Abdominal pain

W E L C O M E A L L

ABDOMINAL PAIN IN CHILDREN

At the end of this session you will learn

• Anything in abdomen can cause pain• Huge overcrowded abdomen has many c/of AP• Most RAP in children are functional• Alarm signs are clues to severe disease• Abdo. migraine may mimic ac. abdomen• RAP with positive MT is suggestive of Abdo. TB• Infantile colic is self-limiting

• ENT infx. is an important c/of ac. AP in children

AP: abdominal pain. RAP: rec. abdominal pain

Introduction

• Almost all children express AP: 5-7% of all ED visits• Most are functional: no anatomic, metabolic,

inflammatory, neoplastic cause. Need no tests• Familial illnesses, environment, parental attitude are

important predisposing factors for AP• Chr. and RAP overlap, ~synonymous

• Never miss medical and/or surgical emergencies

Functional AP (FAP): Clues

• Otherwise healthy/thriving• Good appetite, no NVD• Short episodes, environmental triggers• Periumbilical• Normal PE• FH of RAP/migraine• No tests to DD. Alarm SS justify further inv.

PE: physical examination. DD: differential Dx or differentiate. SS: symptoms and signsInv: investigate

Nature of abdominal pain

• Persistent: aching, burning, pressing, pricking, stabbing

• Colicky/spasmodic: muscle spasm. (coming and going)

• Pain may be diffuse, localized, referred• Mostly are non-surgical. Bilious V may suggest

obstruction/malrotation• Referred Pain: pain felt at another site, not site of origin

(subphrenic ab.: shoulder pain). Why? Somatic and visceral afferents enter the cord closely as of embryonological origin

V: vomiting

Visceral AP: dull, poorly localized, crampy, burning, biting (mechanical stretching or chemical irritation)

Parietal pain: parietal peritoneum. Sharp, well-localized

Generalized pain (felt “everywhere“ but may yet have a local c/): peritonitis, SCD, DKA, adrenal crisis, ac. intermittent porphyria, AGE, bloating/gas, IBS, IBD, obstruction, mesen. Ischemia/LAP, pregnancy

Abdominal migraine: paroxysmal central AP with features of migraine and ANV or pallor as well as FH of M

SCD: sickle cell disease. DKA: diabetic ketoacidosis. AGE: ac. Gastroenteritis. IBS: irritable bowel

syn, IBD: inflam. Bowel d. LAP: lymphadenopathy

Referred pain/reflective p, is felt at a site other than

the site of origin

Onset• Ac./Sudden: perforation, mesentaric infarction, ruptured

AA aneurysm, DKA, Addison D, MIAc. progressive: appendicitis, AGE

• Recurrent/chronic

SiteMay not be specific. Changes in site may mark progression• Diaphragmatic/GB pain may feel at shoulder• Appendicitis: McBurney’s point• Cholecystitis: Murphy’s point• Renal pain: loin to groin• Perforated ulcer: severe diffuse (peritonitis)

Upper abdomen:AGE, PUD, MIEarly appendicitisPancreatitis

Lower abdomen:Non-specificColicEarly appendicitis

Pelvis:ConstipationUTI, UB retentionPelvic appendicitis

Right sideBiliary, hepatitisappendicitisenteritis/IBDovarian

Left sideSpleen/EBVConstipationNon-specificOvarian

Site

Aggravating and Relieving factors

• Peritonitis worsened by movement: lie still• Fatty foods worsen biliary colic, pancreatitis• Eating relieves DU; worsens GU, mesen. ischemia

• Defecation relives colitis pain• No change in renal colic, MI, appendicitis, hepatitis,• Menstruation worsens PID, endometriosis

DU: duodenal ulcer. GU: gastric u. MI: myocardial infarction. PID: pelvic inflam. Ds.

Causes of Upper AP• Hepatitis/Ca/cholangitis/cholecystitis/duodenitis/ CHPS:

RC. Gallstones: R• Dyspepsia/ gastritis/Food P/PUD/ GERD/hiatal H: C • Pancreatitis/intestinal O/injury/mesen. Ischemia/NHL: CRLB• Extra abdominal: ENT infx./pericarditis: C

MI/ pleurisy: CRLB, Pn.- RLB, Pneumothorax- RL, thoracic A. aneurysm- LC

• Infantile colic

right, left, both, center, pelvic: R, L, B, C, PCHPS: cong. Hypertrophic p. stenosis

Lower AP

• Appendicitis- RC, Cancer- RLCP, Crohn's D- LC• Diverticulitis/inguinal H- RLB• Endometriosis- CRLBP, intestinal O.- RLC• Injury- RLBCP, Kidney Infx.- RL, - stones- RLBP• Ovulation/PID- RLCP, ovarian cysts- RL, preg.- CP,

salpingitis/ectopic P- RL, seminal vesiculitis- RLBP• Dysmenorrhea-C, endometriosis-~• Constipation-LC, anal fissure, polyp- P

The above list is incomplete

Look for specific signs

• Murphy’s sign • “Sausage”, Dance’s sign: retraction of the RIF (intussusception)• Rebound tenderness at McBurney, Rovsing’s, psoas sign,

obturator sign• Cecal “squish”• Hernia’s torsion

Extra-abdominal c/of Acute AP

• ENT infx.• Lower lobe pn.• MI• Addison D• DKA• A. migraine

• Sickle CD• Porphyria• Lead P• NAI• HS Purpura

NAI: non-accidental injury

Pointers for Surgery

• Peritonitis: F, distended board like silent abdomen• Obstruction: V, constipation, distension, high pitched BS

• GI bleeding: hematemesis, melena• Appendicitis: RIF pain, LGF, tachycardia, ANV. Rare <2y age

Operate NOW

• Perforated viscus, appendicitis• Vascular compromise: malrotation, volvulus,

incarcerated H, torsed gonads, non-reduced intussusception, ischemic bowel obstruction

• Uncontrolled intra-abdominal hge., ectopic preg.

Operate SOON• Intestinal obstruction, non-perforated appendicitis• Refractory IBD, tumors

No Early Surgical Referral

• Gastroenteritis • Infantile colic• Poisoning• Constipation • PUD, gastritis• Hepatitis

• Pancreatitis, mumps• Worms • Cholecystitis/cholangitis• UTI, NS, Urinary calculus • Dysmenorrhea

DD

Age: consider FAP in ages 4-18y• Ac. cholecystitis: RUQ pain R scapula, Murphy’s• Ac. appendicitis: ANV, periumbilical, settles in RLQ

in 6-8hrs, F, localized peritonitis, mass• Pancreatitis: upper AP, ANV, back pain• IBD: bloody stools, F, wt. loss, arthritis, uveitis• Ac. diverticulitis: mostly sigmoid colon, SS of

inflammation or obstruction. CT useful

FAP: functional AP

• Bowel Obstruction: 70% in adults are post-op. adhesions, incarcerated hernias. Bilious and fecal V distal obstruction. AXR

• Perforated DU: usually duodenal bulb, sudden ac. pain, peritonitis. AXR

• AAA: ac. tearing AP, tender mass in 90%, hypotension, pulsatile mass in 75%. Alert surgeons/anesthetist/theater

AXR: abdominal xray. AAA abdominal aortic aneurysm

• Ac. mesen. ischemia: pain with eating, abdo. bruits., ac. periumbilical AP disproportionate to physical SS– consider in AF, acidosis may herald it– surgery if acute vascular occlusion noted

• Others: endometriosis, salpingitis, tubo-ovarian abscess, ovarian cysts/torsion, ectopic P

http://www.med.mun.ca/anatomyts/radioanat/radiology/Pediatric%20Radiology/small%20bowel%20obstruction%20upright%20labelled.JPG

Rectal Polyp

Polyposis coli: polyps of various size along the entire colon

Peutz-Jeghers syn.: polyps in small bowel and oral pigmentation

Meckel's diverticulum

Investigations: Ac. AP

• Urine: glucose, protein, blood, ketone, CS• CBC, glucose, LFT, amylase, electrolytes• Sickling test for African child• AXR (erect and supine)• USG if needed

Infantile Colic

• 3 mo. colic. Cries >3h/d x >3d/w x >3w• Starts: at 2w in FT or later in preemie. Goes by 3-4mo.

Parenting may be v. stressful• No difference in sex, feeding nor in development• Exclude: otitis, UTI, GER; gut, CNS, heart, eye problem,

fracture, hernia, discomfort, insects

Causes• Not known. No single cause. Overfeeding, undiluted juices,

food allergies, aerophagy, separation stress can aggravate it. Others:– Intolerance of CM protein or lactose; GER– Air in tummy; gut muscles are often in spasm– Hypersensitivity to sound, light, etc.– Increased hormone levels

Rx

• Reassure. Burping. Keep upright after feeds. Change feed, hypoallergenic. Add lactase

• Mom to avoid caffeine, milk, certain vegetables and herbal• Change nipples of bottle • Swaddle your baby. Try massage• Put a warm water bottle on your baby's belly• Warm bath. Try an infant swing• Increase/decrease stimulation in the environmentMedications: No self-medication. Anti-reflux if GER. Anti-gas

drops. Diphenhydramine

Appendicitis

• Common. Progressive. Perforation rare on 1st d• Bacteria infect its wall. May be gangrenous, perforated• Commonest SS: AP, ANV, F, tenderness • Dx: clinical. TLC , DLC, urinalysis, AXR, USG, CT, laparoscopy• Complications: rupture, abscess, peritonitis. Variable

size, location, proximity of other organs may make it difficult Dx

• Rx: AB and surgery• DD: Meckel's D, PID, GB disease, perforation, diverticulitis,

kidney D, salphingitis, abdo. migraine

Pyloric Stenosis (CHPS)

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Cause is unknown. Associations:– Abnormal muscle innervations– Erythromycin in infant, hypergastrinemia

• 3/1000LB: more in whites• M:F= 6:1. Age: 1 w–5 mo (3-6 w)

SS: AP. Nonbilious V on feeding (91% projectile) usually in the 2nd week of age; hungry after V, wt loss, progressive jaundice in 5%(Indirect HB from low glucuronyl transferase)

Examination

• Abdominal distension• Olive mass – RUQ, after feeding

Gastric peristalsis L to R after feeding

Tests

• Low chloride, raised bicarb., BUN and creatinine, ± hypokalemia, ± raised indirect bilirubin

• Plain AXR:• Ultrasound:• Upper Gut Imaging:

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USG: pylorus >15-19mm, thickness >3-4mm, diameter >10-14mm. Shoulder sign: indentation of pylorus into stomach

Upper Gut Imaging

• String sign: pyloric spasm

Treatment

• Resuscitation first: IVF, K+; correct alkalosis (apnea with GA)

• Pyloromyotomy• Endoscopically-guided balloon dilation if surgery is

CI or incomplete pyloromyotomy

Postoperative: feed within 12-24 h (4 h in 1 study)• Vomiting is Not a reason to delay feeding

– GER: 80% post-op– UGI if vomiting persists > 5days

Pyloromyotomy

Intussusception

Invagination of intestine into itselfCause: idiopathic (75% ileocolic; ileoileal)Hyperplasia of Peyer patches in terminal ileumStructural: lymphoma, Meckel DSystemic: cystic F, HSP, Crohn’sM:F=3:2. Age: 3-9 mo (80% <age 2)

Pathophysiology

• Proximal bowel telescopes into distal segment

• Compression of mesenteric BV & lymphatics leads to edema, ischemia, mucosal hge., perforation, and peritonitis

Intussusception: distal small gut obstruction

Ileocolic intussusception

Massive fresh PR bleeding from Meckel's D

CF

• Intermittent, severe cramps with loud cry in curled up position in a previously healthy child

• Vomiting• Currant-jelly stool• Lethargy • Appear normal between attack• Sausage like mass

Mixture of blood and mucus, foul smelling: currant jelly

Tests

• AXR: plain & contrast or air enema (Dx and Rx)• Electrolyte imbalance• CBC: leukocytosis• Ultrasound• CT scan: only if other tests are negative

Contrast: between intussusceptum and intussuscipiens gives coil-spring appearanceUse water-soluble agent prior to barium if high risk of perforation suspected

USG: can Dx ileoileal I. and identify the lead point of intussusception in 2/3rd cases in which underlying pathology exists

Treatment

Air/contrast reduction– Air is better than Ba: less perforation (<1%)– Not very successful if SS >24–48h or with obstruction– Success: 75-90% with ileocolic type

Surgery• Indications: persistent filling defects, failed nonoperative

reduction, prolonged intussusception• Manual reduction and end-to-end anastomosis

Recurrence:• 10%. Not necessarily an indication for surgery

Reduction

Malrotation & Volvulus

• The gut starts as a straight tube. Midgut (distal duodenum-midtransverse C) elongates and protrudes in U cord and lies totally outside

• It rotates around SMA. Duodenum re-enters and get fixed to posterior wall, colon is directed to LUQ

• Then cecum rotates counterclock and lies in RLQ. The colon and mesen. root is fixed to posterior wall

• Such attachments provide a broad base of support to the mesentery and the SMA and prevent twisting

• Completed in 1st TM

Normal development

Midgut volvulus

Cecal volvulus Sigmoid volvulus

band

Cork-screw pattern – barium flowing through restricted bowel lumen

Pathophysiology : bowel O: bowel wall dilation increased secretionsFig. 1: normal, F2 obstruction. Always check for air in rectum

Midgut volvulus with rapid distension

CF

• Bilious V• Rapid abdominal distension

INV:• UGI: duodenum not crossing the midline• Barium enema: malposition of cecum

Rx: surgery

RECURRENT AP/CAP

• Very common. • Criteria: 3 episodes of pain/3mo; severe to affect activities• 90% functional• RAP should not be used as a synonym for FAP*

RAP/CAP is complex, multifactorial Parental anxiety in 1sty of a child: more CAP <6y age; also if

parent(s) have GI problems orphysical illness• 25-50% continue it into adulthood; or have IBS and other

unexplained SS or depression

Chronic AP: Alarm SS

• Wt. loss/FTT; stunting• GI bleeds• Significant V, abdo. distension• Chr. D• Unexplained F• Persistent RUQ/RLQ pain, away from umbilicus• Family H/ of IBD

The History

• Age, duration, site, type, severity, timing• F, V (bile, blood, projectile, timing)• D, constipation, melena, flatus. Food allergy• Aggravating and relieving factors• Genitourinary complaints• Travel, diet, contact history• Medications • H/ of abuse (NAI)

The Teenage Female

• Menstrual h/: regularity, LMP, character, dysmenorrhea• Pelvic/bimanual exam with CS• Pregnancy test/urinalysis• USG• Laparoscopy

DD: ovulation, PID, ovarian cyst/torsion, endometriosis, ectopic P, UTI, PN

Physical Examination

Aim• To confirm suspicions• To localize diseased area• To exclude extra-abdominal causes

Ensure: warm hands, room. DistractionExam from least to most painful areaUnhurried, thorough exam. Plan for serial exams

contd.

Inspection: appearance, activity, diaphoresis, pallor, pigment, agitation, intensity of pain

Palpation: guarding, mass, tenderness, rebound, organomegaly, distention, bruise, scars, hernias. See vitals

Percussion: liver size, tympany Auscultation: BS, pitch, bruits

contd.

• Mild tenderness AGE• Still patient, tender, rigid peritonitis (shake bed, deep

breath)• Agony colic, bowel obstruction• Think of lower lobe pneumonia, MI• Old and very young may present very atypically• Elderly, diabetic, immunocompromised may present with

minimal SS

Pelvic, Genital, PR, hernia for each pt. with severe APcontd.

Bloody Stool

• Newborn: ingested maternal blood, VKD, formula intolerance, NEC, volvulus, Hirschsprung

• Infants: Anal Fissure, colitis, Meckel’s, milk allergy, polyps, HUS, IBD, Intussusception

• 2-6 y: colitis, polyps, AF, Meckel’s, IBD, HSP• Older: IBD, colitis, polyps, hemorrhoids

Bloody Vomit

• Newborn: ingested maternal blood, drug, gastritis, DIC

• Infants: ulcers, gastritis, esophagitis• 2-6 y: ulcers, gastritis, esophagitis, varices, FB• 6 y and older: ulcers, gastritis, esophagitis, varices

Upper GI Hge

• Eesophageal varices, Mallory Weiss, esophagitis

• PUD, Tumor, NSAIDs, aorto-enteric fistula

Presentation• Hematemesis, melena• Hypovolemia, shock, anemia• Recent AP, NSAIDs

Investigation: RAP

Extensive work-up usually negative. Tests is NOT

REQUIRED in children without alarm SS

• CBC and DC, electrolytes

• Urinalysis, CS, renal function

• X-rays: AXR, KUB, CXR. MT

• USG, laparoscopy, CT

• Stool: OBT, ME, CS. LFT, pancreatic tests

• Pregnancy test in all women of reproductive age

Imaging

• Erect AXR: obstruction: air/fluid levels, dilated loops, air in the rectum, fecalith, paucity of air in the right side

• USG for biliary or pelvic symptoms • CT Abdomen and pelvis: evaluates vasculature,

inflammation and solid organs

Use of Laparoscopy

• Diagnosis– non-sp. AP– chr. AP– female patients– undescended testes– Trauma– Tb

• Treatment– appendicitis– Meckel diverticulum– cholecystitis– ovarian

detorsion/excision– lysis of adhesions

Rx of Chr. AP/RAP

• Reassurance: if no alarm SS• Peppermint oil is effective in IBS• Pizotifen for A. migraine. H2B if dyspepsia• Cognitive BT is effective to reduce pain• Not enough evidence that analgesic, sedative, anticolic, etc. are effective; nor extra fibre, lactose free food or lactobacillus

Parental factors rather than psychology of child predict the persistence or recurrence of AP

Continuous attention/suggestion/proxy causes more persistence of pain Recovery is usual if parents accept the Dx

Don’t focus on complete cure; rather on return to normal function

ABDOMINAL MIGRAINE in children

• Variant of migraine; HA unusual. Common• In 2% children. Girls more. Age: 2-10y• Cause is not clear. May have neurologic and

endocrine factors and may be c/by alterations in levels of serotonin and histamine

• FH of M (60%)• Triggers: chocolate/nitrite-containing foods, stress,

and anxiety

SS• Adult migraine: HA, sometimes preceded by aura. NV,

photophobia. AM is rare in adults• AM: central AP and can be severe, often periumbilical;

crampy, ~NV. Pallor is common. ~HA. Relieved by sleep and can last 1 h-several days. Often precipitated by usual triggers of classic M

Dx• Difficult to diagnose, especially during the first episode. no

specific test. Dx by exclusion. Lab and imaging to rule out other conditions

• EEG to rule out a seizure disorder

Treatment

• Aims: relieve ac. attack and prevent recurrence• No ideal single drug. Drugs for adult M are used:• NSAIDs/acetaminophen• Sumatriptan in older children• Tricyclic AD and drugs that block serotonin, ergotamine

have been used in some• Valproic a.; pizotifen

• Long term low dose aspirin and beta-blocker to reduce frequency

• Cyproheptadine is effective in some• IVF if V is severe along with sedatives or antiemetic• Avoid triggers. Avoid food triggers. Stress

management and relaxation programs benefit some

Prognosis• Good; most children grow out• 70% develop M in adulthood

Air under diaphragm: perforated viscus, biliary fistula, cholangitis, gas producing MO, portal pyema, post surgical, abortion, peritoneal dialysis, trauma

Most likely

Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusFree

intraperitoneal air

Most likely

Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusNormal bowel gas

pattern

Pneumobilia after passage of a gallstone. Take a good look at the liver where the biliary tract is outlined by air

Fecal impaction: large stool ball in rectum with proximal dilation. Consider this in elderly with U retention

MCQ

• Most RAP are functional• Most ac. AP in children are functional• Pancreatitis as a c/of ac. AP in children needs a surgical

referral

• Fever is an alarm sign• Peritonitis does not need early surgical referral• Gas under the dome of diaphragm always indicates

perforation

WELCOME ALL

Bronchiole: A tiny continuation of the bronchi and connects to the alveoli. Resp. bronchioles the final branches

A clinical scenario

• Age: 5mo, formula fed, UR catarrh (rhinitis, -/+ cough, LGF x3d) then sudden fast br., tachycardia, chest indrawing, wheezing. Still playful, ~normal feeding

What is the Dx?

BRONCHIOLITIS

At the end of this session you will learn

• Bronchiolitis is a very common viral (RSV) ARI• Infants are most commonly affected• Self-limited• Prognosis is excellent• Needs only supportive Rx: mostly no ABT• It is uncommon in breastfed babies• Can cause hyperactive airways

INTRODUCTION

Bronchiolitis: inflammation of bronchioleswith excessive mucus and bronchospasm

• Common c/of hospitalization• May be associated with significant MM• Can cause Hyperactive/Reactive Airway:

– Bronchospasm from allergy/hypersensitivity– Mostly temporary– Not synonymous with BA; but asthma-like syn.– May later become BA (child is old enough for bronchial

challenge test)

MICROBIOLOGY

• Typically viral– RSV: 80%– Influenza, parainfluenza A B C– Rhinovirus– Metapneumovirus– Coronavirus (SARS. MERS)– Bocavirus

• Occasionally M pneumoniae

RSVUbiquitous• Seasonal

– Temperate SH: May-Sep, peak May-July– ,, Northern H: Nov.- April, peak Jan-Feb– Tropical: rainy season

• 90% by 2y age have exposure

METAPNEUMOVIRUS• Paramyxovirus; may co-infect with other viruses• May cause pneumonia

PARAINFLUENZA: Usually type 3SH: southern hemisphere

INFLUENZA VIRUS• Very similar to RSV or parainf. v. in CF• Similar in distribution to RSV

BOCAVIRUS: May cause pertussis-like illness

RHINOVIRUS• >100 serotypes! Mainly ‘common cold’• Affects LRT in children with chr. LD• Often co-infects with other viruses

CORONAVIRUS• 2nd commonest c/of common cold• Non-SARS types cause bronchiolitis• SARS, MERS

EPIDEMIOLOGY

• Typically 3-9 mo– 60% <6 mo; 80% <1y. Not beyond 5y

• 60% of all LRTI in infants. 3% hospitalized

Incidence: 31/1,000 infants

RSV in admitted pts.• 40% of all LRTI in 1st y of life• 20% of all LRTI in 5 y ..

PATHOGENESIS

• IP: 2-8 days• Inflammation, cell necrosis, ciliary damage• Edema, mucus, sloughed epithelium: block• Peribronchial lymphocytic infiltration (cuffing)

FACTORS FOR SEVERE B.

• Preterm, LBW, age: <6w• BA, Chr. LD or anatomical defects of airways• Cardiac disease, kidney disease• Immunodeficiency

• ENVIRONMENTAL : Smoking active/passive, overcrowding, child care centre, high altitude

CLASSICAL PRESENTATION

• Starts as URT catarrh: rhinitis, -/+ cough, LGF: 1-3d then: – fast br., tachycardia, chest indrawing, wheezing

• Mostly mild. Full recovery: 2-8w• No recurrence. If any, look for HD, BA, CF, etc.

PHYSICAL SIGNS

• Tachypnea: cut-offs– <60d 60 bpm (Preterm 70)– 2mo-12mo 50 ,,– 1y- 5y 40 ,,

• Vesicular br. with prolonged expiration, diffuse wheezes and crackles

• ~Dehydration• ~conjunctivitis or AOM• ~cyanosis or apnea in young infants

S/of SEVERE DISEASEIndication of admission: average stay: 3 d

• Toxic look, dehydrated, apneic spells• RR: >70. O2 <90% on room air, nasal flare (pneumonia)• Age <3 mo. Atelectasis. Parent unable to home care• Poor feeding• CO2 trapping• S/o HF• 2y infx.

Apnea in bronchiolitis

• 20% of admitted RSV B: < 2-3 mo, prematurity• May be the presenting symptom• Recurrence rate 50% • Mortality < 2%

Dehydration in ARI

• Fever• Fast br.• Poor intake• Vomiting• Runny nose• Parenteral diarrhea

DIAGNOSIS: Clinical

• Based on: h/o and PE

• Supported by CXR

• hyperinflation, flat diaphragm, air bronchograms,

peribronchial cuffing, patchy infiltrates, atelectasis

Air trapping. Peribronchial cuffing due to wall thickening. Minimal focal atelectasis. Tubular heart. Flat low-set D

Peribronchial cuffing

DX: VIRAL ISOLATION

• Generally not warranted. It rarely affects Rx/outcomes – it may decrease AB use; may stop spread– may help guide antiviral Rx

• Nasal aspirate: Ag detection; EM; FAB tests; culture and PCR

OTHER TESTSMostly in complications

• CBC: 2y infx.• CRP: …• ABG to evaluate respiratory failure• CXR for pneumonia, heart disease

DD

• BA• Bronchitis/pneumonia• Chr. lung D• FB, GERD or aspiration• Cong. HD or HF• Vascular rings, bronchomalacia, complete tracheal rings or

other anamolies

COURSEDepends on co-morbidities. Usually self-limited

– wheezing may continue >1w– Anorexia and disturbed sleep may persist for 2-4w

TREATMENT: SUPPORTIVE CARE

• Clean airway with saline, correct dehydration• Antipyretics• Humidified O2. Mechanical ventilation for pCO2 > 55 or

apnea• Monitor:

– apnea, hypoxia– hydration, respiratory failure, HF

CHEST PHYSIOTHERAPY• Not recommended: no cl. improvement, nor reduces O2

need or shorten hospital stay• May increase distress and irritability

FLUID ADMINISTRATIONIVF in dehydrationMonitor for fluid overload as SIADH may occur

BRONCHODILATORS: Not recommendedConsider in severe wheezingAlbuterol/racemic epinephrine may work; but SE common: tachycardia, hypoxemia, tremor, constipation, insomnia, etc

Anticholinergics: No benefit

CORTICOSTERIODSNot recommended• May help in chr. LD or recurrent wheezing• Prednisone, dexamethasone• Inhaler: not helpful

RIBAVIRIN• Not routinely recommended• Very costly. May be useful in severe RSV• Must be used earlyANTIBIOTICS: No routine ABT. Used in 2y bacterial infx.

(positive culture, AOM, Consolidation on CXR)

NONSTANDARD THERAPIES

• Heliox– helium and O2 decreases breathing work– only small benefit in limited patients

• RSV-IG or Palivizumab– no improvement in routine cases

• Surfactant– may decrease duration of mechanical ventilation or ICU

stay

DISCHARGE CRITERIA

• Normal RR• Adequate feeding• No supplemental O2• Caretaker educated and confident; capable of bulb suctioning

PROGNOSIS: Excellent • MR <1% in admitted children• 80% deaths in infants

COMPLICATIONS

• Highest in high-risks• Apnea: in young infants• Respiratory failure: 15%• 2y bacterial infx. : 1%• Collapse, consolidation• Otitis media

PREVENTION

• Hand washing; avoid viral contact, smoking• New vaccine under trials• Hyperimmune Ig• MAB: palivizumab

– 55% less admission for preterm/chr. LD and 45% for cong. HD. Given monthly through RSV season

• Influenza vaccine

BRONCHIOLITIS AND B.A.

• RSV is a risk for recurrent wheeze (40%) and reduced FEV1 up to age 11y

• Association of RSV with later BA– may be a predisposition factor

Bronchiolitis obliterans (BO)• Or obliterative/constrictive B usually adenovirus.

Rare but fatal (irreversible): fibrosis +/or inflammation: block

B obliterans organizing pn. (BOOP) or cryptogenic organizing pn. (COP)

• Non-infx.; often in Rh A, or with amiodarone• CF and CXR show pn. But no response to ABT

Some interesting CX-Rays

CDH: Mainly the L side. Asymmetry of a hemidiaphragm or changing diaphragmatic levels. Gas-filled organs or a NGT within the chest confirm DX. confused in diaphragmatic paralysis or after lung reduction

surgery

CDH: Morgagni defect

Pneumoperitoneum: mostly perforation. Erect XR: air crescent under D. Sometimes, a double-wall, or Rigler's, sign can be seen which refers to internal and external air outlining the

intestinal wall

A tension PT: air under pressure: one-way valve. tracheal shift, hyperresonance and no BS, distended neck veins, hypoxia. affected lung collapses; widened IC spaces

Pneumomediastinum. Most commonly follows injury to esophagus/adjacent alveoli. CXR: free air may outline anatomic structures. Common findings are a thin line of radiolucency that outlines the cardiac outline, vertically oriented streaks of air in the mediastinum, a double bronchial wall sign, or lucency

around the right pulmonary artery, the "ring around the artery" sign. Air is most easily detected retrosternally on lateral CXR. Air is fixed in a pneumomediastinum and does not rise to the highest point

Airway FB, most often in children; the commonest site is R main B due to its being posterior, straighter, and wider. Indirect s/of

ingestion include focal overinflation with partial obstruction or collapse in complete obstruction. See a radiopaque object lodged in the R main

bronchus of a child

Aspiration pn.: aspirated flora or gastric contents. A. pneumonitis: from chemical insult. CXR: bilateral opacities in the middle or lower zones. Acute: infiltrates or lobar consolidation. Chr.: solidified mass

Rt. middle lobe collapse with obliteration of R heart border

A hydropneumothorax: esophageal rupture, trauma, gas-forming MO, bronchopleural fistula, surgery. See horizontal AF level

MCQs

• RSV is the commonest c/of bronchiolitis• ABT is usually required in B• Most B are later associated with BA• In EBF babies B is rare• Anticholingergic nebulization is beneficial in B• B is usually a killer D• SARS/MERS is caused by RSV• Antiviral Rx is beneficial in all B cases

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Abdominal pain

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