entertained are hypertrophic
pyloric stenosis, malrotation with volvulus/obstruction, foreign-body ingestion, and
poisoning.
Intussusception
As described, intussusception will present with intermittent, severe abdominal
pain, associated with vomiting that becomes bilious as obstruction sets in. The finding of an elongated mass along the right abdomen is very suggestive of this diagnosis.
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This right-sided location occurs because most idiopathic intussusceptions occur at
the ileocecal junction; however, intussusceptions may be entirely in the jejunum,
between the jejunum and ileum, or entirely colonic. Currant jelly stool is most often
used to describe the finding in this condition, and it correlates with the ongoing
bowel ischemia as the intussusception and edema progress.
Hypertrophic Pyloric Stenosis
Hypertrophic pyloric stenosis is the most common cause of gastrointestinal (GI)
obstruction in infants. It occurs in approximately 3 in 1000 live births, with a male-
to-female ratio of 4:1. The usual presenting age is 3 to 6 weeks old and is often
described as a “hungry baby” with projectile vomiting. Vomiting is nonbilious and
occurs immediately after meals. The infant will demand to be refed immediately.
On examination, there may be an olive-shaped mass felt in the right upper quadrant,
and peristaltic waves may be seen across the upper abdomen moments before emesis
occurs. Ultrasonography shows the thickened pyloric muscles that are causing a
gastric outlet obstruction. An upper GI contrast study usually reveals an elongated
pyloric canal and a “double-track sign,” which is explained by two thin tracks of
barium that are created by compressed pyloric mucosa. Once the diagnosis is made,
surgical referral is indicated, as it is the definitive management. Because of the early
age and dramatic nature of the symptoms, parents will usually seek help before the
infant becomes severely ill from not eating.
Malrotation
Malrotation occurs in about 1 in 500 live births, but it becomes symptomatic in
only 1 in 6000 live births. Approximately 60% of patients will be younger than
1 month of age, with approximately 10% presenting after 1 year of age, even
into adulthood. Because it is primarily a defect that occurs during embryogenesis, the mesentery that is formed will have an abnormally narrow base, which
allows the small bowel to move more freely than normal. This creates a problem
when the intestinal attachment to the mesentery twists around itself, creating a
volvulus. Once obstruction occurs, the child will present with bilious vomiting
and abdominal pain.
If diagnosis is delayed, the involved segments of bowel will eventually become
necrotic, leading to fluid losses and sepsis. The diagnostic approach in such cases
will depend on the stability of the patient. If the patient is hemodynamically stable,
imaging may be performed to confirm the diagnosis. In 75% of patients, the diagnosis will be clearly seen on an upper GI series. Diagnostic findings on an upper GI
series are an obviously misplaced duodenum or a duodenal obstruction with the
classic “beak-like” appearance of the contrast medium caused by a volvulus. If the
patient is hypovolemic or hypotensive, has GI blood loss, or has signs of peritonitis, immediate surgical intervention is necessary, and surgery is the only definitive
treatment. Volvulus may recur in up to 8% of cases, even after surgical intervention. Malrotation can go undiagnosed if a patient never experiences symptoms, and
older children may present with intermittent vomiting, episodes of abdominal pain,
failure to thrive, or syndromes of malabsorption.
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Foreign Body Ingestion
Foreign body ingestion may also present with abdominal pain and vomiting in
a pediatric patient. Only 10% of patients who ingest a foreign body will need an
intervention, either to relieve an obstruction or to prevent GI complications.
Approximately 90% of patients will pass a foreign body spontaneously, and parents need only check the stool within 24 hours to confirm passage. Sometimes,
if an object can be seen on plain radiographs, a repeat x-ray within 24 hours
can be done. Among objects that require immediate intervention are flat disk, or
“button,” batteries in the esophagus. These batteries will conduct electricity when
both poles are in contact with the esophageal wall, which may lead to perforation. Sharp objects and multiple magnets also need to be removed. As a general
rule, any foreign body in the esophagus needs to be removed in less than 24 hours
by upper endoscopy. If a sharp or elongated object (> 6 cm) has already passed
through the stomach and duodenum, daily x-rays should be done to follow the
progress of the object. Those that do not advance within 3 days will require surgical intervention for removal.
Toxic Ingestion
Toxic ingestion must also be included in the differential diagnosis in the evaluation
of a child with vomiting and abdominal pain. Ingestion of over-the-counter analge-
sic drugs, cold remedies, insecticides, pesticides, personal care products, and fume
inhalation are commonly associated with hospital visits. Ingestion of nicotine or
insecticides may cause a cholinergic syndrome, characterized by salivation, lacrimation, diarrhea, vomiting, diaphoresis, intestinal cramps, and seizures. Antihistamines or tricyclic antidepressants produce anticholinergic symptoms, with dry
skin, dry mucosae, urinary retention, and decreased bowel sounds. Some medications and substances are radiopaque, such as iron tablets, mercury, lithium, tricyclic
antidepressants, Play-Doh, and enteric-coated aspirin. Finding the likely agent of
poisoning will mostly depend on the history given. Poison control should be consulted for all patients with suspected toxic ingestion.
Treatment
Initial management in all pediatric patients presenting with nausea and vomiting
should include assessment of volume status with appropriate supportive care and
stabilization. This should include appropriate intravenous fluid resuscitation when
necessary. In cases of intestinal obstruction, a nasogastric tube is recommended.
Surgical intervention will almost always be necessary if an anatomical/mechanical
defect of the GI tract is present.
CASE CORRELATION
See also Case 5 (Well-Child Care) and Case 17 (Electrolyte Disorders).
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COMPREHENSION QUESTIONS
Match the following etiologies (A-F) to the clinical vignette (31.1-31.6):
A. Malrotation with intermittent volvulus
B. Intussusception
C. Insecticide ingestion
D. Esophageal foreign body
E. Pyloric stenosis
F. Volvulus
31.1 A 6-year-old boy left alone for 10 hours, now with hematemesis and pneumo-
mediastinum on chest x-ray.
31.2 A 3-week-old male infant with 2 days of projectile, nonbilious vomiting, and
constant feeding.
31.3 A 7-year-old boy with three episodes of severe abdominal pain and vomiting
in the last month, previously diagnosed with failure to thrive.
31.4 An 8-month-old girl with bilious vomiting, constant abdominal pain for
12 hours, and upper GI study showing beak-like appearance of contrast.
31.5 An 11-month-old boy with sudden-onset intermittent bouts of crying, non-
bilious vomiting, and currant jelly stools. A small, elongated mass is felt on
the right side of his abdomen.
31.6 A 4-year-old girl with profuse vomiting, sweating, lacrimation, and diarrhea,
who seizes in the emergency department.
31.7 A 30-month-old girl is brought to your urgent care clinic with the acute onset
of diffuse abdominal pain that began approximately 6 hours ago. She has
also had two episodes of bilious emesis in the last hour. The parents report
decreased appetite earlier in the day but no fever, weight loss, diarrhea, or
bloody stools. On examination, the patient’s height and weight are in the
50thpercentile for age, blood pressure is normal, heart rate is 115 beats/min,
and temperature is 36.9°C (98.4 °F). Heart and lung examinations are
normal. On examination, the abdomen is significant for slightly hypoactive
bowel sounds and diffuse tenderness to palpation without rebound, guarding, or rigidity. A urine dip is unremarkable. Which one of the following is the
most appropriate next step for the abdominal pain in this patient?
A. Send home with antiemetics and oral rehydration solutions
B. Send to the emergency department for abdominal ultrasonography
C. Send to the emergency department for abdominal and pelvic computed
tomography (CT)
D. Send to the emergency department for an upper GI series
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ANSWERS
31.1 D. The presence of blood in the vomitus and a pneumomediastinum point to
an esophageal perforation, most likely from a foreign body in the esophagus.
31.2 E. The young age and presence of projectile, nonbilious vomiting after feeding
are the keys to this diagnosis. The diagnosis of pyloric stenosis is much more
common in males than females.
31.3 A. This is the presentation of a malrotation that did not cause enough symptoms at a younger age to lead to a diagnosis.
31.4 F. An infant with bilious vomiting and abdominal pain has a volvulus until
proven otherwise. The upper GI study is diagnostic of this condition.
31.5 B. The intermittent nature of the symptoms, currant jelly stool, and palpable
mass are highly suggestive of intussusception. The currant jelly stool especially is a classic finding.
31.6 C. These symptoms (hypermotility of intestines, increased sweating, and
lacrimation) are characteristic of a cholinergic syndrome, possibly caused by
insecticide or nicotine poisoning.
31.7 D. In young children with bilious emesis, anorexia, and lack of fever, the most
likely diagnosis is intestinal malrotation with volvulus. The child should be
sent to the emergency department for further evaluation. Abdominal ultrasonography (answer B) is less sensitive and specific for malrotation than an
upper GI series, so an upper GI series should be ordered initially if volvulus
is suspected. If appendicitis were suspected, ultrasonography would be preferred. CT (answer C) is not a good choice because of the amount of radiation it delivers, especially given efforts to decrease the use of CT in children
unless absolutely necessary.
CLINICAL PEARLS
» When a child appears critically ill, do not delay resuscitative efforts or sur-
gical consultation while waiting for laboratory tests and imaging results.
» Surgical intervention may be required for mechanical intestinal defects
such as intussusception, malrotation, and volvulus.
» For the pediatric patient presenting with abdominal pain, nausea, and
vomiting, the differential diagnosis should include intussusception, malrotation, volvulus, pyloric stenosis, foreign body ingestion, and toxic
ingestion.
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