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  • Abdominal pain is a common presenting symptomin children. A substantial percent of unscheduledpaediatric office visits and paediatric emergency roomvisits are due to abdominal pain.... Scholer et alinvestigated the prevalence presenting complaints in children found that more than 63 childrens reported some kind of abd pain.....
  • Individual children differ greatly in their perception of & tolerance for abdominal pian ..this is one of the sevral reason why pediatric abd pain is Is difficult to deal with..A child with functional abdominal pain may be as uncomfortable as one with an organic cause… will be touching upon the following topics
  • Nociception differs from other sensation in that it sounds a warning that sumthing is wrong & it preempts other signals
  • Many of us think why treat pain if its causeless harmless ,I think q can be better answered by those who suffered from some or other kind of pain may it be severe abd pain of appendicitis or simple headache basically pain turns out to be a comlex. Any pain wen prolong results in alteration of physilogy ranging from hyperacidity to sleep disturbance the importance of pain is so much recognised that separate pain clinics are now well eastablished.
  • Pain can be explained on basis of 4 physilogical phenomenonTransduction is a process by which noxious stimuli are translated into electric signals at sensory n endings..performed Primary afferent fibers -synapse in the dorsal horn of spinal cordSecond order neuron in the lamina of the dorsal horn, ascending neurons projecting to brain stem,thalamus n thalamocortical projections. Transmission is a propagation of impulse through sensory n system by first aferentfibres which synapse in dorsal nerve & second order neurons in matrix of dorsal horne
  • a normal belief that newborns & children have less pain to noxous stimuli is very unphysilogical …..a newborn strts developing skin receptors and sensory nerve as early as 20 weeks ..while the inhibitory mechanism strt developing very slowly after 34 weeks…therefore pediatric pain of any quality & quantity may it b abdo pain or other shud never be overlooked
  • Clinically, abdominal pain falls into three categories: visceral (splanchnic) pain, parietal (somatic) pain, and referred pain…let us see the characteristics of eachThe difference in characteristics are because of different pathways n innervations at sensory end
  • Visceral pain occurs when noxious stimuli affect a viscus, such as the stomach or intestines. Tension, stretching, and ischemia stimulate visceral pain fiber .
  • Parietal pain arises from noxious stimulation of the parietal peritoneum . Pain resulting from ischemia, inflammation, or stretching of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatomal level as the origin of the pain. Parietal pain usually is sharp, intense, discrete, andlocalized, and coughing or movement can aggravate it.
  • Referred pain has many of the characteristics of parietal pain but is felt in remote areas supplied by the same dermatome as the diseased organ . It results from shared central pathways for afferent neurons from different sites . A classic example is a patient withpneumonia who presents with abdominal pain because the T9 dermatome distribution is shared by the lung and
  • Let us go through the causes o abd painsysem wise…in gi system in order of prevalnece
  • In a children with features suggestive of failure to thrive , recurrent abd pain following cause can be suspected
  • Drugs and toxins which can cause abd pain are erythro
  • Pneumonia @ diaphragmatic hernia are the pulm causes abd pain n operate through mech of reffered
  • The infant younger than 2 years old with abdominal pain is the most difficult to evaluate because the child cannot describe or localize the complaint
  • Similar to the infant ,the child who is 2 to 5 years of age usually has an organic cause of abdominal pain*The most common causes of abdominal pain are inflammatory process ,such as GE,and UTI
  • The preadolescent child add another dimension to the spectrum of abdominal pain- that of non organic or psychogenic illness The leading organic causes of abdominal pain still are inflammatory and include GE ,appendicitis and UTI
  • Some children have symptoms that do not fit the definition of organic disorders, functional dyspepsia, or IBS, and are thus described as having functional abdominal pain
  • AP

    1. 1. dnbpaediatrics.blogspot.in Abdominal pain in pediatrics Dr Ajay Agade Dr Sushmita Ghosh Dr Vijayalaxmi Moderator Dr Subodhsaha Department of Pediatrics, Jawaharlal Nehru Hospital & Research Centre
    2. 2. Topics of discussion dnbpaediatrics.blogspot.in
    3. 3. What is Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage ref: international assoc. for study of pain dnbpaediatrics.blogspot.in
    4. 4. dnbpaediatrics.blogspot.in
    5. 5. Nociception • Transduction • Transmission • Modulation • Perception dnbpaediatrics.blogspot.in
    6. 6. DIFFERENCES b/w infant &adult nociception Infant Adult1. Afferent fibers Nonmyelinated C both A∂ & C fibers fibers2. Receptor field large & diffuse small3. Inhibitory pathways less developed well developed4. Substance P Higher concentration lower concentration dnbpaediatrics.blogspot.in
    7. 7. TYPES OF ABDOMINAL PAIN Visceral Pain - Dull poorly localised, usually periumbilical Parietal pain - sharp, intense, discrete Referred pain - same features as parietal pain dnbpaediatrics.blogspot.in
    8. 8. Quick physiology of visceral pain !! dnbpaediatrics.blogspot.in
    9. 9. Pathophysiology visceral pain Tension, stretching, and ischemia stimulate visceral pain fiber. Tissue congestion and inflammation tend to sensitize nerve endings and lower the threshold for stimuli. Because visceral pain fibers are bilateral and unmyelinated and enter the spinal cord at multiple levels, visceral pain usually is dull, poorly localized, and felt in the midline.
    10. 10. Pathophysiology parietal pain Noxious stimulation of the parietal peritoneum Ischemia, inflammation, or stretching of the parietal peritoneum Myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatomal level Sharp, intense, discrete, and localized, Coughing or movement can aggravate it. dnbpaediatrics.blogspot.in
    11. 11. Pathophysiology referred pain  Many of the characteristics of parietal pain  Remote areas supplied by the same dermatome as the diseased organ  Shared central pathways for afferent neurons from different sites dnbpaediatrics.blogspot.in
    12. 12. Site of painForegut structures epigastrium(oesophagus & stomach)Midgut structures periumbilical(small intestine)Hind gut structure lower abdomen(large intestine & rectum) dnbpaediatrics.blogspot.in
    13. 13. Gastrointestinal causes  Gastroenteritis  Appendicaitis  Mesenteric lymphadenitis  Constipation  Abdominal trauma dnbpaediatrics.blogspot.in
    14. 14. Gastrointestinal causes  Intestinal obstruction  Peritonitis  Food poisoning  Peptic ulcer  Meckels diverticulum  Inflammatory bowel disease  Lactose intolerance dnbpaediatrics.blogspot.in
    15. 15. Liver, spleen & biliary tract disorders  Hepatitis  Cholecystitis  Cholelithiasis  Splenic infarction  Rupture of the spleen  Pancreatitis dnbpaediatrics.blogspot.in
    16. 16. Genitourinary causes  Urinary calculi  Dysmenorrhea  Mittelschmerz  Pelvic inflammatory disease dnbpaediatrics.blogspot.in
    17. 17. Genitourinary causes  Threatened abortion  Urinary tract infection  Ectopic pregnancy  Ovarian/testicular torsion  Endometriosis  Hematocolpos dnbpaediatrics.blogspot.in
    18. 18. Metabolic disorders  Diabetic ketoacidosis  Hypoglycemia  Porphyria  Acute adrenal insufficiency dnbpaediatrics.blogspot.in
    19. 19. Hematologic disorders  Sickle cell anemia  Henoch-Schönlein purpura  Hemolytic uremic syndrome dnbpaediatrics.blogspot.in
    20. 20. Drugs and toxins  Erythromycin  Salicylates  Lead poisoning  Venoms dnbpaediatrics.blogspot.in
    21. 21. Pulmonary causes  Pneumonia  Diaphragmatic pleurisy dnbpaediatrics.blogspot.in
    22. 22. Miscellaneous  Infantile colic  Functional pain  Pharyngitis  Angioneurotic edema  Familial Mediterranean Fever dnbpaediatrics.blogspot.in
    23. 23. Differential Diagnosis of AcuteAbdominal Pain by Predominant Age Birth to one year  Infantile colic  Gastroenteritis  Constipation  Urinary tract infection  Intussusception  Volvulus  Incarcerated hernia  Hirschsprungs disease dnbpaediatrics.blogspot.in
    24. 24. Two to five years  Gastroenteritis  Appendicitis  Constipation  Urinary tract infection  Intussusception  Volvulus  Trauma  Pharyngitis  Sickle cell crisis
    25. 25. 6 to 11 years  Gastroenteritis  Appendicitis  Constipation  Functional pain  Urinary tract infection  Trauma  Pharyngitis  Pneumonia  Sickle cell crisis  Henoch-Schönlein purpura  Mesenteric lymphadenitis
    26. 26. 12 to 18 years  Appendicitis  Gastroenteritis  Constipation  Dysmenorrhea  Mittelschmerz  Pelvic inflammatory disease  Threatened abortion  Ectopic pregnancy  Ovarian/testicular torsion dnbpaediatrics.blogspot.in
    27. 27. NONSURGICAL CAUSES OF ABDOMINAL PAIN PULMONARY Lobar pneumonia pleurisy pulmonary embolism Cardiac myocarditis pericarditis CCF Metabolic Diabetes mellitus acute adrenal insufficiency acute intermittent porphyria Poisons Drugs dnbpaediatrics.blogspot.in
    28. 28. Chronic abdominal painChronic and recurrent abdominal pain are common in childrenchronic abdominal pain is defined as pain that has been present forat least three months** Recurrent abdominal pain is defined as three or moreepisodes of pain that are severe enough to limit a childs activity orschool attendance over the course of at least three months* Chronic and recurrent pain occurs in 9 to 15 percent of allchildren* In boys, pain is most common between ages 5 and 6 years ** Girlshave pain most commonly between 5 and 6 years and 9 and 10 years
    29. 29. Functional abdominal painAbdominal pain that cannot be explained by structural, physiological or pathological abnormality.School-aged child or adolescent At least 12 weeks of : a-Continuous or nearly continuous abdominal pain and b- No or only occasional relation of pain with physiologic events (eg, eating, menses, defecation) c- Some loss of daily functioning ,and d- The pain is not malingering e- The patient has insufficient criteria for other functional gastrointestinal disorders dnbpaediatrics.blogspot.in
    30. 30. NONSURGICAL CAUSES OF ABDOMINAL PAIN Pyelonephritis UTI Abdominal migrain Abdominal epilepsy Functional abdominal pain dnbpaediatrics.blogspot.in
    31. 31. MANAGEMENTTreatment should be directed at the underlying cause. dnbpaediatrics.blogspot.in
    32. 32. Indications for SurgicalConsultation in Children Severe or increasing abdominal pain progressive signs of deterioration Bile stained or feculent vomitus Involuntary abdominal guarding/rigidity Rebound abdominal tenderness dnbpaediatrics.blogspot.in
    33. 33. Indications for SurgicalConsultation in Children Marked abdominal distension with diffuse tympany. Signs of acute fluid or blood loss Significant abdominal trauma Suspected surgical cause for the pain Abdominal pain without an obvious etiology dnbpaediatrics.blogspot.in
    34. 34. INTUSSUSCEPTION90% < 2 years of ageMore common in malesAssociated with URI Diarrhoea rotavirus vaccine hematoma(HSP) Hemangioma lymphoma dnbpaediatrics.blogspot.in
    35. 35. symptoms• Pain abdomen of sudden onset• Vomiting• Sausage shaped mass• Normal in between pain• Blood stained finger on PR examination dnbpaediatrics.blogspot.in
    36. 36. InvestigationsBa enema:Thin streak of Ba in intussusceptumUSG: Target lesion in transverse plane dnbpaediatrics.blogspot.in
    37. 37. INTUSSUSCEPTION dnbpaediatrics.blogspot.in
    38. 38. Treatment• Reduction with air enema• Reduction with saline enema• Reduction with radiocontrast material dnbpaediatrics.blogspot.in
    39. 39. ATRESIA JEJUNUM Congenital Megacolon dnbpaediatrics.blogspot.in
    40. 40. TORSION OVARY ASCARIASIS dnbpaediatrics.blogspot.in
    41. 41. ASCARIASIS dnbpaediatrics.blogspot.in
    42. 42. Functional abdominal pain dnbpaediatrics.blogspot.in
    43. 43. Functional abdominal pain includesseveral different types of chronicabdominal pain recurrent abdominal pain three or more bouts of abdominal pain (belly ache) in children 4-16 years old over a three-month period severe enough to interfere with his/her activities. located around the umbilicus functional dyspepsia, upper abdominal pain nausea, vomiting, irritable bowel syndrome (IBS). pain relieved by motion change in stool frequency change in stool consistency dnbpaediatrics.blogspot.in
    44. 44. Implications  Interference with school attendance  Depression  Anxiety  Emotional disturbances Diagnosis Normal physical examination Absence of abnormal pathological tests Absence of red flag signs dnbpaediatrics.blogspot.in
    45. 45. Diagnosis Normal physical examination Absence of abnormal pathological tests Absence of red flag signs dnbpaediatrics.blogspot.in
    46. 46. Absence of red flag signs Fever Fever Wt. loss Poor growth Joint pain Mouth ulcer Unusual rashes Loss of appetite Hemetemesis Melena Night time awakening due to pain or diarrhea dnbpaediatrics.blogspot.in
    47. 47. Goals of management Provide quality life through Support Education Medication Better coping skills dnbpaediatrics.blogspot.in
    48. 48. Management Stick to the diagnosis Avoid unnecessary invasive tests Antispasmodics Low dose tricyclic antidepressents Avoid carbonated drinks Psychological treatment:behavioural therapy relaxation exercises hypnosis dnbpaediatrics.blogspot.in
    49. 49. physician NORMAL LIFEschool parents dnbpaediatrics.blogspot.in
    50. 50. Colic Excessive paroxysmal crying Most often in evening hours Healthy baby Difficult to console Equal frequency in male & female Wessels criteria Cry lasting > 3 hrs Occuring > 3 days for > 3 weeks dnbpaediatrics.blogspot.in
    51. 51. Etiology Increased level of motilin lactalbumin 5 HIAA Psychological stress Drugs during pregnancy Frequency 10 to 30 % Infants worldwide Sex : Equal frequency Age : 2 wks to 4 months dnbpaediatrics.blogspot.in
    52. 52. HistoryDiagnosis of exclusionEvening hoursPeaks at 6 weeksHigh pitched cryExclude other causes : hair in eye strangulated hernia otitis sepsis dnbpaediatrics.blogspot.in
    53. 53. Physical examination Shows normal weight gain Differential diagnosis -Overfeeding -Underfeeding -Milk Allergy -Early introduction of foods -GERD -No burping after feeds dnbpaediatrics.blogspot.in
    54. 54. dnbpaediatrics.blogspot.in MANAGEMENT SIMETHICONE Reduces the surface tension of bubbles over intestinal surface. Anticholinergic drugs dicyclomine/ dicycloverine relax muscles in the wall of the gut Dietary management Elimination of cows milk eggs wheat nut products Car ride simulators Reduced stimulation Focussed parent counselling
    55. 55. Abdominal crisis in SCA Sequestration crisis Sudden enlargement of spleen Shock Pallor vaso occlusive crisis Liver : microinfarct Kidney: microscopic hematuria gross hematuria proteinuria Spleen: infarct dnbpaediatrics.blogspot.in
    56. 56. Treatment of VOC Blood transfusion -low Hb IV fluides -dehydration NSAID -Acetaminophen ibuprofen naproxen Opoides -morphine dnbpaediatrics.blogspot.in
    57. 57. Pelvic inflammatory disease • Endometritis • Tubo ovarian abscess • Salpingitis • Pelvic peritonitis Present with Lower abdominal pain Abnormal vaginal discharge Adnexal temderness Painful cervical movement Dysmenorrhoea dnbpaediatrics.blogspot.in
    58. 58. Visit DNB Pediatric study club at dnbpaediatrics.blogspot.in