Mo1210 Evaluation and Treatment of Children With Abdominal Pain and Constipation in the Emergency Department

Mo1210 Evaluation and Treatment of Children With Abdominal Pain and Constipation in the Emergency Department Corrie E. Chumpitazi, Erin O. Bendure, Karina Valdez, Aammar A. Khan, Bruno P. Chumpitazi Background: Abdominal pain is a leading complaint for children seen in the Emergency Department (ED) and constipation is a frequent etiology. Published guidelines on the evaluation and treatment of childhood constipation are primarily geared toward the outpatient, non-acute setting. However, in the ED there is often a need to rapidly evaluate for potential life-threatening etiologies of abdomen pain, which may result in a different diagnostic approach. Moreover, disimpaction per rectum is often employed, which in our pediatric ED is primarily via soap enema. There is a paucity of literature regarding the evaluation and treatment of children with abdominal pain and constipation in the ED setting. Objectives: 1) To describe the evaluation of children with abdominal pain and constipation in the ED; and 2) To determine the effectiveness of soap suds enemas in this population Methods: A retrospective chart review of children presenting with both abdominal pain and constipation and receiving soap enemas was conducted in a large urban tertiary care PED over a 1 year period. Patient demographics, clinical signs and symptoms, whether a rectal examination was performed, pain scores, diagnostic evaluation, and stool output following the soap enema was systematically captured. Soap enema efficacy was defined by documented stool output. Results: 527 patients with a median age 8 (range 8 months -18 years) were included, of whom 253 (49%) were female. All children completed a history and physical though rectal examination was only documented in 135 (25.6%). Pain scores were documented in 458 (86.9%). Laboratory testing was completed in 120 (22.8%). Radiologic imaging included abdominal radiographs in 402 (76.3 %), abdominal ultrasound in 129 (24.5%), and abdominal computed tomography scan in 25 (4.7%). Minor abdominal findings on abdominal plain film such as ileus or dilated colon were found in 30 (7.4%), with none having serious findings. Those undergoing a rectal examination were significantly less likely to have radiologic imaging (P,0.002). Following soap enema, productive stool was reported in 432/527 (82%), and no serious adverse events were noted. Following the enema, 119/527 (22.6%) were subsequently admitted. Of those admitted, 90 (76%) had a significant past medical history and 14 (11.7 %) required disimpaction in the operating room. Conclusions: The vast majority of children presenting to the ED with abdominal pain and constipation undergo radiologic imaging as part of their evaluation, without significant yield. Rectal examinations should be encouraged in the ED setting, as this leads to decreased use of imaging. Soap enemas are an effective means of treating constipation in the PED setting in the majority of cases.

Mo1208 Laparoscopic Gastrostomy Is Safer Than Percutaneous Endoscopic Gastrostomy in Children: Results of a Systematic Review and Meta-Analysis Nutnicha Suksamanapun, Femke A. Mauritz, David C. van der Zee, Maud Y. van Herwaarden-Lindeboom Background: A gastrostomy is frequently performed in children who require long-term enteral feeding. Nowadays gastrostomy placement is a minimally invasive procedure via either percutaneous endoscopic gastrostomy (PEG) or laparoscopic assisted gastrostomy (LAG). Both procedures are widely used in pediatric patients. However, no consensus exists on which type of approach is best practice in these patients. Aim: The aim of this study was to determine if PEG or LAG is the most effective and safe procedure in pediatric patients requiring a gastrostomy Method: A systematic review and meta-analysis was performed according to the guidelines in the PRISMA-statement. PubMed, EMBASE, and the Cochrane Library were searched to identify eligible articles. Results were pooled in meta-analyses and expressed as risk ratios (RR). Results: Our extensive literature search provided 2,342 articles. After title, abstract and full-text screening five original studies comparing PEG to LAG placement in children were identified. All studies had retrospective study designs. The completion rate (PEG 98%; LAG 100%) and time to full-enteral feeds (PEG 0.7 and LAG 0.8 days) of both procedures were similar. No studies reported data comparing the efficacy of feeding via the gastrostomy or its effect on developing gastroesophageal reflux (GER). Major complications, such as intraperitoneal leakage (RR 0.28; p=0.36; after tube exchange RR 3.14; p=0.28) and persistence of the gastrocutaneous fistula after removal of the gastrostomy tube (RR 0.94; p =0.92 ) were as frequently encountered after both PEG and LAG. However, PEG was associated with significantly more adjacent bowel injury (RR=5.55; p= 0.05), early tube dislodgement (RR=7.44; p=0.02), and complications requiring reintervention under general anesthesia in the operating room (RR=2.79; p=0.0008). The risk of developing minor complications was similar after both PEG and LAG placement. Conclusion: This systematic review and meta-analysis demonstrates a lack in studies comparing the effect of PEG and LAG on the efficacy of feeding via the gastrostomy tube and postoperative GER. However, major complications such as adjacent bowel injury, early tube dislodgements and complications requiring reintervention under general anesthesia in the operating room were significantly less frequent after LAG. Therefore, we conclude that LAG is the safest approach and should be the first choice in children requiring gastrostomy placement.

Mo1211 Mesalamine for Treatment of Proctocolitis Due to Milk Protein Intolerance Unresponsive to 100% Amino Acid-Based Formula Mouhammad Rateb Alwazeer, Karen D. Crissinger Milk protein intolerance is usually effectively treated with 100% amino acid-based formulas (AAF) in patients who remain symptomatic after the use of casein hydrolysate formulas. Some infants, however, have persistent vomiting, diarrhea, excessive irritability, and hemepositive stools despite intake of AAF. Beginning in March 2009, infants with biopsy-proven proctocolitis consistent with milk protein intolerance unresponsive to AAF were treated with mesalamine. There are no reports of mesalamine use for treatment of infantile proctocolitis due to milk protein intolerance. Objective: Evaluate the outcome of mesalamine treatment for proctocolitis due to mik protein intolerance refractory to treatment with AAF in infants ,12 months of age. Methods: Retrospective chart review. Results: Twenty-two patients were identified with 64% female and 72% Caucasian. Symptoms were excessive irritability, vomiting, choking/gagging, coughing/wheezing, gassiness, watery or hard stools, visible blood/mucus in stool, weight loss, skin rash, and sleeping difficulties. There was no statistically significant improvement in symptoms on AAF. Fecal occult blood was present in 73% before use of AAF and in 64% after use of AAF (p=0.5). Before mesalamine treatment, 82% of patients were treated with AAF for ,1 month. When mesalamine was started, 77% were between ages 1½-6 months and 23% were between 6-10 months. Statistically significant improvements in vomiting, visible mucus in stool, watery stool, excessive irritability, choking, gagging, gassiness, and weight loss were seen with mesalamine. Stool hemoccult was negative in all patients after starting mesalamine (p ,0.0001). Mesalamine was used for 1½-4 months in 50% and 4-10 months in 46%. One patient did not return for follow-up. There were no patients with recurrent symptoms after stopping mesalamine and no side effects were noted during mesalamine treatment. Conclusion: Short-term treatment with mesalamine for refractory proctocolitis due to milk protein intolerance in infants ,12 months appears to be effective based on this retrospective chart review, but a prospective study with a larger patient population is necessary to confirm these preliminary results.

Mo1209 Ingestion of Radiopaque and Non-Radiopaque Foreign Bodies. False Negative Matters Miguel Saps, Silvana Bonilla, Jacob S. Ecanow Foreign body ingestion (IFB) is common in children. Parents frequently report possible IFB that was unwitnessed. Pediatric GI often order radiology (XR) but FB visibility (Vi) not always known. Not finding FB may mean no-ingestion or non-Vi FB. Uncertain Vi of FB may prevent extracting dangerous FBs or lead to unnecessary interventions. Aims: Assess Vi of common FB in children. Methods: Ingestible objects selected by pediatric GI, nurses and parents. Most packages had "choking hazard" warnings. A)Body Simulation- Model with x-ray attenuation of child's body made from a water equivalent phantom (WE) with a custom prepared gelatin slab (GS) to encase FB was constructed with cracks and fissures to act as "false positives." C) Process validation: Model validated by comparing visual XR

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density and measured CT density to known standards. D) FB -XRs of 14 FB (12 items + 2 copies) encased in models of different thickness to determine visibility in children of different sizes. XRs performed with various techniques to account for practice variations. E) Vi - 5 board certified radiologists (RD) ( .10 year experience) blinded to number and identity items shown in XR simulating 20 cm thick child asked to number visible items and identify item shape. Results: 5 RDs described: 8,8,7,8,9 objects; false positives: 1,1,1,2,2. True Positive: 7,7,6,6,7.Sensitivity: 58,58,50,50,58%. High agreement objects seen/not seen. 5 RD found same 6 FB. 4 other FBs never seen. Conclusion: Total agreement in some objects, others never seen in XR (possibly missed in practice). Unknown Vi could lead to child mismanagement. Registry of visibility is advised.