Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

Slide 1

Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

Steven Teich, M.D.
Daniel Cohen, M.D.
Ann Deitrich, M.D.
Osama El-Assal, M.D.
John Shultz, M.D.

On the bottom of every slide it has the logo and name "Nationwide Children's", Ohio State.

Slide 2

Study Aims

• Aim 1: Describe the presentation of acute abdomen in medically fragile, high risk children and adults to expedite the recognition of a surgical emergency.
• Aim 2: Develop a diagnostic algorithm for patients with special care needs with possible intra-abdominal emergency.

Slide 3

Background

• There are an estimated 9 million children and 23 million adults in the U.S. with special health care needs.
• Large subset of special health care needs patients at risk to develop acute surgical abdomen due to co-morbidities:
  • Multiple abdominal surgeries.
  • Indwelling abdominal devices.
  • Chronic constipation.
  • Nissen fundoplication.

Slide 4

Background

• Adhesive peritoneal bands occur in 93-100% of patients with prior abdominal surgery.
• Nissen fundoplication increases the risk of adhesive SBO up to 21% in children.
• Incidence of complications after VP shunt varies from 5-47%:
  • CSF pseudocyst.
  • SBO.
  • CSF ascites.
  • Shunt displacement.
  • Inguinal hernia.
  • Intestinal Perforation.
  • Intestinal entanglement.

Slide 5

Background

• Nonverbal children and adults with altered sensation often unable to communicate symptoms classically associated with acute abdomen and often present with subtle manifestations.
• Therefore, this patient population at greater risk for acute abdominal surgical emergencies and delayed or missed diagnoses with potentially catastrophic outcomes.

Slide 6

Study Design

• Study conducted at Nationwide Children's Hospital, Columbus, OH (#IRB09-00151).
• Retrospective case-controlled study with patients serving as their own control.
• Review of hospital discharge data including ICD9 codes and surgical case records.
• Inclusion criteria: patients with neuro-developmental delay with diagnosis of acute surgical abdomen within 48 hours of hospital admission from the Emergency Department between May 2005 and October 2009.

Slide 7

Study Design

• Acute surgical abdomen defined as an abdominal surgical procedure demonstrating a pathological process or an IR procedure for abdominal pathology (e.g. drainage of CSF cyst).
• Each subject had to have an index ED visit during which an acute surgical abdomen was diagnosed and a control ED visit which proved to be negative for an acute surgical emergency.
• The control visit required to have occurred within two years of the acute surgical abdomen visit but at least two months distant to avoid repeat presentation for the same illness.

Slide 8

Study Definitions

• Feeding intolerance:
  • Decreased oral intake or vomiting in orally fed patient.
  • Abdominal distention, discomfort, or increased gastrostomy tube output after oral or gastrostomy feeds.
• Pain:
  • Described by patients able to communicate.
  • Interpreted by caregivers as changes in behavior consistent with feeling abdominal pain such as grimaces or moaning with abdominal touch.
• Constipation:
  • New onset or worsening.

Slide 9

Results

• 169 patients with special needs had abdominal procedures over the study time period.
• 24 patients met the selection criteria after screening for elective surgical procedures and lack of a qualifying ED control visit.

Slide 10

Demographic Data

Variable	Number
Age (years)	14.37 ± 9.58 (22, 31, and 43 year olds)
Gender	16 male/ 8 female
Residence	19 home/ 5 facility
Mode of Feeding	17 tube/ 10 mouth/ 3 combined
Implants/Surgical Procedures	11 VP shunt 17 gastrostomy tube 16 Nissen fundoplication 4 tracheostomy 1 central line
Number of ED visits/year (Over past 3 years)	1.49 ± 1.28
ED visit/admission ratio	2.06 ± 2.35

 

Slide 11

ED Index Visit (Surgery)

Etiology	Number (%)
Adhesive SBO	11 (45.8%)
Shunt-related CSF cyst	5 (20.8%)
Volvulus	3 (12.5%)
Malrotation	2 (8.3%)
Hiatal Hernia	1 (4.1%)
VP-tube related intestinal entanglement	1 (4.1%)
Peritonitis	1 (4.1%)
Total	24 (100%)

Slide 12

ED Control Visit (No Surgery)

Etiology	Number (%)
Ileus	6 (20.8%)
Gastroenteritis	4 (16.6%)
Unknown	3 (12.5%)
UTI	2 (8.3%)
URI	2 (8.3%)
Colitis	1 (4.1%)
Sepsis	1 (4.1%)
Pancreatitis	1 (4.1%)
Feeding intolerance	1 (4.1%)
Pneumonia	1 (4.1%)
SMA Syndrome	1 (4.1%)
Cyclic vomiting	1 (4.1%)
Total	24 (100%)

Slide 13

Symptoms at Presentation

Variable	Surgical Abdomen	Control Visit	p Value
Respiratory distress	Yes 11 No 13	Yes 9 No 15	0.47
Fever	Yes 8 No 16	Yes 12 No 12	0.20
Vomiting	Yes 18 No 6	Yes 10 No 14	0.008*
Feeding intolerance	Yes 9 No 15	Yes 4 No 20	0.059
Constipation	Yes 8 No 16	Yes 4 No 20	0.20
Diarrhea	Yes 3 No 21	Yes 10 No 14	0.019*
Abdominal pain	Yes 19 No 3	Yes 11 No 13	0.011*
Abdominal distention	Yes 17 No 7	Yes 10 No 14	0.034*
Behavior changes	Yes 18 No 6	Yes 13 No 11	0.13

*p <0.05.

Slide 14

Physical Findings at Presentation

Variable	Surgical Abdomen	Control Visit	P Value
Tachypnea (>98%ile)	Yes 13 No 11	Yes 11 No 13	0.50
Tachycardia (>98%ile)	Yes 15 No 9	Yes 14 No 10	0.99
MAP	83.67 + 15.2 (N=23)	80.34 + 20.53 (N=22)	0.55
Dehydration	Yes 18 No 5	Yes 12 No 11	0.031*
Abdominal Distention	Yes 17 No 7	Yes 9 No 15	0.007*
Abdominal Tenderness	Yes 18 No 6	Yes 5 No 19	0.006*

*p <0.05.

Slide 15

Laboratory Results and Diagnosis of Acute Surgical Abdomen

Variable	Surgical Abdomen	Control Visit	p Value
WBC	13,900 ± 7,100	9,900 ± 4,000	0.008*
Segs	61.5 ± 22.4	57.8 ± 23.2	0.036*
Bands	13.2 ± 16.6	12.6 ± 16.6	0.66
Bicarbonate	25.9 ± 7.9	26.0 ± 6.1	0.091
Sodium	140.9 ± 5.5	138.3 ± 3.6	0.013*
Potassium	4.3 ± 0.8	3.8 ± 0.48	0.59
Chloride	99.2 ± 19.7	98.5 ± 19.3	0.022*
Glucose	149.2 ± 50.8	122.8 ± 44.8	0.002*
BUN	22.8 ± 20.6	14.6 ± 6.9	0.044*
Creatinine	0.8 ± 0.60	0.55 ± 0.29	0.047*

*p <0.05.

Slide 16

Early ED Management and Diagnosis of Acute Surgical Abdomen

Variable	Surgical Abdomen	Control Visit	p Value
O2 requirement	Yes 4 No 20	Yes 6 No 18	0.50
Fluid resuscitation	Yes 18 No 6	Yes 12 No 12	0.031*
Number of fluid boluses	1.30 ± 1.10	0.78 ± 0.95	0.036*

*p <0.05.

Slide 17

Radiology Testing

Variable	Sensitivity	Specificity	Negative Predictive Value	Positive Predictive Value
AAS	0.57	1.0	0.62	1.0
Abdominal CT	0.94	1.0	0.92	1.0

 

Slide 18

Patient #1

Image: An x-ray of the patient's torso is shown.

Slide 19

Patient #1

Image: An MRI of the patient's abdomen are shown.

Slide 20

Patient #2

Image: An x-ray of the patient's torso is shown.

Slide 21

Patient #2

Image: An MRI of the patient's abdomen are shown.

Slide 22

Predictive Variables For Surgical Abdomen

Variable	p Value
Abdominal distention	0.027
Abdominal pain	0.009
Vomiting/ Increased gastrostomy output	0.001
No diarrhea	0.017
Abdominal tenderness	0.001
Elevated WBC	0.006
Number of fluid boluses	0.041

Slide 23

Image: A decision flow chart for management of high-risk patients with suspicion of vomiting, abdominal pain, tenderness, dehydration, and other symptoms is shown.

Slide 24

Conclusions

• First study on high-risk patients with suspicion for acute surgical abdomen.
• Presence of abdominal pain, abdominal distention, increased gastrostomy tube output or vomiting, abdominal tenderness, and signs of dehydration are significant predictors of need for emergency surgery in high risk, medically fragile patients.

Slide 25

Conclusions

• We propose abdominal ultrasound as the initial modality for patients with VP shunts when presenting with a possible acute surgical abdomen.
• Positive AAS is reliable finding but negative AAS can be misleading and a further confirmatory test is indicated.
• Abdominal CT is most reliable imaging modality.
• Our pathway for atypical, medically fragile patients at high risk for an acute surgical abdomen needs to be validated by a prospective study with a larger cohort.

Slide 26

Questions?