In this topic :

1) Why acute abdomen in children want to present ??!!!

2) Areal case discussion in dibba hospital .

3) Evaluation of acute abdominal pain clinically .

4) Intussusception

5) Cases .

6) Something missed in my topic . ?????

7) Waiting for us .

On 15 January 2015

Paediatric department

Dana 2 years old girl brought by her mother to paediatric opd with a history of

abdominal pain and vomiting since early morning with poor feeding . No diarrhea

nor fever . With a past history of common cold last week .

CBC / RFT / CRP / RBS investigations requested .

Put in observation room under iv fluids and iv antiemetic for many hours waiting

for any improvement and for investigations results .

But

No improvement !

At 19 : 35 pm - 15 January 2015

A phone call happen :

Nurse : doctor , Dana still in pain with continuous vomiting .

Paed . : even after iv medications ?

Nurse : yes . !

Paed . : I will come this may be a case of …………… .

A case of ……… .

For this case and others I will

present

ACUTE ABDOMEN IN CHILDREN

Done by :

Dr. Mohammed Fawzy - M.O Paediatric

INTRODUCTION

Among children, abdominal pain is a frequent, nonspecific symptom that is typically associated with self-limited, minor conditions such as gastroenteritis and other viral illnesses. The challenge for the clinician is to identify patients with abdominal pain who may have the following:

Serious, potentially life-threatening conditions, such as appendicitis or bowel obstruction (as can occur from volvulus, intussusception, or adhesions)

Infections that require specific treatment (such as streptococcal pharyngitis, urinary tract infection, or pneumonia)

Unusual manifestations of less common diseases (such as Hirschsprung's disease or primary bacterial peritonitis with nephrotic syndrome)

The frequency of surgical intervention in patients presenting with acute abdominal pain is around 1% . Unfortunately, a small number of patients with acute abdominal pain may not receive a definitive diagnosis on first evaluation because of the early stage of the disease and atypical signs . It is important to understand that accurate and timely diagnosis is the key to preventing significant morbidity and mortality

This Topic provides a review of :

1 . the pathogenesis abdominal pain .

2. Etiology .

3 . Most common diseases :

Appendicitis

Abdominal trauma

Intestinal obstruction ( eg . Intussusception )

Gastroenteritis

Constipation

Mesenteric lymphadenitis

Infantile colic

4. Clinical evaluation .

5. Management of children with acute abdominal pain.

PATHOGENESIS

Abdominal pain may be classified as visceral, somatoparietal, and referred

pain according to the nature of the pain receptors involved. most abdominal

pain is associated with visceral pain receptors.

Visceral pain receptors are located on the serosal surface, in the mesentery,

within the intestinal muscle, and the mucosa of hollow organs.

ETIOLOGY

The causes of acute abdominal pain in children are listed in Table 1.

A wide range of surgical and non-surgical conditions can cause acute

abdominal pain in children. A brief discussion of some life-threatening and

common causes of acute abdominal pain follows.

Table 1Causes of Acute Abdominal Pain in Children

Table 1

Causes of Acute Abdominal Pain in Children

Life-threatening causes of abdominal pain often result from hemorrhage, obstruction, or perforation of the gastrointestinal tract or intra-abdominal organs, and may be associated with specific clinical features .

Extra-abdominal causes of abdominal pain (e.g., diabetic , hemolytic uremic syndrome, and myocarditis) also have other clinical features.

Common causes of abdominal pain include gastroenteritis, constipation, systemic viral illness, infections outside of the gastrointestinal tract (e.g., streptococcal pharyngitis, lower lobe pneumonia, and urinary tract infection), mesenteric lymphadenitis, and infantile colic should be in mind .

3 . Most common diseases :

Appendicitis

Abdominal trauma

Intestinal obstruction ( eg . Intussusception )

Gastroenteritis

Constipation

Mesenteric lymphadenitis

Infantile colic

Acute appendicitis

Acute appendicitis is the most common surgical cause of acute abdominal pain in children .

Typically, children with appendicitis present with visceral, vague, poorly localized, periumbilical pain. After that become localized in RLQ of the abdomen

Within 6 to 48 hours, the pain becomes parietal as the overlying peritoneum becomes inflamed.

The pain manifests itself as a well-localized pain in the right lower quadrant. However, some of these characteristic manifestations are frequently absent, particularly in younger children .

Therefore, physicians should consider the diagnosis of appendicitis in all cases of previously healthy children who have a history of abdominal pain and vomiting, with or without fever or focal abdominal tenderness .

Abdominal trauma :

Abdominal trauma may cause hemorrhage or laceration of solid organs,

bowel perforation, organ ischemia from vascular injury .

Blunt abdominal trauma is more common than penetrating injury. Typical

mechanisms of trauma include motor vehicle accidents, falling down, and

child abuse.

Intestinal obstruction :

Intestinal obstruction may produce a characteristic cramping pain.

This clinical feature is usually associated with serious intra-

abdominal conditions that require urgent diagnosis and treatment.

Causes of intestinal obstruction include intussusception,

malrotation with midgut volvulus, necrotizing enterocolitis,

incarcerated inguinal hernia, and postoperative adhesions .

the most common cause of intestinal obstruction in children is intussusception . But the mortality rate is less than 1%. If left untreated, however, this condition is uniformly fatal in 2-5 days.

GastroenteritisGastroenteritis is the most common medical condition of abdominal pain

in children Children with acute gastroenteritis may develop fever, severe cramping abdominal pain, and diffuse abdominal tenderness before diarrhea begins.

Viruses including rotavirus, Norwalk virus, adenovirus, and enterovirusare the most frequent causes . Bacteria and parasites can also cause acute abdominal pain in children.

ConstipationChildren with constipation often present with fecal impaction and severe

lower abdominal pain.

Constipation is likely in children with at least two of the following characteristics: fewer than three stools weekly, fecal incontinence, large stools palpable in the rectum or through the abdominal wall .

Mesenteric lymphadenitis Because mesenteric lymph nodes are usually in the right lower quadrant, this

condition sometimes mimics appendicitis, except the pain is more diffuse. Often, signs of peritonitis are absent.

In one series of 70 children with clinically suspected acute appendicitis, 16% had a final diagnosis of mesenteric lymphadenitis established by ultrasound, clinical course, or surgery .

Etiologies of mesenteric lymphadenitis include viral and bacterial gastroenteritis, inflammatory bowel disease, and lymphoma; viral infection is most common.

Infantile colic Infants with colic, particularly those with hypertonic characters, may have

severe abdominal pain. Typically, infants with colic show paroxysmal crying and draw their knees up against their abdomen.

Colic is relieved with the passage of flatus or stool during the first three to four weeks of life.

Age Emergent Nonemergent

0–3 months old Necrotizing enterocolitis

Volvulus

Incarcerated hernia

Testicular torsion

Nonaccidental trauma

Hirschsprung's

enterocolitis

Constipation

Acute gastroenteritis

Colic

3 months–3 years old Intussusception

Volvulus

Testicular torsion

Appendicites

Vaso-occlusive crisis

Urinary tract infections

Constipation

Henoch-Schönlein purpura

Acute gastroenteritis

3 years old–adolescence Appendicitis

Diabetic ketoacidosis

Vaso-occlusive crisis

Ectopic pregnancy

Ovarian torsion

Testicular torsion

Cholecystitis

Pancreatitis

Urinary tract infections

Tumor

Streptococcus pharyngitis

Inflammatory bowel disease

Pregnancy

Renal stones

Peptic ulcer disease/gastritis

Ovarian cysts

Henoch-Schönlein purpura

Constipation

Acute gastroenteritis

Nonspecific viral syndromes

Algorithmic approach to the children with acute abdominal pain

requiring urgent management

CLINICAL EVALUATION :

. Children with acute abdominal pain should be detained in an

emergency department with serial physical examinations to clarify any

diagnostic signs .

History taking

Important details of the history include symptom onset pattern,

progression, location, intensity, characters, precipitating and relieving

factors of abdominal pain, and associated symptoms. Age of the patient

is a key factor in the evaluation of acute abdominal pain as listed in

Table 2.

Other important historical variables include recent abdominal trauma,

previous abdominal surgery, and a thorough review of systems .

Pain relief after a bowel movement suggests a colonic condition, and

improvement in pain after vomiting may occur with conditions

localized to the small bowel.

In surgical abdomen, abdominal pain generally precedes vomiting,

and vomiting precedes abdominal pain in medical conditions.

Any infants and children presenting with bilious vomiting should be

presumed to have bowel obstruction.

Age Emergent Nonemergent

0–3 months old Necrotizing enterocolitis

Volvulus

Incarcerated hernia

Testicular torsion

Nonaccidental trauma

Hirschsprung's

enterocolitis

Constipation

Acute gastroenteritis

Colic

3 months–3 years old Intussusception

Volvulus

Testicular torsion

Appendicites

Vaso-occlusive crisis

Urinary tract infections

Constipation

Henoch-Schönlein purpura

Acute gastroenteritis

3 years old–adolescence Appendicitis

Diabetic ketoacidosis

Vaso-occlusive crisis

Ectopic pregnancy

Ovarian torsion

Testicular torsion

Cholecystitis

Pancreatitis

Urinary tract infections

Tumor

Streptococcus pharyngitis

Inflammatory bowel disease

Pregnancy

Renal stones

Peptic ulcer disease/gastritis

Ovarian cysts

Henoch-Schönlein purpura

Constipation

Acute gastroenteritis

Nonspecific viral syndromes

Physical examinations

Careful physical examination is essential for accurate diagnosis in children

with acute abdominal pain. Examination of external genitalia, testes,

anus, and rectum should be included as part of the evaluation for

abdominal pain. In addition, pelvic examination is important in sexually

active female adolescents.

General appearance

Children with peritoneal irritation remain still or resist movement, while

patients with visceral pain change position frequently, often discomfort.

Vital signs

Vital signs are useful in assessing hypovolemia and provide useful clues

for diagnosis. Fever indicates an underlying infection or inflammation

including acute gastroenteritis, pneumonia, pyelonephritis, or intra-

abdominal abscess. Tachypnea may indicate pneumonia. Tachycardia and

hypotension suggest hypovolemia or third-space volume loss.

Abdominal examination

The evaluating physician should gently palpate the abdomen moving

toward the area of maximal tenderness. The physician has to make

efforts to determine the degree of abdominal tenderness, location,

rebound tenderness, rigidity, distension, masses, or organomegaly. A

rectal examination provides useful information about sphincter tone,

presence of masses, stool nature, melena .

Investigations

Specific laboratory studies and radiologic evaluation are helpful to

assess the patient's physiological status and to make an accurate

diagnosis . A complete blood cell count and a urinalysis are generally indicated

in all patients with acute abdominal pain. Measurement of serum glucose

and electrolytes helps in evaluating the patient's hydration status and

acid-base balance. A pregnancy test should be performed in

postmenarcheal girls.

Plain abdominal radiographs are helpful if intestinal obstruction or

perforation is suspected. Chest radiographs may help rule out

pneumonia.

In the emergency department, ultrasound and computed tomography

are widely used to identify the cause of abdominal pain .

Although computed tomography is more accurate than ultrasound,

ultrasound is the preferred imaging modality for an initial evaluation of

many potential causes of pediatric abdominal pain because it is

noninvasive, radiation-free, and less expensive modality .

Algorithmic approach to the children with acute abdominal pain

requiring urgent management

MANAGEMENT

Treatment should be directed at the underlying cause of abdominal pain.

urgent intervention and management is required for children who are

prostrated and sick-appearing, have signs of bowel obstruction and

evidence of peritoneal irritation.

Initial resuscitation measures include correction of hypoxemia,

replacement of intravascular volume loss, and correction of metabolic

abnormalities. Gastric decompression using nasogastric tube may be

necessary if there is bowel obstruction. Empirical intravenous antibiotics

are often indicated when there is clinical suspicion of a serious intra-

abdominal infection.

Moreover, adequate analgesics should be provided to patients with

severe pain, preferably prior to surgical evaluation .

Intussusception

Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction.

A common cause of abdominal pain in children, intussusception is suggested readily in pediatric practice based on a classic triad of signs and symptoms: vomiting, abdominal pain, and passage of blood per rectum.

Intussusception presents in 2 variants:

A. Idiopathic intussusception, which usually starts at the ileocolic junction and affects infants and toddlers .

B. Enteroenteral intussusception (jejunojejunal, jejunoileal, ileoileal), which occurs in older children. associated with special medical situations (eg, Henoch-Schönlein purpura [HSP], cystic fibrosis, hematologic dyscrasias) or may be secondary to a lead point and occasionally occur in the postoperative period.

History Two thirds of children with intussusception are younger than 1 year; most commonly, intussusception

occurs in infants aged 5-10 months.

Intussusception is the most common cause of intestinal obstruction in patients aged 5 months to 3 years.

The patient with intussusception is usually an infant, often one who has had an upper respiratory infection, who presents with the following :

a) Vomiting : Initially, vomiting is non bilious and reflexive, but when the intestinal obstruction occurs, vomiting becomes bilious .

b) Abdominal pain : Pain in intussusception is colicky, severe, and intermittent . the child as drawing the legs up to the abdomen and kicking the legs in the air. In between attacks, the child appears calm and relieved .

c) Passage of blood and mucus: Parents report the passage of stools, by affected children, that look like currant jelly; this is a mixture of mucus, sloughed mucosa, and shed blood; diarrhea can also be an early sign of intussusception .

d) Lethargy: This can be the sole presenting symptom of intussusception, which makes the condition’s diagnosis challenging .

e) Palpable abdominal mass .

Physical examination

The hallmark physical findings in intussusception are a right

hypochondrium sausage-shaped mass and emptiness in the right lower

quadrant (Dance sign).

This mass is hard to detect and is best palpated between spasms of colic,

when the infant is quiet. Abdominal distention frequently is found if the

obstruction is complete.

Diagnosis1. Clinically : bilious vomiting , red current gelly stoole , lethargy , abdominal pain .

2. Laboratory investigation : is usually not helpful in the evaluation of patients with intussusception, although leukocytosis can be an indication of gangrene if the process is advanced. With persistent vomiting and sequestration of fluid in the obstructed bowel, dehydration and electrolyte imbalance occur.

3. Radiography : Plain abdominal radiography reveals signs that suggest intussusception in only 60% of cases

Plain radiograph findings may be normal early in the course of intussusception.As the disease progresses, the earliest radiographic evidence includes an absence of

air in the right lower and upper quadrants and a right upper quadrant soft tissue density present in 25-60% of patients.

These findings are followed by an obvious pattern of small bowel obstruction, with dilatation and air-fluid levels in the small bowel only.

If the distention is generalized and the air-fluid levels are also present in the colon, the findings more likely represent acute gastroenteritis than intussusception.???!!! Ask

surgeon !

4. Ultrasonography : Hallmarks of ultrasonography include the target and

pseudokidney signs. (See the image below.) called ……… .

4. Computed tomography (CT) scanning : has also been proposed as a

useful tool to diagnose intussusception (see the image below); however,

CT scan findings are unreliable, and CT scanning carries risks associated

with intravenous contrast administration, radiation exposure, and sedation.

6. contrast enema : The traditional and most reliable way to

make the diagnosis of intussusception in children is to

obtain a contrast enema (either barium or air). Contrast

enema is quick and reliable and has the potential to be

therapeutic.

Exercise caution when performing contrast enema in children older

than 3 years, because most of these patients have a surgical lead

point, usually in the small bowel. The diagnostic and therapeutic

yield of the enema is lower in these patients.

Enema is contraindicated in patients in whom bowel gangrene or perforation is suspected.

Management :

1. Medically : Drug therapy is not currently a component of the

standard of care for intussusception.

Medications are limited to those used for pain control after

surgery. In the immediate postoperative period, weight-

adjusted intravenous morphine is usually administered.

As the oral diet is resumed, acetaminophen with codeine or

ibuprofen is given orally.

Patients with HSP or hemophilia and intussusception require

standard therapy for the individual disease.

Some investigators have advocated the use of steroids in

intussusception secondary to HSP and lymphoid hyperplasia,

with varied results

2. INTERVENTIONS :

Nonoperative reduction

Pneumatic: With air insufflation; this is the treatment of choice in

many institutions, and the risk of major complications with this

technique is small

Surgical reduction

Traditional entry into the abdomen is through a right paraumbilical

incision. The intussusception is delivered into the wound, and manual

reduction is attempted. It is important that the intussusception be

milked out of the intussuscipiens

CONCLUSION

Acute abdominal pain is one of the most common complaints in

childhood, and one that frequently requires rapid diagnosis and

treatment in the emergency department. Although acute abdominal pain

is typically self-limiting and benign, there are potentially life-threatening

conditions that require urgent management, such as appendicitis,

intussusception, or bowel obstruction. Meticulous history taking and

repeated physical examinations are essential to determine the cause of

acute abdominal pain and to identify children with surgical conditions.

Case 1

A 6-month-old, previously healthy boy was

brought to the ED for clear emesis of 1 day. No

history of fever, diarrhea, irritability or trauma.

On exam the child appeared well, with normal

vital signs and with a benign physical exam.

Abdomen was soft to palpation with normal

bowel sounds. The patient was treated in the ED

as a viral gastritis. He tolerated oral fluids well

and was discharged home. Parents returned

because emesis continued. On his second visit,

a rectal exam revealed occult blood in stools. He

was taken for abdominal x-rays which showed a

questionable mass on the right lower quadrant

(RLQ) suggestive of intussusception. Barium

enema failed to reduce the mass and the child

was taken to the OR with uneventful course.

Acute abdomen series in a child with intussusception

provides the picture of multiple dilated intestinal loops with

step-ladder pattern of air fluid leve

FECAL RETENTION IN

CONSTIPATION CASE

11 year old female comes to the clinic presenting

with a chief complaint of abdominal pain. The

abdominal pain is generalized in location, and

described as a dull pain, non-radiating. She

notes some acid reflex, and reports she has a

history of gastritis. She also notes decreased

appetite recently. Denies any nausea or

vomiting, denies any recent bowel changes.

Physical Exam: Unremarkable except some

generalized tenderness in the abdominal region,

no rebound, no guarding.

The abdominal x-ray shows evidence of duodenal

obstruction with a paucity of bowel gas through the

rest of the abdomen

INTESTINAL GASES

Dana 2 years old girl brought by her mother to paediatric opd with a

history of abdominal pain and vomiting since early morning with poor

feeding . No diarrhea nor fever . This is a past history of common cold

last week .

CBC / RFT / CRP / RBS investigations requested .

Put in observation room under iv fluids and iv antiemetic for many

hours waiting for any improvement and for investigations results .

After 5 hours under observation care still complaining continuous

vomiting of whitish vomits with frequent abdominal pain and no passage

of stoole since yesterday .

Something missed in my topic . ?????

Is a common emergent disease

Is

DKA

THANK YOU