Mark BromleyEmergency Medicine PGY-3

Overview

Cases Approach – Work-up Appendicitis

Dealing with surgeons Mesenteric Ischemia ABD films SBO

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Case

21 ♂ with ABD pain onset ~ 24h

Pain Peri-umbilical Escalating to 8/10

Fevers/Chills Emesis x 3 this AM

OE: 38.1 oC 16 85 122/81 ABD:

Diffuse peri-umbilical No Rebound/Guard

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Case

PMHx: WellPSHx: None

Meds: NilAllergies: NKDA

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Approach

Anatomic

Systems

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Work-up

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Case

Order your work-up Morphine 2.5-5mg IV for pain

Return in 1-2h Comfortable Pain – now in RLQ

Tender at McBurneys

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Appendicitis - Classic

Pain Vague peri-umbilical pain that localizes to

the RLQ (McBurney’s) …↑ over 12 to 24h period Pain lasting more than 36h is rare – or

perfed Febrile Anorexic Elevated WBC Rosvings, Psoas, Obturator

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Signs

Psoas sign With pt supine, flex hip against resistance

by pushing down against knee -- pain = +ve

Obturator sign Passively flex hip & knee and internally

rotate leg at the hip -- pain = +ve

Rosvings sign press down in LLQ then release suddenly -

pain = + ve

Differentiate into 3 groups

1. High suspicion for appendicitis – need for immediate surgery i.e. classic presentation

2. Intermediate suspicion for appendicitis – no clear-cut need to go to OR yet Atypical presentation

3. Low suspicion for appendicitis

Appendicitis

Expedient diagnosis Non-ruptured - - - - - - - - - - - Mortality

0.6% Ruptured - - - - - - - - - - - - - - Mortality

5%

…the blood was clotted …nurses are sure the lab dropped it

Surgeon wants a WBC before seeing11

Appendicitis – Role of WBC Methods:

prospective consecutive case series All patients presenting to the ED in whom the

diagnosis of appendicitis was the attending physician’s primary consideration

Patient temperature as taken in the ED, initial total WBC count, and discharge diagnosis.

Results: N=293 wbc > 10 (+LR) 1.59 (-LR) 0.46 wbc > 12 (+LR) 2.70

Fever > 37.2oC (+LR) 1.30 (-LR) 0.8212

Liklihood Ratio

likelihood ratio, is the ratio of the maximum probability of a result under two different hypotheses

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Probability of ↑WBC with Appy---------------------------------------- =

LRProbability of ↑WBC w/o Appy

Probability of ↑WBC with Appy____________________

Probability of ↑WBC w/o Appy

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Design: Random assignment of vignettes with different presentation formats of

diagnostic test accuracy. Setting:

Auditorium at a continuing medical education conference. Participants: 183 physicians. Intervention:

After estimating probabilities of 6 common illnesses described in patient vignettes, physicians

Results: post-test probability estimates deviated to a small and similar extent

from Bayes-based estimates in the groups informed by sensitivity and specificity or

likelihood ratios. An inexact numerical graphic led physicians to come closer to Bayes-

based estimates in the PE and chronic obstructive pulmonary COPD vignettes

some physicians estimated lower illness probabilities after a positive test result if it was accompanied by a low test accuracy value.

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Likelihood Ratios

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Odds and Probability

…only works with odds

I’ll give you twenty to one odds 20:1probability = 20/total (21) = 95% chance

Forty to sixty odds = 40:60 = 40/60 = 0.66

probability = 40/total (100) = 40% chance

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Likelihood Ratios

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Likelihood Ratio % chance this guy has an appy = 0.4

(40%) Convert that to odds (pretest) 0.4/0.6 = 4/6 = 2/3

(2/3) x 3 = 6/3 = 2 Convert back to probability (posttest) 2/3 = 0.67 (67%)

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Likelihood Ratios

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Likelihood Ratio

As a rule (+) LR > 10 (-) LR <0.1

…useful

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Case

Resident comes down and sees the patient

…hmm, didn’t do a rectal? Wow. hmmm….

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Appendicitis - Rectal

Why do we do a rectal exam? Should we do a rectal exam? Looking for other diagnoses

PR bleeding Peri-anal disease Mass in the vault

Does everyone need a rectal?

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Patients and Methods: 100 consecutive adults admitted to the emergency surgical unit with

acute abdominal pain Following DRE, patients completed an anonymous questionnaire The house officer conducted the rectal examination at admission and also

completed an evaluation sheet

Results: A working diagnosis of acute appendicitis in 38 patients and

gastroduodenal, pancreatobiliary pathology in 24 patients was made DRE did not alter clinical diagnosis or initial management in any patients Routine DRE did not detect any unrelated pathology 93 wanted to know why rectal examination was required 78 patients rated the DRE as uncomfortable 43 were willing for DRE as a routine 54 patients preferred to have the DRE at the time of other bowel tests

rather than at emergency admission

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Patients 1204 consecutive patients admitted to hospital with RLQ pain 1028 had a rectal examination on admission Main outcome measures - Odds ratio for each symptom and sign related to final diagnosis Results of multiple logistic regression analysis for acute appendicitis

Results Right sided rectal tenderness (odds ratio 1.34, p<005) RLQ tenderness (odds ratio 5.09) Rebound tenderness (3.34) Guarding (3.07) Muscular rigidity in the abdomen (5.03)

In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance

Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis.

No other unexpected diagnoses were established, and no useful additional

Conclusion If patients presenting with pain in the RLQ of the abdomen are tested for rebound

tenderness then rectal examination does not give any further diagnostic information

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Case

The resident agrees – this sure looks like appendicitis.

But the boss would like some imaging.

…thoughts?

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Ultrasound (Graded Compression) Test Characteristics

Sensitivity 75-90%, Specificity 86-100% Pros

No radiation, safe in kids, pregnant pts Can identify alternate Dx esp. in female pts

Cons Difficult for us to get Operator-dependant Limited in obese pts or with ↑ bowel gas Identifies alternate Dx less often than CT Painful

CT scan

Test characteristics Sensitivity 90-100%, specificity 91-99%

Pros Identifies alternate Dx more often than U/S Fast & accessible in our practice setting

Cons Radiation dose (~100 CXR’s) Delay time to surgery Multiple techniques in literature: controversial

as to which is best but all ~90-100% sensitive Less accurate in pts w/ little intraabdominal fat

CT vs U/S

2 prospective RCT’s of U/S vs CT CT more sensitive & specific than U/S

94-97% sensitive vs. 76 – 100% for U/S 100% specificity vs. 76-90% for U/S

More alternate Dx identified by CT

Horton et al. Am J Surg 2000; 179: 379-81Walker et al. Am J Surg 2000; 180: 450-55

CT vs U/SMethods: 120 consecutive pts 8-81 yo w/ ?appy who

were too well to go to OR but too ill to simply D/C

Did focused CT w/ rectal contrast & U/S w/in 1 hr

Gold standard - pathology or clinical f/u x 6m

Results: CT: 95% sensitive, 89% specific U/S: 87% sensitive, 74% specific CT identified 14 alternate Dx vs. 9 for U/S U/S missed 2/3 of pts w/ perforation

*Pickuth et al. Suspected acute appendicitis: Is ultrasonography or computed tomography the preferred imaging technique? Eur J Surg. 2000; 166: 315-19

Does imaging change mgmt? 2 studies of CT in pts w/ ? appendicitis

comparing Tx plan before & after access to results of scans

Results: CT changed disposition in 27 – 59% of pts Prevented d/c of ~3% pts w/ appendicitis Prevented negative laparotomy in 3-13% Alternate Dx in 11-20%

…yesFrank et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med 2002; 23: 1-7

Rao et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Eng J Med. 1998; 338: 141-6

Bottom line

Group 1 Appendectomy regardless of imaging

result Group 2

Image Group 3

Clearly instructed when to return for re-evaluation

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Appendicitis - Mgmt

Hydration Antibiotics

Ancef/Flagyl (surgical wound) Fluroquinalone/Flagyl (gram(-) rods /

anaerobes) Surgery

Case

65 ♂ with ABD pain

Diffuse ABD pain 8/10 Rapid onset Opiod resistant

N/V/D Watery stools x 3

OE: 104 20 145/67 37.2 ABD: Diffuse tenderness - no rebound/guard Rectal: Normal (-) FOB

PMHx: HTN/DMII/smoke/AFIB/MI x3

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Approach

Differential

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Ischemic bowel - etiology Embolic

LA LV Cardiac Valves

SMA is most susceptible to embolism Multiple emboli Concomitant vasoconstriction occurs

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Ischemic bowel - etiologyThrombotic Arterial

Acute event Chronic intestinal ischemia from progressive

atherosclerosis Involves multiple vessels

Venous venous thrombosis →mesenteric venous flow → bowel wall

edema, fluid efflux into lumen ↓BP ↑ blood viscosity

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Risk FactorsHypercoagulable states Portal hypertensionAbdominal infections Blunt abdominal trauma PancreatitisSplenectomyMalignancy in the portal region

Ischemic bowel - etiology Non-occlusive etiology

systemic illness → systemic shock → ↓CO

cocaine → vasospasm Venous thrombosis → ↓ venous return →

interstitial swelling of bowel wall → ↓ arterial flow

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Mesenteric Ischemia – clinical ABD pain

rapid onset severe out of proportion to exam

N/V/D forceful bowel evacuation

Risk factors AFIB CHF peripheral vascular disease hypercoagulability

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Ischemic bowel - diagnostics Labs (non-specific)

Lactate WBC INR/PTT

Imaging Plain films (nonspecific late findings – not

useful) Thumbprinting Pneumatosis intestinalis Portal venous gas

CT Angiography

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CT scan

sensitivity 64-100% specificity 89-94%

Evidence of ischemia in bowel wall & mesentery

Evidence of clot in SMA First investigation done routinely here

If suspect mesenteric ischemia let radiology know

Good but not good enough If CT is negative & high pre-test probability

you need an angiogram

Ultrasound

Doppler can determine major obstruction to flow in venous & arterial systems Dilated, tubular vessels with echogenic material (clot) Abnormal flow

Limitations Studied primarily in venous thrombosis & chronic

mesenteric ischemia Unsure how it performs for acute mesenteric ischemia Only good for more proximal blockages Has limitations inherent to all U/S exams

Angiography

Gold standard (~90% sens) Diagnostic and therapeutic

Infuse vasodilators into SMA (papaverine) Angioplasty

Drawbacks Time-consuming Risks of contrast & invasive procedure Expensive

Angiography: Early vs Late Angiography → early in pts w/o peritonitis & ↑

suspicion Can buy time (papaverine) Can aid in surgical decision making

Surgical: embolectomy, thrombectomy, endarterectomy, bypass graft

Non-surgical: angioplasty

Early (before peritonitis) angio & intervention ↓ mortality 70-90% → 10%

Down side: ↑ negative angios Associated risks & costs

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Angiography: When to say no Contraindications:

1. Unstable hypotensive pts on vasopressors

Difficult to differentiate b/w occlusive & non-occlusive etiologies

Can’t infuse vasodilators

2. Pts w/ peritonitis Delays surgery

Case

32 ♀ with nausea and vomiting Abdominal pain

periumbilical and crampy paroxysms of pain q 4-5 min abdominal distension

Vomiting q 30 min BM none x 48h

PMHx Crohns – dx in 1997 - resection 2002, 2007

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Crohn’s

Extra-intestinal manifestations Skin manifestations

erythema nodosum, pyoderma gangrenosum

Peripheral arthritis (asymmetric involvement of larger joints)

Ankylosing spondylitis and sacroiliitis Aphthous ulcers Ocular manifestations (eg, episcleritis, recurrent

iritis, uveitis) Amyloidosis and thromboembolic manifestations Liver

elevation of enzyme levels Cholangitis Autoimmune chronic active hepatitis, and cirrhosis

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Comparisons of Crohn's and UC

Crohn's Ulcerative colitis

Terminal ileum involved Commonly Seldom Colon involvement sually Always Rectum involvement Seldom Usually Peri-anal disease Common Seldom Bile duct involvement No ↑ in PSC Higher rate Distribution of Disease Patchy (Skip lesions) ContinuousEndoscopy Deep geographic ulcers

Continuous ulcer Depth of inflammation May be transmural Shallow,

mucosal Fistulae Common Seldom Stenosis Common Seldom Surgical cure Often Cured by

colectomy Smoking risk for smokers ↓risk for smokers

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Complications of Crohn’s

Perforation Fistula Adhesions - obstruction Deficiency / Malabsorption

Protein Vitamins

Abscess Megacolon Steroids

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Abdominal Films

What are they good for?

Rule out Obstruction Perforation Foreign Body

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Obstruction

Small Bowel 1. Distended loops of bowel proximal to

obstruction Intramural width > 3cm

2. Multiple intra-luminal air fluid levels more distal obstruction → more gas-fluid levels

3. Discrepancy b/w bowel size proximal/distal to obstruction

4. Obstruction →→ Intramural gas 2o to ischemia

This is a late poor prognostic sign

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Case

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MATERIALS AND METHODS. A blinded retrospective analysis was done on 78 pts

who underwent plain abdominal radiography, CT, and enteroclysis to assess for suspected SBO.

The findings at enteroclysis and the clinical outcomes were used as standards of reference.

RESULTS Plain film radiography for SBO sens: 69% (44/64)

specificity 57% (8/14). Overall accuracy of plain film radiography was 67%

(52178).

CT sensitivity 64% (41/64) and specificity 79% ( I 1/ 14)

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Abdominal Films

What are they good for?

Rule out Obstruction Perforation Foreign Body

Skip Films59

Abdominal Films - FB

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Abdominal Films - FB

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Abdominal Films

What are they good for?

Rule out Obstruction Perforation Foreign Body

Skip Films62

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Air may be trapped anteriorly in the cupola of the diaphragm

permitting visualisation of the undersurface of the central portion of the diaphragm

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Crescent sign

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Double Wall sign Gas-relief sign Air is present on both sides of the intestine

(usually requires > 1L of free air)

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Rigler’s sign

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Supine

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Supine FilmsSupine Films

69supine

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Supine FilmsSupine FilmsSupine FilmsSupine Films

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Supine Films

Double Blind Retrospective Supine films from 44 cases of pneumoperitoneum

were randomly interspersed among supine films from 87 control subjects without free air

One or more of these signs were present (59%) Right-upper-quadrant gas sign (41%) Rigler's sign (32%) Falciform ligament and football signs (2%)

11 false-positive cases (13%)

SBO - case

32 ♀ with nausea and vomiting Abdominal pain

periumbilical and crampy paroxysms of pain q 4-5 min abdominal distension

Vomiting q 30 min BM none x 48h

PMHx Crohns – dx in 1997 - resection 2002, 2007

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SBO - pathophysiology

Swallowed air and gas from bacterial fermentation accumulates

Bacterial overgrowth occurs in the proximal small bowel the contents of which are normally nearly sterile emesis can become feculent due to bacterial overgrowth

The bowel wall becomes oedematous Normal absorptive function is lost Fluid is sequestered in the bowel lumen ↑ secretion of fluid into the lumen of the proximal bowel ↑ transudative loss of fluid into the peritoneal cavity

Dehydration → tachycardia, oliguria, azotemia, and hypotension

Emesis → loss of Na, K, H, and Cl

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SBO - Treatment

Degree of dehydration Need for surgery – timing of surgery

Partial vs Complete “…never let the sun rise or set on a

SBO!"

IV access – fluid resuscitation Non-operative

NG tube76

Case

42 female presents with diarrhea PMHx

Dental Surgery 2 weeks ago Recent travel to mountains ?questionable

water

Diarrhea Onset ~ 4-5 days ago Large volume – watery Tried some immodium - ?helped a little

No N/V ABD pain

Diffuse generalized abdominal pain77

Thoughts? Differential? Work-up?

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C. difficile 1978 C. difficile identified as the causative pathogen Implicated Abx

Clindamycin Penicillins Cephalosporins

Any antibiotic can predispose to C. diff colonization Risk Factors

Abx Broad spectrum Abx Multiple Abx Increased duration

Advanced Age Gastric Acid Suppression

Protective Factors Neonates

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C. Difficile pathogenesis

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C. Difficile - presentation

Typical Watery diarrhea

Onset durring Abx course or 10-15d post Abd cramping Fever (low grade) Leukocytosis OE: Abd tenderness Colonoscopy:

patchy erythema → pseudomembranous colitis

Atypical Protein losing enteropathy Involvement in IBD Extra colonic involvement

C. Difficile - treatment

IV, O2, Monitor Fluid resuscitation Discontinue antibiotics

∆ to less associated abx Infection control – contact precaution Avoid opiates / loperimide Metonidazole Vancomycin (PO)

Probiotics Intermittent therapy

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Case

Pt is admitted under hospitalist (capped) You see the patient 3 handovers later

Diarrhea has slowed Abd distension Altered sensoriumOE:

Vitals: 120 107/42 19 38.1 Distended tender lower ABD No peritoneal signs

Toxic Megacolon - Diagnosis

Radiographic dilation of colon (>6cm)

PLUS 3 of: Fever > 38 HR > 120 WBC > 10.5 Anemia

PLUS 1 of: Dehydration Altered Sensorium Hypotension Electrolyte disturbances

Toxic Megacolon – pathophysiology Nitric Oxide → generated by

macrophages/inflamed smooth muscle → inhibitor of smooth muscle tone

Inflammation Extension → paralyzes smooth muscle

Toxic Megacolon - Treatment

Goals: Reduce colitis severity Restore colonic motility Decrease likelihood of perforation

Medical Mgmt Bowel Rest / NG decompression D/C anti-motility agents

Opiates, Anticholinergics Abx ?Steroids

Surgical Mgmt Colectomy

Thank you!

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Incarcerated Hernia - Case 52 ♂ with pain, edema → scrotum nausea, vomiting, and low-grade

fever

…if you listen bowel sounds in the scrotal sac

inguinal mass can be palpated separately from the testes

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Incarcerated Hernia - Mgmt Trendelenburg posn with an ice to the groin Sedation Slow, gentle pressure to reduce the hernia

If the hernia cannot be reduced or strangulation is suspected (fever, overlying cellulitis, peritonitis) fluid resuscitation broadspectrum Abx emergent surgical consultation

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Hernia (non-incarcerated) Patients who have a hernia on

routine exam or

who have had the hernia reduced and are without symptoms of incarceration or strangulation

Refer for out pt surgical repair

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Hernia - Peds

Fun Facts Inguinal hernias occur ~ 10-20/1000 live births Prematurity and low birth weight ↑ risk ♂:♀ 4:1 → ↑ ♀ incarceration Most common indication for surgery < 2 yrs

Presentation Abdominal or inguinal pain, an inguinal or scrotal mass, nausea,

vomiting, and low grade fever

Mgmt Attempt reduction if the child appears well Analgesia, sedation Trendelenburg position Slow gentle pressure

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Diverticulitis - case

65 ♂ presents with bloating and LLQ pain Stool:

↓ freq no change in caliber/consistency

OE: 37.5 87 135/24 18 ABD: soft tender LLQ. No rebound/guard Rectal: FOB positive

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Hb: 146 WBC: 10.6 Urine: clean Bili/ALT/ALP/Lipase: N

Imaging CT Barium Enema / Non-contrast Enema US Endoscopy Plain Films

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CT scan: Evaluates the colon and surrounding

structures Diagnose diverticulitis Evaluate the extent of the disease

Peri-colonic fat Thickening of bowel wall > 4mm Free air Abscess

Guide perc drainage Our guy:

Multiple diverticuli Local inflammation

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Diverticulitis

Colon is penetrated by vasa recta (vessels)

Site of penetration is weak Diverticula form 2o to ↑ itracolonic

pressure

Assymptomatic Obstructed → inflammation → microperf

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Diverticulitis

Uncomplicated Peri-colonic fat inflamation

Complicated Fistula Abscess Adjacent obstruction → mass effect

(abscess)

→ stricture

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Diverticulitis – Mgmtuncomplicated Oral Abx x 7-10 days*

Septra DS BID and flagyl 500 mg q6h    Cipro 500 mg BID and flagyl 500 mg q6h    Amoxicillin/clavulanate 500/125 mg TID

Diet Liquid High-fiber (↓ recurrence)

Pain NSAIDs / opiods

Admission Unable to tolerate PO Poor social support / compliance / Follow-up

*Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA (eds): The Sanford Guide to Antimicrobial Therapy, 34th ed. Hyde Park, Vt, Antimicrobial Therapy, Inc, 2004.

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Diverticulitis – MgmtComplicated IV Abx*

Mild to Moderate Infection Ticarcillin/clavulanate 3.1 gm IV q6h    Ampicillin/sulbactam 3 g IV q6h    Ciprofloxacin 400 mg IV q6h and flagyl 500 mg IV q6h

Severe Infection Ampicillin, 2 g IV q 6 hr, and metronidazole, 500 mg IV q 6 hr, and

gentamicin, 7 mg/kg q 24 hr, or ciprofloxacin, 400 mg IV q 12 hr    Trovafloxacin, 300 mg IV once a day    Imipenem, 500 mg IV q 6 hr

NPO – bowel rest Surgical Mgmt

Peritonitis Perforation Sepsis resistant to medical mgmt Fistula Strictures

*Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA (eds): The Sanford Guide to Antimicrobial Therapy, 34th ed. Hyde Park, Vt, Antimicrobial Therapy, Inc, 2004.

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Pediatric Issues

NEC - Case

HPI: 10 day ♂ presents with feeding intolerance and bloody stools Mom also notes abdominal distension, lethargy the bedside nurse notes a decrease in the infant activity level

and temperature instability

PMHx: Ex-36 wk 3 days in SCN - uneventful Some ongoing difficulties with feeding / wt gain – formula fed

OE: 160 60/42 50 35oC Decreased tone – slip through Mottled ABD: distended and tender

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NEC

Most common GI emergency in the neonates

Acute fulminant dz associated with ulceration and necrosis of the distal small intestine and colon

Pathophysiology – poorly understood Infectious – nursery epidemics Prematurity - ↓ after 36wks Enteral alimentation- ↑ metabolic demand Inflamatory mediators -

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NEC - Diagnosis

Radiology Pneumatosis intestinalis Portal venous air Pneumoperitoneum Non-specific

localized dilated loop of bowel thickened loops gasless abdomen

Labs Thrombocytopenia Leukocytosis Electrolyte imbalance Metabolic acidosis Hypoxia or hypercapnia

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NEC - Mgmt

1. Early bowel decompression by NG suction

2. Prompt IV Abx therapy Ampicillin Gentamycin Anaerobic bacterial coverage (clindamycin)

3. Maintain volume/ mesenteric perfusion. NEC is associated with third spacing of fluid into the mesentery Intra-vascular volume supplementation is required to maintain mesenteric

perfusion Follow perfusion of the extremities and urine output (1-2 ml/kg/hour)

4. Except in the milder cases, because of respiratory failure and worsening acidosis, intubation mechanical ventilation is often necessary

5. Pain control is essential → extremely painful disease6. Surgical consultation7. ICU consultation

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Intussusception - case

Hx: 13 month ♀ with profound lethargy A bit snot nosed last week but mom thought she was doing better Earlier today she was quite irritable and was noted to bring her

legs up to her ABD

PMHx - well

OE: AVSS Afeb Child is lethargic ABD distended

Diffuse poorly localized tenderness Not firm

Rectal FOB (-)

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Ultrasound98-100% sensitivity90-100% specificity100% negative predictive value

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Intussusception

lead point causes telescoping of one segment of intestine into another

Edema develops and obstructs venous return

Ischemia of the bowel wall

peritoneal irritation → perforation

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Intussusception - presentation Classic Triad (~30%)1.Abdominal pain2.Vomiting3.Bloody stools

Drawing the legs up to the abdomen Profound lethargy

Dance’s Sign - a sausage-like mass in the RUQ and an empty space in the RLQ representing the displaced cecum

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Intussusception - Mgmt

IV fluids 20 mL/kg NS bolus Repeat PRN

NPO NG tube decompression Ill-appearing or febrile children → ABx

1. Ampicillin 2. Gentamicin3. Clindamycin or metronidazole

Air or hydrostatic barium enema

Surgical intervention if… reduction is unsuccessful perforation occurs

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60 ♂ with DM presenting with back pain 32 ♀ with RLQ pain 5 month ♀ with “colic”

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Which pairing correctly matches the radiological finding with the cause of abdominal pain in infants?

A. Volvulus: Double-bubble sign with associated dilatation and increased gas pattern distal to the volvulus

B. NEC: Asymmetric pattern of gas with dilatation early in the course of illness and subsequent air in bowel wall (pneumatosis intestinalis)

C. HPS: String and pearls sign is seen with a barium upper GI series

D. Intussusception: Proximal colonic dilatation and distal narrowing in barium study

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The most common GI emergency in the neonatal period is necrotizing enterocolitis.

A. TrueB. False

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Diffuse abdominal pain occurs in all of the following except:

A. sickle cell crisis.B. inflammatory bowel disease.C. inguinal hernia.D. diabetic ketoacidosis.

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Which of the following statements is true regarding intussusception?

A. The condition is more common in females.

B. It is the most common cause of intestinal obstruction in children younger than 2 years.

C. Most commonly, the intussusception is ileoileal.

D. Plain films are reliable in diagnosis.122

Which of the following statements is true of hernias in children?

A. Prematurity and low birth weight increase the risk.

B. They are more common on the left side.

C. They occur more in females.D. Males incarcerate more often.

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Which of the following is/are non-abdominal cause(s) of abdominal pain?

A. Lead poisoningB. Black widow spider biteC. Diabetic ketoacidosisD. Sickle cell pain crisisE. All of the above

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