Give three (3) differential diagnoses.
DISCUSSION BOARD 3
1. Give three (3) differential diagnoses. (Explain how you ruled in and ruled out each differential diagnosis
Gastroenteritis involves mild to severe diarrhea, appetite loss, nausea, vomiting, cramps, and abdominal discomfort. (Gotfried, J. 2023). In this case, the patient has no vomiting, diarrhea, or fever, which are all classic symptoms of gastroenteritis. The absence of these symptoms makes gastroenteritis less likely as the primary diagnosis. Furthermore, the child’s sudden onset of severe abdominal pain, as well as the pattern of episodes followed by relief are not characteristic of gastroenteritis.
Urinary Tract Infection (UTI) is a potential differential diagnosis for this case due to factors such as irritability, discomfort, nonspecific symptoms, abdominal pain and absence of other symptoms. UTIs can cause general dscomfort and irritability in young children, especially when the infection affects the bladder or urethra (Leung, A. 2019). They may not always present with classic symptoms like pain or burning during urination, but may exhibit more nonspecific symptoms like fussiness and irritability. Lower abdominal pain may align with the child’s symptoms of episodic pain and leg drawing.
Appendicitis is inflammation of the vermiform appendix, presenting acutely within 24 hours or as a chronic condition (Jones, M., Deppen, J. 2023). It is the most common cause of emergency abdominal surgery in children. Though it can happen at nay age, appendicitis occurs mmore frequently in school aged children and rarely occurs under the age of 1. Appendicitis is characterized by abdominal pain, fever, nausea, vomiting, and appetite loss, and commonly affects the lower right abdomen and the umbilicus. While stomach discomfort is a common indication of appendicitis, the location and type of the pain, as well as the absence of fever, vomiting, and appetite loss, reduce the likelihood of appendicitis in this case.
Intussusception. The first sign of intussusception in an otherwise healthy child maybe sudden, loud crying caused by belly pain. Children who have belly pain may pull their chests when they cry. The pain of intussusception comes and goes, usually every 15 to 20 minutes at first. These painful episodes last longer and happen more often as time passes. Other symptoms of intussusception include: stool mixed with blood- sometimes referred to as currant jelly stool because of its appearance, vomiting, a lump in the belly, weakness or lack of energy, diarrhea. Not everyone has all of the symptoms. Some children have no obvious pain. Some don’t pass blood or have a lump in the belly. And some older children have pain but no other symptoms. I ruled in this differential diagnosis due to its similarity with the prevailing signs and symptoms that are present in the case scenario which highly suggest that intussusception is to be considered as the primary diagnosis.
2. What is the most likely diagnosis? (Explain how you arrived at your diagnosis)
Intussusception is the most likely diagnosis based on the sudden onset of severe abdominal pain, the child doubling over, and the episodes of pain being followed by periods of being relatively fine. It is associated with an “empty” feeling in the right lower abdomen on palpation and is caused by the telescoping of one intestine segment into another, causing blockage and severe pain. This is known be to called as “Dance Sign”, which is thought to be characteristic of intussusception. Infants and children may strain, draw their knees up, act very irritable and cry loudly. They recover and become playful in between bouts of pain, or may become tired and weak from crying. Vomiting may also occur with intussusception, and it usually starts soon after the pain begins. The absence of nausea, vomiting, diarrhea, or fever is unusual for common gastrointestinal problems such as gastroenteritis or gastrointestinal obstruction. Intussusception is more common in children and boys, with an average age of six to 18 months (Jain, S. 2023).
3. Demonstrate your understanding of the pathophysiology in regard to the most likely diagnosis.
Intussusceptions typically occur when the ileum enters the cecum, with the intussusceptum located proximally to the intussuscipiens. The part that prolapses into the other is called the intussusceptum, while the part receiving it is called the intussuscipiens (Jain, S. 2023). An anatomic lead point occurs in about 10% of intussusceptions. This telescoping action often blocks food or fluid from passing through. Ischemia occurs when the blood supply is cut off, causing mucosa to slough off into the gut, creating a “red currant jelly” stool. This occurs in a minority of cases and should be considered in the differential diagnosis of children passing bloody stool. Intussusception is the most common cause of intestinal obstruction in children younger than 3 years old. The cause of most cases of intussusception in children is unknown.
4. What are the next appropriate steps in management? (Management should be confined to an outpatient setting, this includes proper referral if needed).
In an outpatient setting, the next appropriate steps include:
A. Diagnostic Imaging: Order an abdominal ultrasound, which is the imaging of choice for diagnosing intussusception. Ultrasonographic imaging has been found to have a high sensitivity and specificity in the detection of ileocolic intussusception. The “bulls eye” or “target sign” or “doughnut sign” on ultrasound pictures can be used to confirm the diagnosis. This sign indicates that the intestine is coiled in within the intestine.
B. Fluid Management: Encourage oral rehydration if the kid is tolerating fluids and not displaying signs of dehydration.
C. Referral: Even if the treatment is initially outpatient, a prompt referral to Emergency medical care is required to avoid severe dehydration and shock, as well as to prevent infection that can occur when portion of intestine dies due to lack of blood. Referral to pediatric surgeon is warranted as well.
Treatment options for intussusception may include:
Water soluble contrast or air contrast
Both a diagnostic procedure and a treatment, if an enema works, further treatment is usually not necessary. This treatment can actually fix intussusception 90% of the time in children and no further treatment is needed. If the intestine is torn (perforated), this procedure can’t be used.
Intussusception recurs up to 20% of the time, and the treatment will have to be repeated. It is important that a surgeon be consulted even if treatment with enema is planned. This is because of the small risk of a tear or rupture of the bowel with this therapy.
Surgery
If the intestine is torn, if an enema is unsuccessful in correcting the problem or if a lead point is the cause, surgey is necessary. The surgeon will free the portion of the intestine that is trapped, clear the obstruction and if necessary, remove any of the intestinal tissue that has died. Surgery is the main treatment for adults and for people who are acutely ill.
D. Pain management: Pain management involves providing relief for child’s distressing episodes of severe pain using pain medications such as:
Acetaminophen 149 mg (10mg/kg/dose) every 4 to 6 hours as needed for pain
Ibuprofen 99 mg (15mg/kg/dose) every 6 to 8 hours as needed for pain
Ibuprofen is usually the drug of choice for the treatment of mild to moderate pain, if no contraindications exist. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclo-oxygenase, resulting in inhibition of prostaglandin synthesis.
In the immediate postoperative period, weight-adjusted intravenous morphine is usually administered. As the oral diet is resumed, acetaminophen with codeine or ibuprofen is given orally
References:
Gotfried, J. (2023b, August 10). Overview of gastroenteritis. MSD Manual Consumer Version. https://www.msdmanuals.com/home/digestive-disorders/gastroenteritis/overview-of-gastroenteritis#:~:text=
Jain S, Haydel MJ. Child Intussusception. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431078/
Jones MW, Lopez RA, Deppen JG. Appendicitis. [Updated 2023 Apr 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/
Leung AKC, Wong AHC, Leung AAM, Hon KL. Urinary Tract Infection in Children. Recent Pat Inflamm Allergy Drug Discov. 2019;13(1):2-18. doi: 10.2174/1872213X13666181228154940. PMID: 30592257; PMCID: PMC6751349.
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