Tumor Rupture and Organ

from an irritated diaphragm Gagneja and Sinicrope 2002 ; Yip and Goddard 2010 . Laboratory workup may reveal relative leuko- cytosis, neutrophilia, and anemia due to peritonitis and hemorrhage as well as electrolyte imbalances that need correction prior to surgery Gagneja and Sinicrope 2002 . Initial imaging consists of an upright KUB to evaluate for air under the dia- phragm that may extend into the liver, enabling visualization of the hepatic ligament, and decubi- tus KUB to evaluate for air along the fl ank. Another clue to the presence of perforation is visualization of both sides of the bowel wall. In the setting of an indeterminate KUB, CT scan should be utilized Gagneja and Sinicrope 2002 . Surgical consultation is paramount with suspi- cion of tumor rupture or organ perforation. Pending surgical intervention, immediate man- agement includes making the patient NPO with nasogastric tube placement with suction to evac- uate the stomach and protect the airway. In addi- tion, urinary catheterization and analgesics may be necessary to monitor fl uid status and control pain, respectively. Given the risk of infection, adequate coverage for Gram- negative enteric and anaerobic organisms should be implemented similar to treatment for neutropenic enterocolitis. Laparoscopy should be utilized when possible, with surgery consisting of bowel resection of the affected area followed by reanastomosis. Patients with excessive tumor burden, such as those with disseminated Burkitt lymphoma, require reduc- tion by chemotherapy prior to surgical interven- tion Gagneja and Sinicrope 2002 ; Fisher and Rheingold 2011 .

7.7 Abdominal Compartment

Syndrome Although mostly seen in adult patients who have sustained trauma, abdominal compartment syndrome ACS may occur in pediatric patients, including those with large tumor masses at pre- sentation or as a postoperative complication Fisher and Rheingold 2011 ; Terpe et al. 2012 . The mechanism of ACS appears to be ischemia- reperfusion injury with associated bowel isch- emia or necrosis Beck et al. 2001 . Two large prospective studies report the incidence of ACS among children admitted to the intensive care unit to be 1 , irrespective of an oncologic diagnosis and with high risk of mortality Cheatham et al. 2007 . Increased intra- abdominal pressure IAP leads to multiorgan compromise by initially impairing respiratory mecha nics which alter cardiac output leading to organ hypoperfusion and subsequent renal and cerebral insuffi ciency De Backer 1999 . Although no defi nitive ACS diagnostic crite- ria exist for the pediatric population, children are thought to require an IAP of ≥20 mmHg with associated organ compromise Beck et al. 2001 ; Cheatham et al. 2007 ; Fisher and Rheingold 2011 . Patients with ACS will present with a tense and distended abdomen with associated hypotension, oliguria or anuria and respiratory compromise Beck et al. 2011 . The aims of ACS management are to: 1 improve abdominal wall compliance with positioning and medications; 2 decrease intraluminal content with nasogas- tric suction; 3 decrease extraluminal content with percutaneous catheter decompression of intraperitoneal air or fl uid; and 4 optimize fl uid balance to reduce end-organ hypoperfusion with- out worsening IAH. Elevating the head of the bed increases IAP and should be avoided; similarly, sedatives and analgesics will increase abdominal muscle tone and should be minimized, as possi- ble. Studies in adults with ACS are investigating neuromuscular blockade as a means to decrease IAP. Careful aggressive fl uid resuscitation with hypertonic crystalloids and colloids should be attempted although refractory IAH or end-organ damage requires immediate surgical decompres- sion Cheatham et al. 2007 .

7.8 Summary

Prompt identifi cation of abdominal emergencies in pediatric oncology patients can be a chal- lenge due to decreased signs and symptoms of infl ammation in the immunocompromised host. Successful outcomes require vigilance for atypi- cal presentations in immunocompromised chil- dren; early initiation of broad-spectrum, empiric antibiotics to reduce infection-related mortality; supportive care measures such as volume resusci- tation and bleeding control; identifi cation of incit- ing chemotherapeutic agents as well as radiation therapy; appropriate utilization of imaging modalities; and a multidisciplinary team approach with oncology, surgery, and radiology to acceler- ate diagnosis and treatment. Prompt diagnosis and early medical management reduces the necessity of invasive measures. The majority of guidelines for care of these emergent issues are based on consensus panels and expert opinion due to a lack of randomized controlled trial data. 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