4 mechanisms of esophageal injury by button batteries

Coins, the most commonly encountered ingested foreign body in children, cause complications related to chronic impaction and erosion. Button batteries are more dangerous. Methods by which they can cause damage (mostly when stuck in the esophagus) include

1. Toxic effect of mercuric oxide: some batteries contain lethal levels of mercuric oxide (5g). Batteries containing other heavy metals, lithium, or manganese are not toxic.
2. Electrical discharge from the battery
3. Pressure necrosis (as with coins)
4. Caustic injury from leakage of the battery's contents

Interestingly, batteries smaller than 1.6cm in diameter do not get lodged in the esophagus. Restricting the size of batteries produced to less than 1.6cm may help prevent serious injuries that can occur in as little as 5 hours after ingestion.

Reference:
Yardeni et al. Severe esophageal damage due to button battery ingestion: can it be prevented?
Pediat Surg Int (2004) 20:496

Variation in resource utililization associated with the management of appendicitis in children (APSA2011)

This presentation shed light on the spectrum of hospital costs entailed by different institutions for a somewhat uniform disease process, simple appendicitis, and the more heterogenous form, complicated or perforated appendicitis.

Not surprizingly, the authors found a significan variation in resourse utilization between institutions. This included the use of imaging studies and laboratory tests, readmission rates for both simple and complicated appendicitis, and hospital costs. Most strikingly, the authors noted an adjusted, case-related hospital cost for simple appendicitis that ranged from $4,000 to $10,000. As to complicated appendicitis, the cost ranged from $6,000 to $27,000.

Despite the limitation of studies obtained from databases, and the lack of correlatio between resource utilization and outcome, this study highlights the marked variability in management of a common condition that results in substantial resource utilization.

Why does simple appendicitis cost $4K in one hospital and $10K in another. Is the answer as simple as using cheaper but equally effective instruments? And if so, should we not all be standardizing this operation to help save what seems to me to be a lot of money?

Reference:
Variation of resource utilization associated with the management of appendicitis in children: implications for quality improvement through comparative analysis and collaborative networking.
Rangel SJ, Baxter J, Barnes J.

A bowel prep is not necessary before colosotmy reversal in kids (APSA 2011)

In this retrospective study looking at data from three institutions, the authors compared LOS and complication rates after colostomy takedown between pediatric patients who underwent a mechanical bowel prep and those who did not.

When they reviewed the data from 272 children (187 underwent a prep) they noted a longer hospital LOS for the prep group (5.6 vs 4.4 days); 122 of them had been pre-admitted for the prep. They also noted a higher rate of wound infections for the prep group (14.4 vs 5.8%). No significant difference was noted in the rate of abdominal abscess formation, anastomotic leaks, or C-diff infections.

Despite the limitations of this retrospective study, which may be comparing individual surgeon outcomes rather than the effect of bowel preps, this is another nail in the coffin of the pre-op bowel prep dogma that will hopefully be sealed by a PRS by the same group.

Reference:
A multi-center evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown.
Serrurier K, Liu j, Breckler F, et al.

What's the Pediatric Appendicitis Score (PAS) and is it actually helpful?

So who hasn't received the call for a kiddo with 'classic' appendicitis only to see the kid and send him home because he's constipated.

What if there was a consistent and reliable way of communicating the "classic'ness" of someone's abdominal pain between healthcare workers; NP from an outside hospital calling for a transfer or ED physician calling for a surgical consult.

Enter PAS.

The PAS was introduced by Maden Samuel in 2002 as a way to stratify children's risk of having appendicitis when they present with abdominal pain. The scoring system consists of 8 findings (6 worth 1 point, and 2 worth 2 points for a total score of 10 points). Since Samuel's inception, several studies have addressed the sensitivity and specificity of this scoring system and attempted to develop strategies for it's use, mostly in deciding whom to take to the OR without imaging, whom to image, and whom to send home.

Goldman et al from Sick Kids in Toronto prospectively tested the PAS on unselected children with abdominal pain. Based on the scoring system, they noted that if they had sent kids with a score less than or equal to 2 home, there would have been a 2.5% missed appendicitis rate. on the other hand, if they took anyone with a score greater or equal to 7 to the OR, the rate of negative appendectomies would have been 4%.

Another study by Bhatt et al looked at the use of PAS on children suspected of having appendicitis and noted that sending home children with a PAS of 4 or less would have resulted in a missed appendicitis rate of 2.4%, while operating on those with a PAS greater or equal to 8 would have resulted in a negative appendectomy rate of 8.8%.

Reading through the papers, it is clear that the PAS is not perfect. What about the female who is mid cycle and has severe, sudden onset abdominal pain, nausea, and right lower quadrant tenderness. I wouldn't take her to the OR without imaging even if her score was 10/10. Clearly there's an important role of the "intangible ingredient" in patient evaluation, and no scoring system could take the place of a thorough history, exam, and experience. What the PAS does do is help standardize the way we communicate the level of suspicion for appendicitis, and may have a role in developing pathways to help physicians decide on whom to image, and whom not to, before a surgical consult is called.

So instead of 'classic' appendicitis (which clearly means different things to different people), a phone call about a patient with PAS of 8 would probably be much more meaningful to all parties involved.

References:

Maden S. Pediatric appendicitis score. Journal of Pediatric Surgery 2002;37:877

Goldman et al. Prospective validation of the pediatric appendicitis score. Journal of Pediatrics 2008;153:278

Bhatt et al. Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Academic Emergency Medicine 2009;16:591