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The condition, lessons for the clinician, poster presentations:, section editor’s note, suggested readings, case 5: a 13-year-old boy with abdominal pain and diarrhea.

AUTHOR DISCLOSURE

Drs Sudhanthar, Okeafor, and Garg have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Anjali Garg , Sathyan Sudhanthar , Chioma Okeafor; Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev December 2017; 38 (12): 572. https://doi.org/10.1542/pir.2016-0223

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A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen. Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes. However, he arrived at the emergency department the next day due to increased severity of abdominal pain. The pain had localized into the right lower quadrant. Further imaging revealed the diagnosis.

The differential diagnosis for an adolescent who presents with abdominal pain is broad, including gastrointestinal causes such as gastroenteritis, appendicitis, or constipation and renal causes such as nephrolithiasis or urinary tract infections. With our patient, the more plausible answers were ruled out through laboratory studies and physical examination, and he was assumed to have gastroenteritis based on the history of similar symptoms in his family members. However, with the worsening of his abdominal pain, further diagnostic study became imperative and a computed tomographic (CT) scan of the abdomen was obtained to assess for appendicitis or nephrolithiasis.

The CT scan showed a cecum located midline; the large intestine was on the left side of the abdomen, and the small intestine was on the right ( Figs 1 and 2 ). The appendix was buried deep in the right pelvis, and there was no indication of appendicitis. These findings were consistent with intestinal malrotation. Intestinal malrotation is rare beyond the first year of life. Maintaining a higher index of suspicion in any patient with an acute presentation of severe abdominal pain is imperative because of the severity of potential complications such as bowel obstruction, volvulus, and eventual necrosis. Our patient’s pain is assumed to have been due to compressive effects of the peritoneal bands (Ladd bands), which were irritated by an initial gastroenteritis. He did not have the signs or symptoms of a more severe complication, such as bowel obstruction or volvulus.

Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Owing to the severity of the pain, our patient was taken for surgery, specifically, a Ladd procedure and a prophylactic appendectomy. Ladd bands were seen to extend from the cecum to above the duodenum. During the procedure, these bands were lysed, then the mesentery was spread out, and the bowels were rearranged. He tolerated the surgery well and was discharged 3 days after the operation.

His abdominal pain improved after surgery, and he has been doing well at his postoperative checks.

Intestinal malrotation is when the intestines fail to rotate properly in utero. From the fifth to 10th weeks of embryologic development, the small intestine lies in the right aspect of the abdomen, with the ileocecal junction midline, and the large intestine in the left hemi-abdomen. The segments are then pushed out of the abdomen into the umbilical cord. Both segments grow in the first stage of rotation. During the second stage of rotation, the small intestine rotates counterclockwise 270 degrees around the superior mesenteric artery. The remaining intestine is pulled into the abdomen, and the mesentery is fixed to the retroperitoneal space. The large intestine comes in last, with the final segment of the cecum lying anterior to the small intestine in the right lower quadrant.

Nonrotation is the most frequent cause of intestinal malrotation. Nonrotation occurs when the 270-degree rotation does not occur and, thus, the mesentery is not fixed to the retroperitoneal space. Derangements of the second stage of rotation are defined as having the small intestine in the right hemi-abdomen, with the cecum midline in the pelvis, and the large intestine in the left hemi-abdomen.

One percent of the population has intestinal rotation disorders. The incidence decreases with age. Approximately 90% of patients are diagnosed within the first year of their life, with 80% among them within the first month after birth. Due to a delay in diagnosis, the 10% of patients who present beyond that first year after birth can have severe complications.

Symptoms of malrotation are different in infants compared with adolescents. Neonates typically will have bilious emesis. In contrast, children and adults commonly exhibit acute abdominal pain. Some older patients have had chronic abdominal pain that goes unnoticed; others may be asymptomatic before diagnosis. The co-occurrence of intestinal malrotation with congenital cardiac anomalies is a common finding. Twenty-seven percent of intestinal malrotation patients were found to have a concurrent cardiovascular defect such as ventricular septal defect or another minor/major abnormality.

The diagnostic modality of choice is an upper gastrointestinal tract contrast study. This study modality shows any obstruction and depicts the malrotation through contrast media. Sometimes a contrast medium is not needed for diagnosis, as in the case of our patient, where CT scanning was enough to diagnose the malrotation.

Asymptomatic neonates and all symptomatic individuals, regardless of age, go through the Ladd procedure to correct the abnormality. However, the guidelines are not as clear for treatment of children older than 1 year who are asymptomatic. Currently, there is some consensus for performance of the procedure regardless of symptom status because of the severity of the complications or mortality that can occur due to malrotation. The narrow pedicle of the mesentery that forms in malrotation is prone to volvulus and ischemia, leading to complications at any point in an individual’s life. A diagnostic laparoscopy should be performed at the very least and can be therapeutic as well. Removal of the appendix has been suggested to prevent any diagnostic complications on future presentation. Additionally, the Ladd procedure can lyse Ladd bands, which are abnormal fibrous adhesions from the cecum that also arch over the duodenum. Removal of these bands is imperative because they can cause intestinal obstruction and ischemia as well.

Diagnosis of intestinal malrotation should be considered in a patient presenting acutely with severe abdominal pain, especially in a patient with known cardiac anomalies.

Often the symptoms of intestinal malrotation can be vague, and a patient can be asymptomatic for years before presentation.

The diagnostic modality of choice is an upper gastrointestinal tract series, but other imaging, such as computed tomographic scan, can help diagnose the presence of malrotation in emergency situations.

A Ladd procedure should be conducted on a patient even if he/she does not have current symptoms of obstruction due to increased risk of obstruction or complications such as volvulus and gut necrosis with this disease.

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 39th Annual Michigan Family Medicine Research Day Conference in Howell, MI, May 26, 2016.

Poster Session: Student and Resident Case Report Poster Presentation

Poster Number: 23

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 2016 AAP National Conference and Exhibition in San Francisco, CA, October 22-25, 2016.

Poster Session: Section on Pediatric Trainees Clinical Case Competition

Abdominal Pain in Children: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx

Diarrhea: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx

For a comprehensive library of AAP parent handouts, please go to the Pediatric Patient Education site at http://patiented.aap.org .

This case was selected for publication from the finalists in the 2016 Clinical Case Presentation program for the Section on Pediatric Trainees of the American Academy of Pediatrics (AAP). Ms Anjali Garg, BS, was a medical student from Michigan State University College of Human Medicine, East Lansing, MI, when she wrote this case report, and she now is a medical resident at Rainbow Babies and Children's Hospital in Cleveland, OH. Choosing which case to publish involved consideration of not only the teaching value and excellence of writing but also the content needs of the journal. Other cases have been chosen from the finalists presented at the 2017 AAP National Conference and Exhibition and will be published in 2018.

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Innovative Teaching Strategies Using Simulation for Pediatric Nursing Clinical Education During the Pandemic: A Case Study

Affiliations.

• 1 T.C. Cook is assistant professor, Mary Black School of Nursing, University of South Carolina Upstate, Spartanburg, South Carolina.
• 2 L.J. Camp-Spivey is assistant professor and director of simulation, Mary Black School of Nursing, University of South Carolina Upstate, Spartanburg, South Carolina.
• PMID: 34817401
• PMCID: PMC8855774
• DOI: 10.1097/ACM.0000000000004538

Existing challenges associated with pediatric clinical placements for prelicensure nursing students were heightened when clinical agencies halted nursing student entry in response to the COVID-19 pandemic. At the same time, the pandemic created opportunities for innovative teaching strategies for pediatric clinical rotations in nursing education. The purpose of this project was to design, develop, and implement meaningful, interactive, and intentional clinical experiences for nursing students that enhanced their pediatric assessment skills, reduced their anxiety about pediatric inpatient care, and advanced their proficiency in the nursing process. Two simulated clinical experiences were created: (1) a virtual pediatric physical assessment checkoff and (2) a pediatric escape room. The pediatric physical assessment checkoff was performed in a remote, virtual setting while students used personal resources to demonstrate their assessment skills. For the escape room, students worked in small, in-person groups using the nursing process to unlock clues to improve their client's health condition. Students reported gaining meaningful clinical experiences through simulation that allowed them to apply their nursing knowledge and increased their confidence in pediatric assessment skills, dosage calculation competency, communications and interactions with the pediatric population, and teamwork abilities. The virtual pediatric physical assessment checkoff and the pediatric escape room were enjoyable and beneficial educational events that facilitated student learning.

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Fever Case Study (Pediatric) (30 min)

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A 3-month-old child presents to the emergency room with her mother. The mother reports that the baby is not acting like herself and she is having a hard time arousing the baby. Upon inspection the baby is wrapped in blankets in her car seat sleeping. The nurse unwraps the baby and feels heat radiating off the child. 

The vital signs are as follows:

Temp 104°F Rectally

BP 66/32 mmHg (54 MAP)

The child is not opening their eyes or crying. The nurse notices the fontanelle is sunken in and the baby’s skin is hot but dry.

What questions should the nurse ask the mother?

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