Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Acute abdominal pain in childhood Alan M. Lake To cite this article: Alan M. Lake (1979) Acute abdominal pain in childhood, Postgraduate Medicine, 65:6, 119-127, DOI: 10.1080/00325481.1979.11715177 To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715177
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 17 August 2017, At: 11:08
Acute abdominal pain in childhood Finding the cause
Alan M. Lake, MD
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
Consider What intestinal disorders must be considered in the child who presents with acute abdominal pain? What possible under(l'ing cause of acute abdominal pain should be considered in the child who has recently had mumps or a course of steroid therapy? When is consultation with a surgeon indicated?
The child with acute abdominal pain poses a problem of differential diagnosis. Selection of diagnostic studies and ini.tial management depends on the unique characteristics of history or physical examination that narrow the range of possible underlying causes. Acute abdominal pain in children may originate from intestinal, pancreatic, hepatobiliary, genitourinary, or systemic disorders or from the presence of an intestinal foreign body. The emphasis of this article is on differentiating in pediatric patients the cause of abdominal pain of recent onset accompanied by objective findings of abdominal tenderness. Recurrent abdominal pain is not considered. Differential diagnosis Intestinal considerations-Gastroenteritis is probably the most common nonfunctional cause of acute abdominal pain in children. Although a virus is usually responsible, infection with Salmonella, Shigella, and Yersinia organisms should be considered. The pain of gastroenteritis, usually diffuse and cramping, follows the onset of diarrhea, nausea, and emesis. In contrast, the pain of appendicitis nearly always precedes emesis. Other hallmarks of childhood appendicitis include loss of appetite, low-grade fever, and acute abdominal tenderness. Diarrhea, while frequent, is rarely as severe as that seen in gastroenteritis. Rectal examination is essential to define the
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
point of greatest tenderness and to exclude constipation. Appendicitis in infants is rare, and diagnosis prior to perforation is uncommon. The ability of the physician to localize the pain and demonstrate rebound in infants is severely limited. A primary physician may annually document several cases of peptic ulcer disease in children. Duodenal lesions far surpass gastric ulcers in incidence. Classic symptoms should not be expected until early adolescence. In infancy, failure to thrive and emesis predominate. In schoolage children, pain is more common; eating may alleviate or exacerbate the pain. Night pain and a positive family history of peptic ulcer may also be found. When epigastric pain is acute, gastritis is more likely than ulcer disease. In my experience, salicylates are often implicated in acute gastritis. If the patient has melena with pain, Meckel's diverticulum should be considered. Intestinal obstruction must be excluded in the child with pain, distention, and emesis. Many congenital lesions, especially Hirschsprung's disease, become evident in the neonatal period. 1·2 Beyond the neonatal period, intussusception, malrotation, volvulus, enteric duplication, continued
119
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
The pain of gastroenteritis follows onset of emesis, whereas the pain of appendicitis almost always precedes emesis.
incarcerated hernia, trauma, inflammatory bowel disease, and extrinsic compression remain foremost in the differential diagnosis. Paralytic ileus resulting from perforation, vascular insufficiency, primary peritonitis, or metabolic imbalance (eg, hyperglycemia, hypokalemia, hypocalcemia, or acidosis) mimics mechanical obstruction. If obstruction is suspected, nasogastric decompression should be instituted and strict attention paid to increased fluid, protein, and electrolyte requirements. If obstruction is not recognized and corrected, acidosis and shock will ensue. Intussusception in children 6 to 30 months of age is rarely missed. Severe cramping pain that is acute in onset and recurs at 15- to 30-minute intervals is the hallmark. Between pain episodes the child may sleep or act well. A mass may be found on examination or seen on upright abdominal films. The passage of blood in the stool is a common, though late, sign. A barium enema study done by an experienced radiologist is both confirmatory (by excluding volvulus) and therapeutic in most toddlers. In children older than 3 years, barium reduction is less likely to succeed. Lead points such as Meckel's diverticulum, intestinal polyp, or lymphosarcoma and predisposing conditions such as cystic fibrosis and anaphylactoid (Henoch-Schonlein) purpura should be suspected in older children with
120
intussusception. Intramural hematomas of the intestinal wall, present in several conditions, also produce severe cramping abdominal pain and occult blood in stools (positive Hematest). Blunt trauma is an etiologic factor which may be especially difficult to consider in the battered child because the parents offer no explanation for the abdominal findings. In Henoch-Schonlein purpura, abdominal pain and presence of occult blood in stools may precede appearance of the more characteristic diagnostic features, ie, dermatologic, renal, and joint lesions. 3 The development of pain and appearance of blood-streaked stools following gastroenteritis should alert the physician to the hemolyticuremic syndrome, 4 consisting of microangiographic hemolysis, thrombocytopenia, and nephritis. Renal failure with hypertension may ensue, both greatly complicated by unnecessary exploratory laparotomy. Submucosal colonic hematomas produce a "thumbprint" sign on barium enema study that may be confused with acute ulcerative colitis. In other coagulopathies, such as idiopathic thrombocytopenic purpura or hemophilia, intramural hematomas rarely develop in the absence of significant trauma._ Inflammatory bowel disease occasionally presents with acute pain secondary to hemorrhage, perfora-
tion, obstruction, fistula formation, or toxic megacolon. Symptoms, however, are generally much more insidious, with moderate cramping, chronic loss of appetite, increasing diarrhea, and growth failure. Positive findings on sigmoidoscopy, rectal biopsy, and barium studies, and an increased ESR confirm the diagnosis. Acute ileitis is occasionally found at laparotomy for "appendicitis." If the ileal pathology resembles Crohn's transmural enteritis, fistula formation may follow appendectomy, particularly if the cecum is involved. Y enterocolitica increasingly has been implicated with acute ileitis. s Parasitic intestinal infection may lead to severe cramping pain, usually with diarrhea. Ascariasis and other helminthic infection may be suspected by a history of exposure or by examination of the stool. Giardiasis is rarely acutely symptomatic, though it may induce postprandial pain as a result ofthe duodenal infection. Pinworms should not be implicated as a cause of abdominal pain. Constipation with rectosigmoid impaction may produce significant cramping, especially after meals. Diagnosis, which should be made on the basis of abdominal and rectal examination, may be obscured by the history of "diarrhea"- caused by leakage of mucous stool around the impaction. Mesenteric adenitis is believed to
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
A foreign body in the intestine rarely pro· duces acute abdominal pain.
result from lymphoid hyperplasia in the distal ileal mesentery in association with respiratory illness. This entity is usually diagnosed postoperatively. Tuberculous mesenteric adenitis is now extraordinarily rare in the United States. The incidence of primary peritonitis with pneumococcal or streptococcal infection has also diminished. It is most common in women and children with nephrotic syndrome or ascites. Patients present with acute pain, abdominal distention, high fever, and marked toxic reaction. Diagnosis is made by peritoneal aspiration.
Pancreatic conditions-Pancreatitis is often ignored as a possible cause of acute abdominal pain in children. Nausea, emesis, and lowgrade fever are common. Pain rarely radiates to the back. Serum and urine amylase determinations confirm the diagnosis: The cause is usually viral (especially mumps) or is related to medications (eg, steroids, azathioprine, and isoniazid). The family history, however, should be explored for hyperlipidemias and familial pancreatitis. Pseudocysts of the pancreas may result from inflammation or trauma. As palpation may be difficult, abdominal ultrasonography offers a benign, well-tolerated adjunct to diagnosis.
Hepatobiliary conditionsAcute abdominal pain in the right upper quadrant may herald viral
hepatitis. Pain may precede clinical icterus, but anorexia, elevated enzyme levels, and urine bilirubin should be present. Similar pain with asymmetric liver enlargement should suggest hepatic tumor, abscess, or choledochal cyst. Pain, hepatitis, and splenic enlargement are rare in portal venous thrombosis and common in Wilson's disease, infectious mononucleosis, and cytomegalovirus infection. Pain with unconjugated hyperbilirubinemia in the absence of hepatitis is an uncommon finding with Gilbert's disease. Pain in the right upper quadrant in the absence of jaundice or a mass should suggest pneumonia of the right middle or lower lobe. While cholelithiasis in teenagers with a family history of gallbladder disorders may be seen, it is usually of clinical significance only with hemolytic anemias, such as thalassemia, sickle cell disease, or spherocytosis. Isolated cholecystitis is extraordinarily rare, thoug:: enlargement (hydrops) may be seen with systemic bacterial or viral disease.
Genitourinary conditions-
Alan M. Lake Dr Lake is a clinical and research fellow, pediatric gastrointestinal unit, Massachusetts General Hospital, Boston. In July he will become assistant professor, pediatric gastrointestinal and nutrition unit, Johns Hopkins University Hospital. Baltimore.
Pyelonephritis in early childhood is as likely to present with abdominal as with costovertebral pain. While pyuria may be encountered with appendicitis and other pelvic inflammation, bacteriuria and cellular casts are not. Acute pyelonephritis in infancy often results from underlying hydronephrosis secondary to congenital or acquired obstruction.
continued
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
121
Peritrate~
SA Sustained Action (pentaerythritol tetranitrate)
80 mg
Peritnte"~
(pentaerythritol tetranitrate) Peritnte6 (pentaerythritol tetranitrate) Peritnte" (pentaerythritol tetranitrate)
40 mg 20 mg 10 mg
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
CAUTION: Federal law prohibits dispensrng without prescription. Oucriptln: Each tablet of Peritrate SA Sustained Action contains: pentaerythritol tetranitrate 80 mg (20 mg in immediate release layer and 60 mg in sustained release base). Each tablet of PenIrate 40 mg contains pentaerythritol tetranitrate 40 mg. Each tablet of Peritrate 20 mg contains pentaerythritol tetranitrate 20 mg. Each tablet of Peritrate 10 mg contains pentaerythritol tetranitrate 10 mg. Peritrate (pentaerythritol tetranitrate) is a nitric acrd ester of a tetrahydric alcohol (pentaerythritol). lndlutions: Based on a revrew of this drug by the Natronal Academy of Sciences-National Research Council and/or other information. FDA has classrfied the indications as follows: "Possibly" effectrve: Peritrate (pentaerythritol tetranrtrate). is mdicated for the relief of angina pectons (pain associated wrth coronary artery drsease). 1t rs not mtended to abort the acute angmal episode but it rs wrdely regarded as useful rn the prophylactic treatment of angma pectoris Frnal classrfrcation of the less-than-effective mdrcatrons requires further investigation. Contrtindications: Pentrate SA Sustarned Action (pentaerythntol tetranitrate) 80 mg and Peritrate (pentaerythritol tetranitrate) are contraindicated in patients who nave a history of sensrtivity to the drug. Warning: Data supporting the use of Peritrate (pentaerythntol tetranitrate) during the early days of the acute phase of myocardial infarction (the penod during whrch clin~cal and laboratory hndmgs are unstable) are insufficrent to establish safety. This drug can act as a physiologrcal antagonist to norepinephnne. acetylcholine. histamme. and many other agents Prec1utions: Should be used wrth cautiOn rn patrents who have glaucoma. Tolerance to thrs drug. and cross-tolerance to other nitrites and nitrates may occur Adverse Ructions: Side effects reported to date nave been preoominantly related to rash (whrch requires discontinuatron of medication) and headache and gastrointestlnal distress. which are usually mrld and transrent with continuatron of medrcatlon. In some cases severe. persrstent headaches may occur. In addrtion. the followmg adverse reactions to nitrates such as pentaerythritol tetranitrate have been reported in the literature: (a) Cutaneous vasodilatation wrth flushmg. (b) Transient eprsodes of dizziness and weakness. as well as other signs of cerebralrschemia assocrated wrth postural hypotension. may occasronally develop. (c) An occasional rndrvidual exhrbrts marked sensitivity to the hypotensive effects of nitrite and severe responses (nausea. vomiting. weakness. restlessness. pallor. perspiration and collapse) can occur. even with the usual therapeutic doses. Alcohol may enhance this effect. lle11ge: Peritrate (pentaerythritol tetranitrate) may be adminiStered rn individualized doses up to 160 mg a day. Dosage can be initiated at one 10 mg or 20 mg tablet q.r.d. and trtrated upward to 40 mg (two 20 mg tablets or one 40 mg tablet) q.i.d. one-half hour before or one hour after meals and at bedtime. Alternatively, Peritrate Sustained Action 80 mg can be administered on a convenient b.i.d. dosage schedule. s.,,led: Peritrate SA Sustained Actron (pentaerythritol tetranitrate) 80 mg-double-layer. biconvex. dark green/light green tablets in bottles of 100 (N 0047-0004-51) and 1000 (N 0047-0004-60). Also unit dose. package of 10 x 10 strips (N 0047-0004-11). Peritrate (pentaerythritol tetran~trate)40 mg-pink scored tablets in bottles of 100 (N 0047-000B-51). Peritrate (pentaerythritol tetranitrate)20 mg-light green. scored tablets in bottles of 100 (N 0047-0001-51) and 1000 (N 0047-0001-60). Also unit dose. package of 10 x 10 strips (N 0047-0001-11). Peritrate (pentaerythritol tetranitrate) 10 mg-lignt green. unscored tablets in bottles of 100 (N 0047-0007-51) and 1000 (N 0047-0007-60). STORE BETWEEN 59o lftd 86o F (15o 1nd 30o CJ. Alillll l'lllr•ICIIDtY: In a series of carefully designed studies in pigs, Peritrate (pentaerythritol tetranitrate) was administered for 48 hours before an artifically induced occlusion of a major coronary artery and for seven days thereafter. The pigs were sacrificed at various intervals for periods up to six weel
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Acute abdominal pain in childhood Alan M. Lake To cite this article: Alan M. Lake (1979) Acute abdominal pain in childhood, Postgraduate Medicine, 65:6, 119-127, DOI: 10.1080/00325481.1979.11715177 To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715177
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 17 August 2017, At: 11:08
Acute abdominal pain in childhood Finding the cause
Alan M. Lake, MD
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
Consider What intestinal disorders must be considered in the child who presents with acute abdominal pain? What possible under(l'ing cause of acute abdominal pain should be considered in the child who has recently had mumps or a course of steroid therapy? When is consultation with a surgeon indicated?
The child with acute abdominal pain poses a problem of differential diagnosis. Selection of diagnostic studies and ini.tial management depends on the unique characteristics of history or physical examination that narrow the range of possible underlying causes. Acute abdominal pain in children may originate from intestinal, pancreatic, hepatobiliary, genitourinary, or systemic disorders or from the presence of an intestinal foreign body. The emphasis of this article is on differentiating in pediatric patients the cause of abdominal pain of recent onset accompanied by objective findings of abdominal tenderness. Recurrent abdominal pain is not considered. Differential diagnosis Intestinal considerations-Gastroenteritis is probably the most common nonfunctional cause of acute abdominal pain in children. Although a virus is usually responsible, infection with Salmonella, Shigella, and Yersinia organisms should be considered. The pain of gastroenteritis, usually diffuse and cramping, follows the onset of diarrhea, nausea, and emesis. In contrast, the pain of appendicitis nearly always precedes emesis. Other hallmarks of childhood appendicitis include loss of appetite, low-grade fever, and acute abdominal tenderness. Diarrhea, while frequent, is rarely as severe as that seen in gastroenteritis. Rectal examination is essential to define the
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
point of greatest tenderness and to exclude constipation. Appendicitis in infants is rare, and diagnosis prior to perforation is uncommon. The ability of the physician to localize the pain and demonstrate rebound in infants is severely limited. A primary physician may annually document several cases of peptic ulcer disease in children. Duodenal lesions far surpass gastric ulcers in incidence. Classic symptoms should not be expected until early adolescence. In infancy, failure to thrive and emesis predominate. In schoolage children, pain is more common; eating may alleviate or exacerbate the pain. Night pain and a positive family history of peptic ulcer may also be found. When epigastric pain is acute, gastritis is more likely than ulcer disease. In my experience, salicylates are often implicated in acute gastritis. If the patient has melena with pain, Meckel's diverticulum should be considered. Intestinal obstruction must be excluded in the child with pain, distention, and emesis. Many congenital lesions, especially Hirschsprung's disease, become evident in the neonatal period. 1·2 Beyond the neonatal period, intussusception, malrotation, volvulus, enteric duplication, continued
119
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
The pain of gastroenteritis follows onset of emesis, whereas the pain of appendicitis almost always precedes emesis.
incarcerated hernia, trauma, inflammatory bowel disease, and extrinsic compression remain foremost in the differential diagnosis. Paralytic ileus resulting from perforation, vascular insufficiency, primary peritonitis, or metabolic imbalance (eg, hyperglycemia, hypokalemia, hypocalcemia, or acidosis) mimics mechanical obstruction. If obstruction is suspected, nasogastric decompression should be instituted and strict attention paid to increased fluid, protein, and electrolyte requirements. If obstruction is not recognized and corrected, acidosis and shock will ensue. Intussusception in children 6 to 30 months of age is rarely missed. Severe cramping pain that is acute in onset and recurs at 15- to 30-minute intervals is the hallmark. Between pain episodes the child may sleep or act well. A mass may be found on examination or seen on upright abdominal films. The passage of blood in the stool is a common, though late, sign. A barium enema study done by an experienced radiologist is both confirmatory (by excluding volvulus) and therapeutic in most toddlers. In children older than 3 years, barium reduction is less likely to succeed. Lead points such as Meckel's diverticulum, intestinal polyp, or lymphosarcoma and predisposing conditions such as cystic fibrosis and anaphylactoid (Henoch-Schonlein) purpura should be suspected in older children with
120
intussusception. Intramural hematomas of the intestinal wall, present in several conditions, also produce severe cramping abdominal pain and occult blood in stools (positive Hematest). Blunt trauma is an etiologic factor which may be especially difficult to consider in the battered child because the parents offer no explanation for the abdominal findings. In Henoch-Schonlein purpura, abdominal pain and presence of occult blood in stools may precede appearance of the more characteristic diagnostic features, ie, dermatologic, renal, and joint lesions. 3 The development of pain and appearance of blood-streaked stools following gastroenteritis should alert the physician to the hemolyticuremic syndrome, 4 consisting of microangiographic hemolysis, thrombocytopenia, and nephritis. Renal failure with hypertension may ensue, both greatly complicated by unnecessary exploratory laparotomy. Submucosal colonic hematomas produce a "thumbprint" sign on barium enema study that may be confused with acute ulcerative colitis. In other coagulopathies, such as idiopathic thrombocytopenic purpura or hemophilia, intramural hematomas rarely develop in the absence of significant trauma._ Inflammatory bowel disease occasionally presents with acute pain secondary to hemorrhage, perfora-
tion, obstruction, fistula formation, or toxic megacolon. Symptoms, however, are generally much more insidious, with moderate cramping, chronic loss of appetite, increasing diarrhea, and growth failure. Positive findings on sigmoidoscopy, rectal biopsy, and barium studies, and an increased ESR confirm the diagnosis. Acute ileitis is occasionally found at laparotomy for "appendicitis." If the ileal pathology resembles Crohn's transmural enteritis, fistula formation may follow appendectomy, particularly if the cecum is involved. Y enterocolitica increasingly has been implicated with acute ileitis. s Parasitic intestinal infection may lead to severe cramping pain, usually with diarrhea. Ascariasis and other helminthic infection may be suspected by a history of exposure or by examination of the stool. Giardiasis is rarely acutely symptomatic, though it may induce postprandial pain as a result ofthe duodenal infection. Pinworms should not be implicated as a cause of abdominal pain. Constipation with rectosigmoid impaction may produce significant cramping, especially after meals. Diagnosis, which should be made on the basis of abdominal and rectal examination, may be obscured by the history of "diarrhea"- caused by leakage of mucous stool around the impaction. Mesenteric adenitis is believed to
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
A foreign body in the intestine rarely pro· duces acute abdominal pain.
result from lymphoid hyperplasia in the distal ileal mesentery in association with respiratory illness. This entity is usually diagnosed postoperatively. Tuberculous mesenteric adenitis is now extraordinarily rare in the United States. The incidence of primary peritonitis with pneumococcal or streptococcal infection has also diminished. It is most common in women and children with nephrotic syndrome or ascites. Patients present with acute pain, abdominal distention, high fever, and marked toxic reaction. Diagnosis is made by peritoneal aspiration.
Pancreatic conditions-Pancreatitis is often ignored as a possible cause of acute abdominal pain in children. Nausea, emesis, and lowgrade fever are common. Pain rarely radiates to the back. Serum and urine amylase determinations confirm the diagnosis: The cause is usually viral (especially mumps) or is related to medications (eg, steroids, azathioprine, and isoniazid). The family history, however, should be explored for hyperlipidemias and familial pancreatitis. Pseudocysts of the pancreas may result from inflammation or trauma. As palpation may be difficult, abdominal ultrasonography offers a benign, well-tolerated adjunct to diagnosis.
Hepatobiliary conditionsAcute abdominal pain in the right upper quadrant may herald viral
hepatitis. Pain may precede clinical icterus, but anorexia, elevated enzyme levels, and urine bilirubin should be present. Similar pain with asymmetric liver enlargement should suggest hepatic tumor, abscess, or choledochal cyst. Pain, hepatitis, and splenic enlargement are rare in portal venous thrombosis and common in Wilson's disease, infectious mononucleosis, and cytomegalovirus infection. Pain with unconjugated hyperbilirubinemia in the absence of hepatitis is an uncommon finding with Gilbert's disease. Pain in the right upper quadrant in the absence of jaundice or a mass should suggest pneumonia of the right middle or lower lobe. While cholelithiasis in teenagers with a family history of gallbladder disorders may be seen, it is usually of clinical significance only with hemolytic anemias, such as thalassemia, sickle cell disease, or spherocytosis. Isolated cholecystitis is extraordinarily rare, thoug:: enlargement (hydrops) may be seen with systemic bacterial or viral disease.
Genitourinary conditions-
Alan M. Lake Dr Lake is a clinical and research fellow, pediatric gastrointestinal unit, Massachusetts General Hospital, Boston. In July he will become assistant professor, pediatric gastrointestinal and nutrition unit, Johns Hopkins University Hospital. Baltimore.
Pyelonephritis in early childhood is as likely to present with abdominal as with costovertebral pain. While pyuria may be encountered with appendicitis and other pelvic inflammation, bacteriuria and cellular casts are not. Acute pyelonephritis in infancy often results from underlying hydronephrosis secondary to congenital or acquired obstruction.
continued
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
121
Peritrate~
SA Sustained Action (pentaerythritol tetranitrate)
80 mg
Peritnte"~
(pentaerythritol tetranitrate) Peritnte6 (pentaerythritol tetranitrate) Peritnte" (pentaerythritol tetranitrate)
40 mg 20 mg 10 mg
Downloaded by [Australian Catholic University] at 11:08 17 August 2017
CAUTION: Federal law prohibits dispensrng without prescription. Oucriptln: Each tablet of Peritrate SA Sustained Action contains: pentaerythritol tetranitrate 80 mg (20 mg in immediate release layer and 60 mg in sustained release base). Each tablet of PenIrate 40 mg contains pentaerythritol tetranitrate 40 mg. Each tablet of Peritrate 20 mg contains pentaerythritol tetranitrate 20 mg. Each tablet of Peritrate 10 mg contains pentaerythritol tetranitrate 10 mg. Peritrate (pentaerythritol tetranitrate) is a nitric acrd ester of a tetrahydric alcohol (pentaerythritol). lndlutions: Based on a revrew of this drug by the Natronal Academy of Sciences-National Research Council and/or other information. FDA has classrfied the indications as follows: "Possibly" effectrve: Peritrate (pentaerythritol tetranrtrate). is mdicated for the relief of angina pectons (pain associated wrth coronary artery drsease). 1t rs not mtended to abort the acute angmal episode but it rs wrdely regarded as useful rn the prophylactic treatment of angma pectoris Frnal classrfrcation of the less-than-effective mdrcatrons requires further investigation. Contrtindications: Pentrate SA Sustarned Action (pentaerythntol tetranitrate) 80 mg and Peritrate (pentaerythritol tetranitrate) are contraindicated in patients who nave a history of sensrtivity to the drug. Warning: Data supporting the use of Peritrate (pentaerythntol tetranitrate) during the early days of the acute phase of myocardial infarction (the penod during whrch clin~cal and laboratory hndmgs are unstable) are insufficrent to establish safety. This drug can act as a physiologrcal antagonist to norepinephnne. acetylcholine. histamme. and many other agents Prec1utions: Should be used wrth cautiOn rn patrents who have glaucoma. Tolerance to thrs drug. and cross-tolerance to other nitrites and nitrates may occur Adverse Ructions: Side effects reported to date nave been preoominantly related to rash (whrch requires discontinuatron of medication) and headache and gastrointestlnal distress. which are usually mrld and transrent with continuatron of medrcatlon. In some cases severe. persrstent headaches may occur. In addrtion. the followmg adverse reactions to nitrates such as pentaerythritol tetranitrate have been reported in the literature: (a) Cutaneous vasodilatation wrth flushmg. (b) Transient eprsodes of dizziness and weakness. as well as other signs of cerebralrschemia assocrated wrth postural hypotension. may occasronally develop. (c) An occasional rndrvidual exhrbrts marked sensitivity to the hypotensive effects of nitrite and severe responses (nausea. vomiting. weakness. restlessness. pallor. perspiration and collapse) can occur. even with the usual therapeutic doses. Alcohol may enhance this effect. lle11ge: Peritrate (pentaerythritol tetranitrate) may be adminiStered rn individualized doses up to 160 mg a day. Dosage can be initiated at one 10 mg or 20 mg tablet q.r.d. and trtrated upward to 40 mg (two 20 mg tablets or one 40 mg tablet) q.i.d. one-half hour before or one hour after meals and at bedtime. Alternatively, Peritrate Sustained Action 80 mg can be administered on a convenient b.i.d. dosage schedule. s.,,led: Peritrate SA Sustained Actron (pentaerythritol tetranitrate) 80 mg-double-layer. biconvex. dark green/light green tablets in bottles of 100 (N 0047-0004-51) and 1000 (N 0047-0004-60). Also unit dose. package of 10 x 10 strips (N 0047-0004-11). Peritrate (pentaerythritol tetran~trate)40 mg-pink scored tablets in bottles of 100 (N 0047-000B-51). Peritrate (pentaerythritol tetranitrate)20 mg-light green. scored tablets in bottles of 100 (N 0047-0001-51) and 1000 (N 0047-0001-60). Also unit dose. package of 10 x 10 strips (N 0047-0001-11). Peritrate (pentaerythritol tetranitrate) 10 mg-lignt green. unscored tablets in bottles of 100 (N 0047-0007-51) and 1000 (N 0047-0007-60). STORE BETWEEN 59o lftd 86o F (15o 1nd 30o CJ. Alillll l'lllr•ICIIDtY: In a series of carefully designed studies in pigs, Peritrate (pentaerythritol tetranitrate) was administered for 48 hours before an artifically induced occlusion of a major coronary artery and for seven days thereafter. The pigs were sacrificed at various intervals for periods up to six weel
