a perf-ect differential - sohm library...nephrolithiasis urinalysis: +ketones, negative blood...
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A Perf-ect Differential
Carolyn Marcus, MD
Disclosure of Financial Relationships
Husband works as in-house legal counsel at Sanofi
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Case Presentation
6 year old boy with a history of constipation presents with 24 hours of abdominal pain
Pain is diffuse and colicky, has periods without pain
Review of Systems
• 2 episodes of NBNB emesis
• Has been having daily soft small bowel movements, no diarrhea
• Tactile fevers, no documented fevers
• Decreased PO but no anorexia
• Sore throat
• No dysuria, rashes, testicular pain, respiratory symptoms
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Earlier today…
Initial ED: KUB revealed a “large stool burden”
Enema given which led to a bowel movement with pain relief, so discharged home with diagnosis of constipation
Pain recurred in the ED parking lot, so sent to our ED
PMH: constipation, seen by GI 2 months earlier
PSH: none
Meds: Miralax PRN
Allergies: none
Family: non-contributory
Social: non-contributory
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Most common/likely
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Must not miss
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis Fits with
symptoms
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Physical Exam T 37 HR 108 RR 20 BP 106/59
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
IntussusceptionAppendicitis
Testicular torsion
Nephrolithiasis
Workup
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis Urinalysis: +ketones, negative blood
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Moderate stool
burden
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Limited exam but no evidence of intussusception,
appendix not visualized
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Differential Diagnosis
ConstipationViral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Differential Diagnosis
Constipation – Admit for clean outViral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
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Hospital Course
NG Golytely initiated, started having soft bowel movements
Parents thought pain was possibly improving
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Continued with Golytely…
Continued with Golytely…
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Hospital Day 2
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Small questionably blind ending loop of bowel in midline pelvis which appears mildly
thickened and associated with adjacent fat stranding and trace amount of free fluid
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Small questionably blind ending loop of bowel in midline pelvis which appears mildly
thickened and associated with adjacent fat stranding and trace amount of free fluid
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“A probable blind-ending tubular structure off the ileum demonstrating hyperenhancementand wall thickening in the periumbilical region, most consistent with…”
“A probable blind-ending tubular structure off the ileum demonstrating hyperenhancementand wall thickening in the periumbilical region, most consistent with Meckel’s diverticulitis”
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Surgical Findings
Meckel’s diverticulum lined by gastric and small intestinal type mucosa with a focal perforation of adjacent small intestinal wall with inflammation
Final Diagnosis
Meckel’s diverticulitis with perforation
Meckel’s Diverticulum
When symptomatic…• Bleeding• Abdominal pain • Obstruction • Inflammation/diverticulitis• Perforation
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Meckel’s Diverticulitis
Occurs in 2% of
population
Male-to-female ratio
of 2:1
Located within 2 feet from
ileocecal valveCan be 2 inches in
length
2% with complication
over course of their lives
(typically before age 2)
Bleeding Meckel’s lined by 2 different
types of mucosa
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Our Patient
• Post-operative ileus that slowly improved
• Small bowel obstruction secondary to adhesions requiring repeat surgery
• Now doing well 1 year later
Cognitive Biases
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Cognitive Biases
6 year old boy with a history of constipation (seen by GI 2 months prior) presents with 24 hours of abdominal pain
Cognitive Biases
6 year old boy with a history of constipation (seen by GI 2 months prior) presents with 24 hours of abdominal pain
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Cognitive Biases
• KUBs revealed moderate-large stool burden
• Pain relief with enema
Lessons Learned
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Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis
Meckel’s diverticulitis
Differential Diagnosis
Constipation
Viral infection
Strep pharyngitis
Intussusception
Appendicitis
Testicular torsion
Nephrolithiasis Meckel’s diverticulitis
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References
• Abizeid GA, Aref H. Case report: preoperatively diagnosed perforated Meckel’s diverticulum containing gastric and pancreatic-type mucosa. BMC Surg. 2017 Apr 11; 17(1):36
• Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug; 78(8):775-80.
• Javid P and Pauli EM. Meckel’s diverticulum. In: UpToDate, Soybel DI and Heyman MB (Eds), UpToDate, Waltham, MA, 2016.