Acute abdomen in children

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 .

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 …………… .

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
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 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 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.

Gastroenteritis
 Gastroenteritis 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 enterovirus
are the most frequent causes . Bacteria and parasites can also cause
acute abdominal pain in children.
Constipation
 Children 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 .

 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
3 years old–adolescence Appendicitis
Diabetic ketoacidosis
Vaso-occlusive crisis
Ectopic pregnancy
Ovarian torsion
Testicular torsion
Cholecystitis
Pancreatitis
Urinary tract infections
Streptococcus pharyngitis
Inflammatory bowel disease
Pregnancy
Renal stones
Peptic ulcer disease/gastritis
Ovarian cysts
Henoch-Schönlein purpura
Constipation

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.

 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 .

 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.

Diagnosis
1. 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

 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

Acute abdomen in children

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