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Flashcards in Case 22 Deck (31):
1

What are key findings from history in a patient with PID?

-Acute abdominal pain
-Vomiting, no diarrhea
-No ill contacts
-Hx of UTI
-Sexually active

2

What are key findings from physical exam in a patient with PID?

-Fever
-Diffuse abdominal tenderness with rebound and guarding
-Negative McBurney's sign
-Cervical motion tenderness
-RUQ pain
-No CVA tenderness
-No jaundice

3

What is on the differential diagnosis for PID?

Appendicitis, Acute gastroenteritis, UTI, Ectopic pregnancy, Pancreatitis, Hepatitis, Pneumonia

4

What are key findings from testing for PID?

Cervical discharge gram stain, culture and wet mount positive for intracellular gram negative diplococci (N. gonorrhea)

5

What is the epidemiology of pelvic inflammatory disease (PID)?

-Sexually active girls 15-19 years are highest-risk group due to biological and behavioral factors:
--Fewer protective antibodies in vagina than in older women
--Cells in cervical ectropion (transitional zone) particularly susceptible to infection
-More common in sexually active women:
--Risk factors include intercourse during menses, infrequent or no condom use, multiple sexual partners

6

What is the microbiology associated with pelvic inflammatory disease?

Most common organisms (greater than 50 percent of cases) are Neisseria gonorrhea and Chlamydia trachomatis.

7

What is the pathophysiology of PID?

Lower-tract infection alters normal vaginal flora and allows bacteria (such as E. coli, Bacteroides species, other anaerobes, Mycoplasma hominis or Ureaplasma urealyticum) access to uterus and fallopian tubes.

8

What are the complications of PID?

Fitz-Hugh-Curtis Syndrome, Tubo-ovarian or other intra-abdominal abscess, risk of infertility.

9

What is the epidemiology of appendicitis?

-Most common condition requiring emergency surgery in the pediatric population
-60,000 to 80,000 cases a year in the US
-Most often occurs in older children
-Rare in children less than 2 years
-Prevalence in children with acute abdominal pain 1-4 percent
-Due to a third of pediatric patients presenting with atypical symptoms, there is both an over-diagnosis of appendicitis (false-negative appendectomy rate 5-25 percent) and a high incidence of perforation (23-73 percent) in the pediatric population.

10

What studies are used to diagnose appendicitis?

Many clinicians use adjunctive lab and radiographic studies to increase accuracy of diagnosis, including:
-CBC with differential (sensitivity 19-88 percent, specificity 53-100 percent)
-Creactive protein (sensitivity 48-75 percent, specificity 57-82 percent)

11

What is a useful pneumonic to remember when asking questions about pain?

PQRST-AAA:
Postion (be exact)
Quality (dull, sharp, burning)
Radiation (be exact)
Severity (scale from 1 to 10, if patient and o this)
Timing (when it happens)
Alleviating factors
Aggravating factors
Associated symptoms

12

Pelvic exam:

-Perform in any sexually active adolescent girl with abdominal pain
-Small amount of vaginal discharge is normal; a significant amount indicates infection
-Cervical motion tenderness or adnexal mass or uterine tenderness is important in making a diagnosis of PID
-A chancre is usually found with syphilis (not usually associated with vaginal discharge unless co-infection is present)

13

Rectal exam:

-With any abdominal complaint (eg, atypical diarrhea, constipation, pain, bleeding), think about doing a digital rectal examination.
-It is also part of an in-depth neurological examination
-Inspect for fissures, inflammation or lack of tone
-Asking child to bear down as you insert examining finger into the rectum relaxes the external sphincter and makes the process less uncomfortable.

14

What are more likely differential diagnosis for PID?

Pancreatitis, Hepatitis, UTI, Ectopic pregnancy, Appendicitis, Cholecystitis

15

What are less likely differential diagnosis for PID?

Acute gastroenteritis, Ovarian torsion, pneumonia, incarcerated hernia, testicular torsion

16

Pelvic inflammatory disease (PID):

May be diffuse abdominal pain, but more typically in lower abdomen. Right upper quadrant pain, perhaps referring to the right shoulder, can occur with perihepatitis that complicates PID in 5 percent of cases (Fitz-Hugh-Curtis syndrome). Highest rates are in sexually active women 15-19 years of age, but should be considered in a young woman with acute abdominal pain, even without history of sexual activity. Sometimes associated with fever and vomiting. Cervical motion tenderness pathognomonic for PID.

17

Pancreatitis:

Constant, severe abdominal pain (either right upper quadrant or more localized to the epigastric region) common in pancreatitis. Band-like pain radiating to the back is highly suggestive. Almost always accompanied by nausea and vomiting and low-grade fever. (Vomiting without diarrhea suggests extra-insteinal pathology)

18

Hepatitis:

Usually presents with fever, malaise, diffuse abdominal pain, nausea, vomiting- no diarrhea. Associated with jaundice and change in urine color. Hepatomegaly is usually seen. Onset of symptoms depends on etiology (Hep A, B, C or alcohol-induced)

19

UTI:

In older children, usually present with dysuria, frequency, and urgency. Fever and/or back pain (CVA tenderness) suggest pyelonephritis. More common in sexually active women. Prior history of UTI may suggest structural abnormality.

20

Ectopic pregnancy:

Strongly consider in a sexually active female patient with abdominal pain. Classically presents with lower abdominal pain, bleeding, and abnormal menses. Requires emergent evaluation and treatment. Physical exam may be completely normal in an early, unruptured ectopic pregnancy.

21

Appendicitis:

Must always consider with acute abdominal pain. Fever is often seen, but is non-specific. Classic pattern (60 percent of the time) is periumbilical pain followed by generalized, severe right lower quadrant tenderness (sensitivity of 87-99 percent in adults). RLQ tenderness at McBurney's point is expected. Vomiting is common; diarrhea is not.

22

Cholecystitis:

Most often causes RUQ pain (either constant or colicky), sometimes radiating to the shoulder. Murphy's sign - severe pain and interruption of breath on palpation of the RUQ - may be seen. Eating fatty foods may worsen the pain. Decreased appetite, nausea and vomiting can accompany attacks. Cholecystitis is less common in children than in adults but does occur.

23

Acute gastroenteritis:

While vomiting is a common presenting complaint, by three days into the illness, typically diarrhea is the most pronounced symptom.

24

Ovarian torsion:

Stabbing abdominal pain is a common symptom, typically in lower abdomen or pelvic region. Also nausea and vomiting. Can happen in any age group, but more common in post-menarchal women.

25

Pneumonia:

Irritation of the pleural by a lower lobe infection is an important cause of abdominal pain in young children. One would expect also to find cough, difficulty breathing and chest pain.

26

Incarcerated hernia:

-Most present before 1 year of age
-Incarcerated hernias occur slightly more often in girls, and an ovary may be in the hernia instead of intestine.
-Tender mass in groin or labia majora
-Irritability (in an infant) is a common symptom
-Vomiting and abdominal distention may be seen if there is accompanying intestinal obstruction

27

Testicular torsion:

-Most often occurs in early adolescence
-Acute onset of severe hemi-scrotal pain, nausea, and vomiting
-Enlarged, tender testis, scrotal edema, and absence of cremasteric muscle reflex
-Irreversible changes in testis may occur within four hours
-Requires prompt surgical exploration and detorsion to save affected testis

28

Nucleic Acid Amplification Test (NAAT):

Tests for presence of bacteria (eg, chlamydia, gonorrhea) or viruses in urine and cervical discharge

29

What is the clinical diagnosis and treatment of PID based on?

History and examination findings.

30

How do you treat PID?

-Tx with antibiotics often empiric unless rapid diagnostic tests are available
-Partners must also be tested and treated to minimize risk of recurrence.

31

When are patients with PID hospitalized?

Patients with mild/moderate PID may be managed as an outpatient. Reasons for hospitalization include:
-Pregnancy
-Previous noncompliance
-High fever
-Intractable vomiting
-Inability to exclude surgical emergency