Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Acute Abdominal Pain in Children

4,854 views

Published on

  • Hello! I can recommend a site that has helped me. It's called ⇒ www.HelpWriting.net ⇐ So make sure to check it out!
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • 1 Weird Trick To Easily Cure Vitiligo For Good In As Little As 7 Days - Guaranteed! More Info.. ▲▲▲ https://j.mp/3kTNHDZ
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • I like this service ⇒ www.WritePaper.info ⇐ from Academic Writers. I don't have enough time write it by myself.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Very nice tips on this. In case you need help on any kind of academic writing visit our website ⇒ www.HelpWriting.net ⇐ and place your order
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Get Instant Access to 12000 SHED PLANS, Download plans now. ☺☺☺ https://url.cn/I86oXShh
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Acute Abdominal Pain in Children

  1. 1. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN Raymond G Buick Paediatric Surgeon Birmingham Length: approx 55 minutes
  2. 2. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN Lecture given to Paediatric Surgery for Specialist Trainees Raymond G Buick Paediatric Surgeon Birmingham February 2009
  3. 3. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN •Pathophysiology •Causes of abdominal pain •Diagnosis of acute abdominal pain •Acute appendicitis •A few rare causes of acute abdominal pain ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
  4. 4. pathophysiology Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain, • referred pain.
  5. 5. Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain---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 • parietal (somatic) pain, • referred pain.
  6. 6. Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain--- 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, and localized, and coughing or movement can aggravate it. • referred pain.
  7. 7. Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain, • referred pain-- 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 with pneumonia who presents with abdominal pain because the T9 dermatome distribution is shared by the lung and the abdomen.
  8. 8. ABDOMINAL PAIN • Causes of ACUTE ABDOMINAL PAIN
  9. 9. Causes of Acute Abdominal Pain in Children Gastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation Flatulence Abdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckel's diverticulum Inflammatory bowel disease Lactose intolerance Hernia Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhoea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Hematocolpos Metabolic disorders Diabetic ketoacidosis Hypoglycaemia Porphyria Acute adrenal insufficiency Hematologic disorders Sickle cell anemia Henoch-Schönlein purpura Haemolytic uremic syndrome Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Iron overdose Soap ingestion Pulmonary causes Pneumonia Diaphragmatic pleurisy Miscellaneous Infantile colic Functional pain Pharyngitis Angioneurotic oedema Familial Mediterranean fever Floating Rib Syndrome Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
  10. 10. ABDOMINAL PAIN • Causes of ACUTE ABDOMINAL PAIN • AGE • SEX
  11. 11. Differential Diagnosis of Acute Abdominal Pain by Predominant Age Birth to one year Two to five years Six to 11 years 12 to 18 years Infantile colic Gastroenteritis Gastroenteritis Appendicitis Gastroenteritis Appendicitis Appendicitis Gastroenteritis Constipation Constipation Constipation Constipation Urinary tract infection Urinary tract infection Functional pain Dysmenorrhoea Intussusception Intussusception Urinary tract infection Mittelschmerz Volvulus Volvulus Trauma Pelvic inflammatory disease Incarcerated hernia Trauma Pharyngitis Threatened abortion Hirschsprung's disease Pharyngitis Pneumonia Ectopic pregnancy Trauma Sickle cell crisis Sickle cell crisis Ovarian/testicular torsion Henoch-Schönlein purpura Henoch-Schönlein purpura Mesenteric lymphadenitis Mesenteric lymphadenitis Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
  12. 12. ABDOMINAL PAIN Causes of ACUTE ABDOMINAL PAIN in very young children • Neonates – acute abdomen • Intestinal volvulus • Incarcerated inguinal hernia • Hirschsprung's disease • Intussusception • Trauma – non-accidental
  13. 13. Causes of Abdominal Pain in Children   Emergencies/life-threatening Other causes Medical causes Diabetic Ketoacidosis Gastroenteritis (bacteria or viruses) Inflammatory bowel disease Constipation Acute adrenal failure Flatulence   Mesenteric lymphadenitis   Peptic ulcer disease   Urinary tract infection   Ureteric calculi   Hepatitis   Cholecystitis   Pancreatitis   Sickle cell anaemia/crises   Henoch Schonlein purpura Surgical causes Appendicitis   Bowel obstruction (e.g.  intussusception, volvulus) Trauma Incarcerated hernia Peritonitis Testicular torsion Gynaecological causes   Dysmenorrhoea Mittelschmerz Pelvic inflammatory disease Endometriosis Obstetric causes Ectopic pregnancy   Ovarian cyst rupture/torsion Abortion Drugs/Toxins Paracetamol overdose Soap ingestion Iron overdose Erythromycin Venoms   Referred pain   Pneumonia Rare causes   Angioneurotic oedema Familial Mediterranean fever Unknown aetiology   Infantile colic Functional bowel disease
  14. 14. ADMISSIONS 363 OPERATIONS 125 35% OTHER SURGICAL DIAGNOSES OR NEGATIVE 24 6% MEDICAL 129 35% APPENDICITIS 106 29% NON-SPECIFIC ABDOMINAL PAIN 108 30% OBSERVED 237 65% Admissions with Abdominal Pain to a District General Hospital in one year HOME CHEMIST NHS DIRECT GP
  15. 15. Admissions with Abdominal Pain to a Paediatric Surgical Unit in one year
  16. 16. • The most common medical cause is gastroenteritis • The most common surgical cause is appendicitis. ACUTE ABDOMINAL PAIN
  17. 17. Pain & vomiting • In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions.
  18. 18. • The most common medical cause is gastroenteritis – Viruses rotavirus, Norwalk virus, adenovirus, Enterovirus Bacteria Escherichia coli, Yersinia, Campylobacter, Salmonella, Shigella. ABDOMINAL PAIN
  19. 19. Causes of Acute Abdominal Pain in Children Gastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation Flatulence Abdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckel's diverticulum Inflammatory bowel disease Lactose intolerance Hernia Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhoea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Hematocolpos Metabolic disorders Diabetic ketoacidosis Hypoglycaemia Porphyria Acute adrenal insufficiency Hematologic disorders Sickle cell anemia Henoch-Schönlein purpura Haemolytic uremic syndrome Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Iron overdose Soap ingestion Pulmonary causes Pneumonia Diaphragmatic pleurisy Miscellaneous Infantile colic Functional pain Pharyngitis Angioneurotic oedema Familial Mediterranean fever Floating Rib Syndrome Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
  20. 20. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN
  21. 21. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Up to 20% of infants First 6 months Scream Draw knees up
  22. 22. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Over diagnosed Pain – Visceral / LIF Acute – organic cause Chronic – functional cause Diagnosis of last resort
  23. 23. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Adenovirus Preceding upper resp infectionMay Other lymphadenopathy mimic appendicitis Pain more diffuse Higher temperature Shifting tenderness
  24. 24. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN ACCIDENTAL NON-ACCIDENTAL Parents may conceal information
  25. 25. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Includes •Malrotation •Volvulus •Intussusception •Incarcerated hernia •adhesions
  26. 26. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Includes •Malrotation •Volvulus •Intussusception •Incarcerated hernia •Adhesions – ACQUIRED -- CONGENITAL
  27. 27. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Chlamydia Neisseria infection and inflammation of the upper female genital tract, uterus, fallopian tubes and ovaries. infection in the vagina & cervix passing to the internal reproductive organs. Age 15 to 24 2% female population 20% recurrent
  28. 28. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Chlamydia Neisseria AND Pregnancy History may be concealed
  29. 29. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN Chlamydia Neisseria AND Pregnancy History may be concealed PregnancyPregnancy 10% occur in 13 to 15 (7.8 per 1000)10% occur in 13 to 15 (7.8 per 1000) 52% occur in 13 to 17 (41 per 1000)52% occur in 13 to 17 (41 per 1000)
  30. 30. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN NICE Guidelines -August 2007 www.nice.org.uk/Guidance/CG54/NiceGuidance/pdf/English
  31. 31. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN NICE Guidelines -August 2007 e Symptoms and signs Most common Least Common Preverbal Fever Abdominal pain Loin tenderness Vomiting Poor feeding Lethargy Irritability Haematuria Offensive urine Failure to thrive Verbal Frequency Dysuria Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine
  32. 32. • Infantile colic • Constipation • Mesenteric adenitis • Abdominal trauma • Intestinal obstruction • Pelvic inflammatory disease • Urinary Tract Infection • Meckel’s Diverticulum ABDOMINAL PAIN
  33. 33. Meckel’s Diverticulum
  34. 34. Meckel’s Diverticulum • Meckel's diverticulum, • congenital • remnant of the vitelointestinal duct (omphalomesenteric duct) • 2 feet (from the ileocecal valve) • 2 inches (in length) • 2% (of the population) have it • 2% are symptomatic • 2 is the most common age at clinical presentation • 2:1 male:female • 2 types of common ectopic tissue (gastric and pancreatic) • first described by Fabricius Hildanus C16first described by Fabricius Hildanus C16 • named after Johann Friedrich Meckelnamed after Johann Friedrich Meckel who described the embryological originwho described the embryological origin of this type of diverticulum in 1809of this type of diverticulum in 1809
  35. 35. ABDOMINAL PAIN • diagnosis
  36. 36. ABDOMINAL PAIN • History • A challenge in young children • poor sense of timing and location
  37. 37. ABDOMINAL PAIN • History • PAIN Location • Onset • Character • Change of location or character • Severity • Radiation • Precipitating/relieving factors
  38. 38. ABDOMINAL PAIN • History • VOMITING character • frequency • content bile / blood • BOWELS frequency • consistency • blood • URINARY frequency/dysuria/polyuria/urgency/odour/colour • RESPIRATORYcough/SOB/chest pain • GENERAL temperature/headache/joint pains-swelling/rash/sore throat • GYNAE menstruation/LMP/sexual activity/contraception/vaginal discharge/?midcycle • PAST MEDICAL HISTORY / DRUG HISTORY / FAMILY HISTORY
  39. 39. ABDOMINAL PAIN • Examination • GENERAL APPEARANCE • GENERAL – ENT • – Chest • ABDOMINAL Breathing pattern • distension • Point to pain • Maximum tenderness • Muscle guarding • Rebound tenderness • bowel sounds • groin / testes / introitus • Rectal Examination
  40. 40. ABDOMINAL PAIN • Investigations • Tailored to symptoms and signs • CONSIDER Full Blood Picture • Differential White Cell Count • Urinalysis • CRP • Pregnancy Test • • Abdominal X-Ray • Chest x-Ray • Ultrasound • CT
  41. 41. ABDOMINAL PAIN Active Observation
  42. 42. ABDOMINAL PAIN “repeated physical examination by the same physician often is useful”
  43. 43. ABDOMINAL PAIN repeated physical examination is MANDATORY by the same physician is BENIFICIAL
  44. 44. ABDOMINAL PAIN Active Observation
  45. 45. ABDOMINAL PAIN RECORDED Active Observation
  46. 46. ABDOMINAL PAIN Recorded Active Observation
  47. 47. • in most instances, abdominal pain can be diagnosed through the history and physical examination.
  48. 48. ‘THE PAIN’ in ABDOMINAL PAIN • Use analgesia as required - it does not affect diagnostic accuracy Patient UK at www.patient.co.uk/showdoc/40000523/
  49. 49. ‘THE PAIN’ in ABDOMINAL PAIN • Traditionally, the use of analgesics is discouraged in patients with abdominal pain for fear of interfering with accurate evaluation and diagnosis. • However, several prospective, randomized studies have shown that judicious use of analgesics actually may enhance diagnostic accuracy by permitting detailed examination of a more cooperative patient.
  50. 50. APPENDICITIS
  51. 51. APPENDICITIS • Age
  52. 52. The approach to common abdominal diagnosis in infants and children Irish M S et al Pediatric Clin North Am. 1998 Aug: 45(4): 729-72 % PERFORATED % NORMAL Age <= 8 years 33 13 Age > 8 years 18 11 Male 22 8 Female 18 17
  53. 53. Age in Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Acute appendicitis without perforation 2 8 17 30 33 17 43 57 97 111 137 168 144 163 104 91178 Acute appendicitis with perforation 2 3 10 23 20 16 16 23 27 25 16 16 12 22 8 18 42 Total number of patients 4 11 27 53 53 33 59 80 124 136 153 184 156 185 112 109220 Percentage perforated 50 27 37 46 38 48 27 27 22 18 10 9 8 12 7 17 19
  54. 54. APPENDICITIS • What causes appendicitis
  55. 55. APPENDICITIS • Types of Appendicitis pathogenesis primary obstruction of the lumen of appendix filled with mucus and swells. increasing pressure within the lumen Pressure on the wall of the appendix resulting in thrombosis & occlusion of blood vessels Inflammation of appendix Pus may form within the appendix (suppuration) stasis of lymph flow - leads to ischaemia and necrosis (gangrene) Bacteria begin to leak out through appendix walls Pus forms within and around the appendix Perforation of appendix - peritonitis / abscess Septicaemia - death }Appendix Mass
  56. 56. APPENDICITIS • Types of Appendicitis – Acute – Perforated
  57. 57. APPENDICITIS • Types of Appendicitis – Acute • Acute inflammatory appendicitis • Acute Suppurative appendicitis – Perforated (complicated) • Perforated • Gangrenous
  58. 58. APPENDICITIS • Types of Appendicitis – Acute • Acute inflammatory appendicitis • Acute Suppurative appendicitis – Perforated (complicated) • Perforated • Gangrenous • Normal • (Registrar’s Appendicitis)
  59. 59. APPENDICITIS • Types of Appendicitis – Acute • Acute inflammatory appendicitis • Acute Suppurative appendicitis – Perforated (complicated) • Perforated • Gangrenous • Normal Appendix Mass Appendix Abscess
  60. 60. Clinical Features - Symptoms
  61. 61. Clinical Features - Symptoms • Pain – Central » Vague » Crampy » Wants to move around – Moves to Right Iliac Fossa » Acute » Sharp / constant » Wants to lie still Anorexia Nausia Vomiting Mild Pyrexia Halitosis Change in bowel habit – diarrhoea -- constipation Urinary Symptoms LOCALISED
  62. 62. Clinical Features - Signs
  63. 63. Clinical Features - Signs • Localised Tenderness • Muscle Guarding Tachycardia Flushed Circum-oral pallor Rectal Examination ? Rovsing’s Sign Psoas sign Obturator sign Caecal Gurgle
  64. 64. Clinical Features - Signs • Localised Tenderness • Muscle Guarding Tachycardia Flushed Circum-oral pallor Rectal Examination ? Rovsing’s Sign Niels Thorkild Rovsing Danish surgeon 1907, Psoas sign Obturator sign Caecal Gurgle
  65. 65. Clinical Features - Signs • Localised Tenderness • Muscle Guarding Tachycardia Flushed Circum-oral pallor Rectal Examination ? Rovsing’s Sign Psoas sign Obturator sign Caecal Gurgle Action:- Hip flexion Pain:-Pain:- Hip ExtensionHip Extension
  66. 66. Clinical Features - Signs • Localised Tenderness • Muscle Guarding Tachycardia Flushed Circum-oral pallor Rectal Examination ? Rovsing’s Sign Psoas sign Obturator sign Caecal Gurgle Action:- Abducts Lat Rotates Pain:-Pain:- Hip AdductionHip Adduction Internal RotationInternal Rotation
  67. 67. Clinical Features - Signs • Localised Tenderness • Muscle Guarding Tachycardia Flushed Circum-oral pallor Rectal Examination ? Rovsing’s Sign Psoas sign Obturator sign Caecal Gurgle
  68. 68. Clinical Features - Signs • Localised Tenderness • Localised Guarding
  69. 69. Anatomical positions of appendix • Retrocaecal – poor localising signs • Retroileal – diarrhoea • Pelvic – diarrhoea / Bladder
  70. 70. CLASSICAL CARDINAL FEATURES • Localised Pain • Localised Tenderness • Muscle Guarding • (Rebound Tenderness) McBurney’s Point Charles McBurney U.S. surgeon, 1845–1913
  71. 71. Investigations • Blood Test – Sickle – Neutrophil leucocytosis – Lymphopenia – CRP
  72. 72. Investigations • Radiology – Abdominal film • Obstruction • faecolith • Soft tissue mass • Loaded colon – Ultrasound • Gynaecological • Abscess/mass/thick bowel loops • stones
  73. 73. APPENDICITIS • Preparation for theatre – Analgesics – Fluids – Antibiotics – Consent
  74. 74. APPENDICITIS • In theatre – EUA • Open or Laparoscopic ?
  75. 75. APPENDICITIS • In theatre – EUA • Open or Laparoscopic ? • What if it is perforated ?
  76. 76. APPENDICITIS • In theatre – EUA • Open or Laparoscopic ? • What if it is Crohn’s ?
  77. 77. APPENDICITIS • In theatre – EUA • Open or Laparoscopic ? • What if it is normal ?
  78. 78. A few less common causes ofA few less common causes of ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
  79. 79. Henoch-Schönlein purpura • systemic vasculitis • deposition of immune complexes containing the antibody IgA in the skin and kidney • occurs mainly in young children.
  80. 80. Henoch-Schönlein purpura • self-limiting • no treatment - symptom control, • in a third of cases disease may relapse -irreversible kidney damage in about 1% of cases • Cause unknown, post viral and bacterial infections, / adverse drug reactions
  81. 81. 12th Rib Syndrome • Floating Rib • Slipping Rib • Rib Dysfunction

×