to inspect for rashes, jaundice, or bruising. of irritability such as hair tourniquets on the digits or penis, or corneal abrasion
symptoms can arise at any time in a person's life.
and may have signs of compensated or uncompensated Fever is not necessarily a presenting sign, and its absence can be helpful in distinguishing volvulus from septic shock.
The differential diagnosis for volvulus includes intussusception, duodenal stenosis or atresia (especially in infants with trisomy 21), bowel perforation from any cause, and sepsis
These studies may be normal with intermittent volvulus, and
Laboratory evaluation does not confirm the diagnosis but is useful to delineate complications of NEC (sepsis) and to narrow the differential diagnosis.
incidence of incarceration of inguinal hernias is highest in the first year of life.
simple inguinal hernia is often asymptomatic and incidentally noted as scrotal swelling or an inguinal mass during diaper change.
and short-acting agents such as fentanyl, propofol, or etomidate may be used.for elective surgical repair once the swelling has subsided
Vomiting is rare in the first few hours but usually develops after 6 to 12 hoursis present even then in only 50% of cases,8
Sausage-shaped mass on the right side of the abdomen At least one third
when the history is consistent
Us for patients with an atypical presentation in whom the diagnosis is ambiguous.prompt surgery can ensue if reduction is unsuccessful or if there is a complication
, as abdominal or sacral tumors are a rare but important cause of pathologic constipation
vomiting being more common in younger children and as the disease progresses.
. However, a low or normal WBC has consistently been shown to be correlated with decreased likelihood of appendicitis.23,24 A [LR– of 0.22].22white blood cell count (WBC) has insufficient sensitivity or specificity to confirm the diagnosis of appendicitis. Sterile pyuria can be seen with acute appendicitis
ambiguous cases, imaging with ultrasonography (Figure 124-5) or CT (Figure 124-6) are useful.
, although a mild leukocytosis is entirely compatible with nonspecific abdominal pain. Upon discharge, follow-up is essential, as other conditions may declare themselves with time.
(indistinguishable from IgA nephropathy)
Radiographic imaging is not routinely indicated unless intussusception or volvulus is suspected.
are the most common type of gallstones in children.
Pain can be insidious, with onset over a few days, then increasing exponentially over a few hours
34 Serum lipase rises within hours and remains elevated for up to 14 days.
There are no recommendations to culture or treat asymptomatic contacts of a patient with group A Streptococcus pharyngitis.36
Abdominal pain in children
Acute Abdominal Pain in Children Priya Kantanon, MD. 3rd year Emergency Medicine Resident, Siriraj Hospital, Mahidol University
• Common complaint of children seeking medical care in the pediatric ED• <1 week duration
Classification of Abdominal Pain by Age GroupAge Emergent Nonemergent0–3 mo old Necrotizing enterocolitis Colic Volvulus Acute gastroenteritis Testicular torsion Constipation Incarcerated hernia Trauma Toxic megacolon Tumor3 mo–3 y old Intussusception Acute gastroenteritis Testicular torsion Constipation Trauma Urinary tract infections Volvulus HSP Appendicitis Toxic megacolon Vaso-occlusive crisis
Clinical Features• History• Physical Examination• Do not forget a genital examination !!!!
General management ofabdominal pain in children
• Basic labs work up – POCT glucose – BUN, Cr, Elyte – UA, UPT – Toxico – CBC not useful for screening test
• Imaging – Plain film abdomen – US – CT (radiation exposure 600 times of plain film, risk develop CA)
Pain management• Opiates does not negatively impact patient care.• Although physical examination findings can change after the administration of opiates• There is no evidence that this changes final management or outcome
Common Parenteral Analgesics for Abdominal Pain in Children Drug DoseMorphine 0.05–0.1 milligram/kg/dose IV every 4 h insulfate neonates. 0.1 milligram/kg/dose IV every 2–4 h in infants and children.Hydromorphone 0.015 milligram/kg/dose IV every 3–6 h if 6 mo old and <50 kg. If weighing >50 kg, use adult dosing.Fentanyl 1–2 micrograms/kg/dose IV every 30–60 min.Ketorolac 0.5 milligram/kg/dose IV every 6 h (maximum of 30 milligrams per dose) if 6 mo old.
• Special Considerations 1. Neonates and Young Infants (0 to 3 Months) 2. Older Infants and Toddlers (3 Months to 3 Years Old) 3. Children (3 to 15 Years of Age)
Neonates and Young Infants (0 to 3 Months) Other urgentLife-threatening conditions include• Necrotizing enterocolitis • Incarcerated hernias (NEC) • Testicular torsion• Malrotation with midgut • Nonaccidental trauma. volvulus
Neonates and Young Infants (0 to 3 Months)• S&S• Inconsolability or lethargy associated with poor feeding• Constant pain + sudden in onset• Episodic, paroxysmal pain suggests infant colic, intussusception, or gastroenteritis.• Pain related to feeds suggests gastroesophageal reflux disease.
S&S• Bilious vomiting (bright yellow or green) malrotation with volvulus or intussusception• Any change in stooling pattern• Timing of passing the first stool
PE• If the infant is crying, one must rely heavily on observation, though auscultation and palpation remain important.• Undress• Scrotum• Check for other causes
Malrotation and Volvulus • Life-threatening complication • Malrotation of the midgut occurs in 1 in 6000 births • 90% of complications occurring in the first year of life
Clinical Features• No significant past medical history• Abrupt onset of constant abdominal pain, bilious vomiting, abdominal distention, and irritability.• As bowel ischemia progresses, shock and peritonitis develop.
• Ill appearing• Shock• Ominous signs include tachypnea, grunting respirations, and jaundice.• Diffusely tender and distended and may be rigid• Rarely, a mass can be palpated.• Intermittent volvulus may present with stable vital signs and focal tenderness on abdominal examination.
DiagnosisImaging• Useful in diagnosing malrotation with volvulus• Should not delay surgical consultation
Imaging• Plain abdominal radiographs – a loop of bowel overriding the liver – evidence of obstruction, including air fluid levels and a paucity of gas• Upper GI series – "birds beak" appearance of the duodenum at the site twisting, and may be seen to the right of the spine• CT scan of the abdomen and pelvis with oral contrast – intestinal malrotation
Treatment• Immediate surgical consultation• Aggressively resuscitate the patient in shock
Necrotizing Enterocolitis• Premature and weigh <1500 grams at birth• Full-term infants at higher risk – congenital heart disease – other disorders that place the infant under significant stress (e.g., sepsis, respiratory distress).
S&S• Poor feeding• Lethargy• Abdominal distention, and tenderness• Signs of sepsis• Pneumoperitoneum
Investigation• CBC• Serum electrolytes• Septic work up (blood, urine, and cerebrospinal fluid cultures)• A cross-table lateral view of the abdomen – dilated loops of bowel – abnormal gas pattern – pneumatosis intestinalis
Treatment• Bowel rest (NPO)• Aggressive IV hydration• Broad-spectrum antibiotics (to cover abdominal/gut flora)• Consultation with a pediatric surgeon• Should be admitted to a neonatal or pediatric intensive care unit
Incarcerated Hernia• Inguinal hernias occur in up to 5%• More common in children born prematurely• Incarceration occurs in up to one third of cases• Highest in the first year of life.
Clinical Features• Irritability, poor feeding, vomiting, and an inguinal or scrotal mass• DDx – Hydrocele of the cord or the scrotum – Undescended testicle – Torsion of the testicle – Torsion of the appendix testis – Inguinal lymphadenopathy – Inguinal node abscess – Orchitis – Inguinal or scrotal trauma
Treatment• Medical, and sometimes, surgical emergency• Manual reduction of the incarcerated hernia is often possible early in the course of disease.
Manual reduction • Sedation • Once the hernia is reduced, arrange follow-up in 24 to 48 hours with a pediatric surgeon • One third of children will redevelop incarceration
Older Infants and Toddlers (3 Months to 3 Years Old)DDX• Intussusception• Acute gastroenteritis• Constipation• Urinary tract infection (UTI)• Testicular torsion• Accidental and nonaccidental trauma• Malrotation with midgut volvulus and appendicitis are rare
S&S• Pulling up of legs in association with episodic pain followed by periods of normal behavior or lethargy Intussusception• Pain with urinationUTI• Day care attendance and sick contacts should be noted when fever, vomiting, and diarrhea are present together Infectious gastroenteritis
PE• Vary greatly in their ability to cooperate with a physical examination, and stranger anxiety• Avoiding direct eye contact• Look first and then feel.• Non-touch maneuvers and observations• Ask a parent to palpate the childs abdomen while you observe
Colic• "rule of threes“• Crying >3 hours per day for >3 days per week for >3 weeks• Starts in the first week of life• Resolves by 3 to 4 months of age• Colic is a diagnosis of exclusion.
Intussusception• most common cause of intestinal obstruction in children between 3 months and 6 years
Pathophysiology • Leading points – Lymphoid hyperplasia – Meckel diverticulum, intestinal polyps, congenital duplications, lymphosarcoma, or as a complication of HSPIleum invaginates into the upper colon bringing themesentery with it (ileocolic) constriction of themesentery obstructs venous return engorgement of theintussusceptum Bowel ischemia
Clinical Features• Infant aged 6 to 18 months old• Sudden onset of colicky pain• Episodes of pain – shorter with increasing duration• Vomiting is rare in the first few hours• The classic "currant jelly" stool is a late manifestation• Stool is usually guaiac positive even in the absence of gross blood
Clinical Features• Apathy or lethargy may be the only presenting sign• Sausage-shaped mass on the right side of the abdomen• Absence of a mass should not delay further investigation• An ileoileal intussusception may have a less typical presentation
Diagnosis and Treatment• Presumptive diagnosis is usually made by history alone• Well-appearing child with a normal examination does not exclude the diagnosis
Imaging • Plain films of the abdomen may suggest a mass or filling defect in the right lower quadrant of the abdomen • US is highly sensitive and specific for diagnosis. • Air contrast enema :both diagnostic and frequently curativePediatric surgeon should be consulted before diagnostic air enema
Air contrast enema• After successful reduction in radiology, children are generally admitted for observation• 5% to 10% recurrence rate, usually within the first 24 to 48 hours after reduction
Acute Gastroenteritis• most common cause of abdominal pain in children of all age groups
Constipation• Infrequent, dry, hard stools• Defects in filling or emptying the rectum• May be a sign of either a pathologic or functional process
• In infancy – Maternal drugs – Congenital GI anomalies – Cystic fibrosis – Hirschsprung disease – Poor intake – Anal fissures• In older children – Chronic medical conditions such as anorexia nervosa, cerebral palsy, neuromuscular disease, spinal cord abnormalities, depression, sickle cell disease (secondary to opiate use), or hypothyroidism – Acute - dehydration, electrolyte abnormalities (hypercalcemia or hypokalemia), or drug ingestions (diuretics, antihistamines, anticholinergics, or narcotics) History is the key to the diagnosis of constipation
Questions to Ask about Constipation• The frequency and texture of the stools• The presence of blood on the stool• The association of pain with defecation• A history of waxing and waning of hard stools and watery diarrhea suggesting overflow incontinence
• Rectal examination – presence of stool – rectal tone sensation – size of the anal vault• Palpate the abdomen for the presence of a mass
Treatment• Disimpaction with a glycerin suppository in infants and bisacodyl suppository in adolescents• Sodium phosphate (e.g., Fleet Enema®) or soap suds enemas
Treatment of Constipation in Children >1 year of ageOsmotic laxatives: polyethylene glycol (1–2 packs/d with 8 oz ofwater or juice)Lubricants: mineral oil (1–3 cc/kg/d) (should be used withcaution in young children and those at risk for aspiration)Stool softeners: docusate sodiumStimulant laxatives Senna (for 2–6 y olds: sennosides: 3.75 milligrams/d;maximum of 15 milligrams/d; for 6–12 y olds: sennosides: 8.6milligrams once a day, maximum of 50 milligrams/d) Bisacodyl ( if >6 years old): 5–10 milligrams at bedtime orbreakfast
Children (3 to 15 Years of Age)Common cause Less common• Appendicitis • DKA• Constipation • Inflammatory bowel disease• pain secondary to (IBD) nonspecific viral syndrome • Cholelithiasis• acute gastroenteritis • Sickle cell anemia• strep pharyngitis • Henoch-Schönlein purpura• UTI • Toxic ingestion• pneumonia • Testicular ovarian cyst, ectopic pregnancy, pelvic inflammatory disease, renal
S&S• Verbalize the time of onset and location of the pain by age 3 or 4 years old• Older children may be able to characterize the frequency and severity
PE• Use verbal and tactile techniques• Observation remains a key• Note general appearance, position of comfort, respiratory effort, and gait.
Appendicitis• most common• peak ages 9-12 yrs• M>F• Perforation rates approach 90% in children <4 years old.
• Vomiting may be the first symptom noted by the parents.• Peritoneal inflammation in children can be elicited by asking patients to walk, hop, or cough• Assess for hernias in males and females and perform a testicular examination in all males• A pelvic examination may be needed in adolescent females
Diagnosis• WBC <10,000/mm3 is a strong negative predictor for appendicitis• Ambiguous cases, imaging with ultrasonography or CT are useful.
Treatment• Once the diagnosis of appendicitis is strongly• NPO, IV hydration• Antibiotic – nonperforated ampicillin/sulbactam or cefoxitin – Perforated piperacillin/tazobactam
• Appendectomy is definitive treatment (laparotomy or laparoscopy)• In ambiguous cases, admission for serial abdominal examination by a surgeon is reasonable.
Nonspecific Abdominal Pain • Largest single group of children seen in the ED with acute abdominal pain • The key to the establishment of nonspecific abdominal pain as a working diagnosis is reexamination in 24 hours and repeated examinations over time if symptoms continue.
Clinical features • Nausea - most common symptom after abdominal pain. • Midepigastric or in the Lower half • Tenderness is not usually severe, is 1/3 absent and 1/3 localized to the right lower quadrant or midepigastric • Laboratory tests are usually normal • Abdominal radiographs are also normal.follow-up is essential
Henoch-Schönlein Purpura • Vasculitic disease of children between 2 and 11 years • Elevated IgA levels and IgA deposits in the glomeruli and vessel walls.
• Triad of acute onset of – abdominal pain – purpuric rash – arthritis• Diffuse and colicky + vomiting• Usually presents after the rash• 5% of cases of HSP are associated with intussusception
Palpable purpuric rash• 50% of the cases• typically present on the lower extremities and buttocksArthralgia or arthritis• 25%, Joint symptoms are migratory and usually involve the knees and ankles with periarticular swelling and tenderness• Painful edema of the feet
• Renal involvement – not common – any time in the course – hematuria and hypertension• Peripheral and central nervous system, hematologic system, and testes may also be involved
Investigation• UA BUN, Cr• stool guaiac• Radiographic imaging
Treatment• Mainly supportive• Hydration• NSAIDs, such as ibuprofen (10 milligrams/kg/dose every 6 to 8 hours) and ketorolac• Corticosteroids (abdominal, joint, and scrotal )• Consultation with a pediatric rheumatologist or nephrologist
Cholecystitis• Very rare in children• Bile stones – hemolytic disease (e.g., sickle cell disease) – total parenteral nutrition
• Restless and unable to lie still• Right upper quadrant tenderness and a positive Murphy sign with or without guarding• US
Treatment• Any child with evidence of cholecystitis or cholangitis should be admitted to the hospital.• IV hydration, bowel rest, analgesics, and antibiotics, if febrile.
• Antibiotics should target gram-negative organisms and Enterococcus. – Ampicillin – Gentamicin – Ampicillin/sulbactam – Piperacillin/tazobactam
Pancreatitis• Extremely rare in infants• Most commonly a secondary process in children and adolescents• Diverse etiologies
Structural anomaliesIdiopathic Pancreas divisumHereditary Common channelTrauma Congenital duodenal stenosis Blunt Choledochal cysts Penetrating Stricture Surgical Sclerosing cholangitisSystemic Cholelithiasis Sepsis/shock Ascaris Viral infection (mumps, coxsackie B, influenza, hemolytic MetabolicStreptococcus, Salmonella, hepatitis A and B) Reye syndrome Cystic fibrosis Collagen vascular disorders (systemic lupus erythematosus, 1-antitrypsin deficiencyperiarteritis nodosa, Henoch-Schönlein purpura) Peptic ulcer Hypercalcemia (hyperparathyroidism) Uremia Hyperlipidemia (hypercholesterolemia) Malnutrition Organic acidemias Vitamin A and D deficiency Drugs Steroid Chlorothiazides Valproic acid L-asparaginase
Clinical Features• Acute onset of epigastric (occasionally periumbilical) abdominal pain associated with anorexia, nausea, and vomiting.• Dull and constant in the epigastric region, pain may radiate to the back• Worsened by eating or lying supine
• Risk factors – Recent chemotherapy with L- asparaginase – Recent motor vehicle accident with blunt trauma – Past medical history of cystic fibrosis – Family history of pancreatitis (hereditary)
• The specificity of serum lipase for pancreatitis is nearly 100%.• The severity of the disease does not correlate with the degree of enzyme elevation.• Obtain liver function studies, as pancreatitis may be secondary to liver or biliary disease, and serum electrolytes, including calcium.
• Abdominal US is the modality of choice to visualize the head of the pancreas and associated anomalies.
• Children with pancreatitis usually undergo a CT scan to rule out alternative diagnoses.• ERCP or MRCP may be used for diagnosis and management once the patient has been stabilized and admitted to the hospital.• Treatment is supportive.
Pneumonia• The respiratory component of the patients history and examination may be mild, and the predominant complaint may be abdominal pain• Several days of mild cough precede the abdominal pain, and if the child has emesis, it is typically post-tussive in nature.
• On physical examination, specifically look for fever, tachypnea, or hypoxia.• The lung examination may reveal rales, rhonchi, or decreased air entry at the base.• Chest x-ray is needed to confirm the diagnosis.
Group A Streptococcus Pharyngitis • Typically affects children 4 years of age and older • Fever, sore throat, tonsillar erythema, and exudate with anterior cervical lymphadenopathy in the absence of upper respiratory tract symptoms.
• Fever and abdominal pain with or without vomiting, and without sore throat• For this reason, all children >3 years of age with abdominal pain, especially if febrile, deserve a thorough oropharyngeal examination
• The treatment of choice for Streptococcus pharyngitis – a one-time IM dose of benzathine penicillin – Amoxicillin has no advantage over penicillin other than taste – Erythromycin can be used in children with a penicillin allergy. Treatment reduces the duration of symptoms, time absent from school, infectivity time, and rheumatic complications when started within 10 days of symptoms.
Renal Stones• Melamine-tainted formula was responsible for an outbreak of urolithiasis in children in China• calcium (most common in children), uric acid, or struvite
• Unlike adults, children with renal stones present with abdominal pain less frequently (approximately 50% of the time).• An infant with nephrolithiases may be misdiagnosed as having colic. A preschool child may present with recurrent UTIs. Microscopic hematuria may
• standard for diagnosis is the unenhanced helical CT.
• Melamine-induced renal stones have feeble or absent acoustic shadows.38 Although hematuria and plain abdominal films still appear in many clinical algorithms, the weak LR of both tests, as shown in Table 124-7, do not provide strong support for their use as sole predictors of the presence of renal stones, although they may aid in the diagnosis when considered along with the history and physical examination of the child.39• A basic metabolic panel with calcium, phosphorous, and uric acid levels may help in identifying the type of stone and underlying disease. The stone should be analyzed, if passed, or a 24-hour urine collection for stone evaluation should be performed.
• ED management is centered on pain control. If the childs pain cannot be controlled with oral medication, the child is not tolerating oral fluids, or there is evidence of renal dysfunction, the child should be admitted to the hospital. Morphine sulfate (0.1 milligram/kg every 2 to 4 hours, as needed, to a maximum of 8 milligrams/dose IV) and/or ketorolac (0.4 to 1.0 milligram/kg/dose every 12 hours, maximum of 30 milligrams/dose IV) are effective analgesics for renal stones. Depending on the type of stone, urine alkalinization or diuretics may be added to the treatment. Finally, if needed, a urologist may perform extracorporeal shock wave lithotripsy or stone removal using a rigid or flexible endoscope.37
Inflammatory Bowel Disease • older children or teenagers, and commonly the first presentation involves severe acute abdominal pain
• colicky and is associated with diarrhea, which may be bloody. Abdominal pain is not the sole presenting symptom, and IBD is associated with fever, weight loss, fatigue, and blood per rectum.41 For example, 80% of the patients with Crohn disease have a history of weight loss, and 20% have
• On physical examination, tachycardia and hypotension may be present secondary to dehydration or anemia from chronic blood loss. Abdominal tenderness and guarding may be localized (especially to the right lower quadrant in Crohn disease), which can mimic appendicitis. Patients with
• An abdominal CT is commonly obtained to evaluate for thickening of the terminal ileum. Definitive diagnosis requires endoscopy and biopsy, and a pediatric GI specialist should be consulted for further evaluation and management.