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Acute abdominal pain in a child with inflammatory bowel disease

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f563 (Published 14 February 2013) Cite this as: BMJ 2013;346:f563
  1. F L Cameron, paediatric registrar in gastroenterology, hepatology, and nutrition1,
  2. L Armstrong, consultant paediatrician2,
  3. E Stenhouse, consultant paediatric radiologist3,
  4. C Davis, consultant paediatric surgeon4,
  5. R K Russell, consultant in paediatric gastroenterology, hepatology, and nutrition1
  1. 1Department of Paediatric Gastroenterology, Hepatology and Nutrition, Yorkhill, Royal, Hospital for Sick Children, Glasgow G3 8SJ, UK
  2. 2Department of Paediatrics, Crosshouse Hospital, Kilmarnock, UK
  3. 3Department of Paediatric Radiology, Yorkhill, Royal Hospital for Sick Children, Glasgow, UK
  4. 4Department of Paediatric Surgery, Yorkhill, Royal Hospital for Sick Children, Glasgow, UK
  1. Correspondence to: F L Cameron fcameron{at}doctors.org.uk

A 10 year old girl with inflammatory bowel disease presented with a two week history of eight to 10 bloody diarrhoeal stools a day, abdominal pain, and lethargy. She had been started on oral prednisolone four days before admission. On admission, her inflammatory markers were raised, with a C reactive protein 312 mg/L (reference value <3; 1 mg/L=9.52 nmol/L), white blood cell count 30×109/L (4-10), albumin 34 g/L (35-45), and haemoglobin 104 g/L (110-160). On examination she was unwell, with a heart rate of 140 beats/min, blood pressure of 100/70 mm Hg, and temperature of 38.2°C. She was cool peripherally, with a capillary refill time of three to four seconds, and her abdomen was soft but generally tender. Her paediatric ulcerative colitis activity index (PUCAI) score was 65 (≥65 defines severe disease). She underwent plain abdominal radiography (fig 1).

Questions

  • 1 What is the diagnosis and what features on the radiograph point to it?

  • 2 What management strategies should be used here?

  • 3 What risk factors and infections should be excluded?

  • 4 What is the long term prognosis?

Answers

1 What features are seen in this radiograph and what is the diagnosis?

Short answer

The radiograph shows abnormal colonic dilation, particularly in the transverse colon, with loss of normal haustration and thumbprinting, indicative of mucosal oedema (fig 2). Mild central dilation of the small bowel is also present, but no evidence of perforation. The diagnosis is toxic megacolon complicating a case of acute severe colitis. A colonic diameter of greater than 56 mm, together with systemic toxicity, is diagnostic in children over the age of 10.1

Fig 2 Plain abdominal radiograph showing abnormal colonic dilation (double headed white arrow), loss of normal haustration, and thumbprinting indicating mucosal oedema within the colon (two single headed white arrows) in a child with inflammatory bowel disease and a toxic megacolon

Long answer

Although it may be …

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