an unusual cause of abdominal pain in children cause of abdominal pain in... · an unusual cause of...
TRANSCRIPT
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AN UNUSUAL CAUSE OF ABDOMINAL PAIN
IN CHILDREN
PADMAVATHY.VPROF. P. RAMACHANDRAN
G5 WARD, ICH & HC.
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CLIN ICAL SCENARIO
6 yr old male child.
Referred from Chengalpet medical college.
c/o poor appetite & loss of weight for 1 yr
abdominal pain for 1month
fever for 2days prior to admission.
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At Chengalpet :
Hb : 10.4gm%
TLC: 16500; P91 L7 E2
Platelet count: 2.1 lakhs
TBR: 0.7 DBR: 0.2
OT/PT:11/14 SAP:97
Tot protein:7.5 Alb:4.1 Glo: 3.4
Amylase : 150 IU
Widal- negative
CXR- NAD
X Ray Abd – NAD
USG Abd – Normal study
ECG- Normal study
Sugar:94
Urea : 26 ; Creat: 0.9
Na-139;K-3.3;Hco3-23
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At ICH
C/C – Abdominal painIntermittentPeriumbilicalTypically postprandial, starting at around ½ hr to 1hr after food.Assoc with refusal of feedsNo vomiting/diarrhea/abd distension/malena/constipation
“PHAGOPHOBIA”
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Clinical profile
Prev illness: Known case of Seizure disorder on regular treatment with Tab.Valproate 1-0-1/2 for 2yrs.Family h/o: 1st born male child out of non-consanguinous marriage.
No family h/o chronic illnessBirth history: Uneventful.Developmental h/o: Normal milestones.Contact h/o: No h/o contact with a case of PTB.
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On Examination :
Grade III undernutrition
Scaphoid abdomen with mild epigastric tenderness, with the child writhing with pain when symptomatic.
Other systems- NAD
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Provisional diagnosis
Gastritis
Acute pancreatitis
Tb abdomen
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Investigations
Hemogram: Hb: 9.6TLC:12800;P57 L43Platelet: 3.4lakhsPS: Mod hypochromic
anemiaUrine /Stool- NADHIV- Non reactiveRFT/LFT – WNLAmylase : 55 IU/mlESR : 8/24
Mantoux- negativeRGJ-NegativeParental screening for Tb-NegativeXray Chest&Abd- NAD
INITIAL USG ABD-dilated stomach & duodenum with minimal free fluid in pelvis.
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SMA
AORTA
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Paediatric surgeons suggested BMFT & Vascular surgeon’s opinion
Vascular surgeons suggested CT angiogram of abdominal aorta with mesenteric vasculature.
Surgical Gasteroenterologists advised to treat as Abdominal angina & start Inj. Heparin infusion.
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Barium meal follow through – dilated bowel loops with no ischemic changes, with no malrotation.Hematologist’s opinion-
Serum Homocysteine- NormalPro thrombotic work-up after the
acute episode settles down.Heparin infusion
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CT Angiogram
Hepatic & Splenic arteries arising from the Superior mesenteric artery (a normal variant).SMA thrombus (distal to the hepatic & splenic arterial origins) with multiple collaterals.Large collateral between the hepatic & IMA ( Arc of Riolan).
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SMASMV
AORTA
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Upper GI endoscopy- Pan erosive gastritis with duodenitis.
ECG- Normal
Cardiac evaluation : Normal study of the heart & great vessels.
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Course in the hospital
Inj.Heparin infusionPPI therapyChild became asymptomatic nearly 15 days after starting anticoagulants & PPI therapy.Better appetite & gain in weight.Discharged on Oral anticoagulants, pending prothrombotic work-up.
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Working diagnosis
Gastritis with SMA thrombus
SMA thrombus D/D:
Mesenteric vasculitis
Prothrombotic states
Isolated idiopathic superior mesenteric artery thrombus
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On follow upOn Follow up
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STATISTICS
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Take home message
The possibility of Vascular problems should be
considered in children with abdominal pain.
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Thank you