Dr. Balakrishna Shetty is a pediatric radiologist who discusses several acute abdominal conditions that present similarly in children and adults, such as appendicitis. He notes that some findings differ in children, such as appendicitis sometimes presenting without fecalith. Transient intussusception is more common in children and often associated with mesenteric adenitis. Pneumonia can also mimic acute abdominal conditions. Overall, many pediatric abdominal issues are non-surgical and can be managed conservatively with careful evaluation to rule out serious conditions requiring surgery.

1. Dr. Balakrishna ShettyDr. Balakrishna Shetty
MD, DMRD, DNBMD, DMRD, DNB
Fellow in Pediatric Radiology, Univ. of Texas.Fellow in Pediatric Radiology, Univ. of Texas.
Fellow in Body Imaging, Baylor College, Houston, USA.Fellow in Body Imaging, Baylor College, Houston, USA.
Professor of Radiology,Professor of Radiology,
Sri Siddhartha University, TumkurSri Siddhartha University, Tumkur
Chief OF Radiology,Chief OF Radiology,
ISHA Diagnostics, BengaluruISHA Diagnostics, Bengaluru

2. Pediatric
Acute AbdomenAcute Abdomen

3. INTRODUCTION:
1.Whether Pediatric Abdomen is just like a miniature Adult?
2.Entities with findings similar to adults will not be discussed.
-Appendicitis
-Mesenteric/enteritis
-Intussusception

4. APPENDICITIS (Plain X Ray)
-Airless abdomen (not that common)
-Normal (not uncommon)
-Scoliosis (most common finding)
-Fecalith (not in all cases)
-Functional obstruction with perforation

7. COLOR FLOW DOPPLER
─Very good in equivocal cases
─Real advantage over CT

8. CT imaging

9. Appendicular
Mass

10. MRI in Acute Appendicitis
Miglioretti et al reported that a radiation-induced solid cancer is
projected to result from every 300-390 abdomen/pelvis CTs in
girls and every 670-760 CTs in boys.
fast-protocol MRI is accurate, efficacious and limited only by
widespread availability (Moore 2012, Johnson 2012). European
data show that using MRI as the sole imaging modality may
reduce overall cost of care.

11. MRI

13. DWI is a valuable technique
Increases the conspicuity of the inflamed
appendix.
both qualitative and quantitative evaluation
( ADC values).
Should be done if the child is in MRI to
diagnose acute abdomen.

14. Limitations of DWI:
poor anatomic localization,
relatively poor spatial resolution,
increased anatomic distortion with the use of high b values
b=800

15. FECALITH
CONSIDERED CLASSIC FOR DECADES but
NOT ALWAYS PRESENT ( maybe 50 % )
APPENDICITIS WITH NO FECALITH
What is the etiology?

16. There was no histologic evidence of acute appendicitis in
116/610 (19%) of children who underwent appendectomy. The
majority had enlarged lymphoid tissue in the appendix and/or
signs of recurrent inflammation of the appendix.
Abes M, Petik B, Kazil S. Nonoperative Treatment of Acute
Appendicitis in Children. J Pediatric Surgery 2007;42:1439-1442.

17. enteric and systemic viral
infection such as measles, chicken
pox, and cytomegalovirus cause
reaction of the lymphoid follicle.
LYMPHOID TISSUE IS NORMAL IN THE APPENDIX BUT IS
MORE ABUNDANT AND ACTIVE
IN THE INFANT AND YOUNG CHILD
THAN THE OLDER CHILD
AND SO ONE MIGHT THINK OF THE APPENDIX
AS JUST ANOTHER LYMPH NODE
WHICH CAN REACT TO VIRAL INFECTION IN TERMS OF
LYMPHOID HYPERPLASIA AND RESULT IN VIRAL
APPENDICITIS

18. Peletti AB, Baldisserotto M: Ped Rad 2006;36:1171-7
Lymphoid Appendicitis

19. THE PINK APPENDIX,
Lymphoid Appendix, ( IMAGING
FINDINGS )

20. THE PINK APPENDIX
USUALY SEEN WITH MESENTERIC
ADENITIS/ ENTERITIS

22. MESENTERIC ADENITIS/ENTERITIS IS MORE
COMMON THAN APPENDICITIS
PATHOPHYSIOLOGY
LYMPH NODES
And
THICKENED SMALL BOWEL MUCOSA

24. IN SUMMARY
MESENTERIC ADENITIS /
ENTERITIS
THICKENED SMALL BOWEL
AND NODES
USUALY VIRAL INFECTION

25. Emergency
vs
Conservative Management

26. Obstruction
distal lumen fills with mucous -acts as a closed-loop obstruction.
Distension - increase in intraluminal/ intramural pressure.
Resident bacterial proliferation. ( Bacteroides fragilis, E.coli).
Distension - reflex anorexia, nausea, vomiting, visceral pain.
Small venules, capillaries thrombosis,
arterioles remain open,
Engorgement and congestion.

27. Inflammation extends to serosa of the appendix, adjacent parietal
peritoneum - Right lower quadrant pain.
Arterioles thrombose, ischemia of anti-mesenteric border,
infarction, perforation.
Bacterial leak out, pus formation(suppuration) within and around
the appendix. ( Perforations are usually anti mesenteric border just
beyond the obstruction rather than at the tip of the appendix)

28. Appendix: a Lymphatic Organ of
Pediatric Abdomen
Abdominal Infection ( Viral)
Appendicular Enlargement
Fever: manifestation of diffuse infection, Pain because of
increased intra luminal pressure.
No organic obstruction, ischemia- confirmed by Doppler flow
Vascularized Appendix- can be managed conservatively

29. Are there risk of complications ?
PERFORATION
RECURRENT APPENDICITIS

30. Urgent appendectomy
basis of management for acute appendicitis
morbidity and mortality rates between perforated
and non perforated appendicitis.
Immediate surgery results in the confirmation of
diagnosis
control of abdominal sepsis
No risk of recurrent appendicitis

31. 81 patients, who underwent appendectomy were reviewed. All patients had
preoperative CT scans and all operations were performed by one of two surgeons.
Group A: emergency (within 10 hours of CT diagnosis) Group B: Interval
appendectomies
Parameters A B
operative time 54.1 55.7
length of stay 2.65 2.09
wound infections 4 0
antibiotic use at discharge 19 3
delaying operative intervention for acute appendicitis to
accommodate surgeon's preference/ to maximize hospital's
efficiency does not pose a significant risk to the patient

32. Children operated
after overnight antibiotics & resuscitation
significant lower risk of IAA
(intra abdominal abscess)
compared with children managed
by other strategies (P < 0.0003).

33. FECALITH
Lumen obstruction
Increased Intraluminal pressure
COMPROMISED BLOOD
SUPPLY
ISCHEMIA – NECROSIS
BACTERIAL INVASION
PURULENT APPENDICITIS
PROPOSED
PATHOPHYSIOLOGY OF TIP
LYMPHOID HYPERPLASIA
INCREASED INTRASEROSAL
PRESSURES
COMPROMISED BLOOD
SUPPLY
THE TIP - MOST
VULNERABLE
ISCHEMIA – NECROSIS
BACTERIAL INVASION
PURULENT APPENDICITIS OF
THE TIP

34.  No FecalithNo Fecalith
 Uniform enlargementUniform enlargement
 Good or increasedGood or increased
blood flow on Colorblood flow on Color
DopplerDoppler
Fever First
Pain Next

35. Pain:
1. visceral receptors:
on serosal surface, walls of viscera, mesentery,
Respond to mechanical and chemical stimuli,
Poorly localized,
perceived in the midline (bilaterally symmetric innervation)
2. mucosal receptors: respond primarily to chemical stimuli.
Parietal peritoneum (which is somatically innervated) becomes
inflamed, Precise localization, like Appendicitis.
Referred pain usually is located in the cutaneous dermatomes
sharing the same spinal cord level as the visceral inputs.

36. Other Organs which look angry in a
sick child with high fever.
Shetty B.P, Broome D.R, (1998) sonographic analysis of Gallbladder
in Salmonella Enteric fever. Journal Of Ultrasound In Med, RSNA
presentation, 1994.

38. Compression
USG
Should not be done if there is obvious Appendicitis
If not, compress the Left Iliac Fossa: If there is pain on RIF, good
sign of Appendicitis - Rovsings Sign, ( specificity 84%)

39. "Red Flag Signs" for Acute Abdominal Pain
in Children
Signs Bilious vomiting
Signs History of intra abdominal surgery
Signs Features of peritonitis
Signs Blood in stool
Signs Blood in vomitus
Signs Features of Intestinal obstruction
Signs Abdominal distension

40. Appendicitis:
Increased success is seen with longer duration of symptoms. Bachur
et al completed at prospective observational trial in 2012 that enrolled
over 1800 patients and noted that sonography sensitivity increased
from 81% at 24 hours to 96% at 48 hours.

41. Abo A, Shannon M, Taylor G, Bachur R. The influence of body
mass index on the accuracy of ultrasound and computed
tomography in diagnosing appendicitis in children. Pediatr
Emerg Care. 2011 Aug;27(8):731-6.
Sivitz A, Cohen S, Tejani S. Evaluation of Acute Appendicitis
by Pediatric Emergency Physician Sonography. Annals of
Emergency Medicine. 2014 Oct:64 (4) 358-372.

42. INTUSSUSCEPTION
–Previously idiopathic
–Now related to mesenteric adenitis / enteritis

45. Intussusception:
Typically, a completely normal and healthy child
between the ages of 2 months and 5 years
presents with history with intermittent acute abdominal pain with
pain free intervening period.
The clinician should be sensitive to the possibility of
intussusception in all infants in this age range with acute
intermittent abdominal pain.
Textbook clinical signs such as blood in stool appear late and by
that time the intussusception may be irreducible and/or bowel
necrosis might have set in.

49. TRANSIENT INTUSSUSCEPTION
Usually non-obstructive/merely transient
Most common in jejunum
with mesenteric adenitis/enteritis

50. Fluid Sign

51. Small diameter, short segment

52. Typical US findings of transient small bowel intussusception
1)small size without wall swelling, (less than 2.5 cm)
2)short segment, (less than 3 cm)
3)preserved wall motion,
4)absence of the lead point.
5)Good blood flow in CDI
Spontaneous reduction was confirmed by combinations of US (n =
32), small bowel series (n = 8), CT scan (n = 3), and surgical
exploration (n = 1).
transiently invaginated benign SBIs that do not need immediate
surgical intervention.

53. Transient vs Ileo Colic Intussusception

54. OUR CASES OF
TRANIENT INTUSSUSCEPTION
Viral mesenteric adenitis
most common predisposing factor
even in young adults

55. PNEUMONIA PRESENTING AS
ACUTE ABDOMEN
-Very common in pediatrics
-May not always be lower lobe
pneumonia
-Etiology unknown
-Pulmonary symptoms maybe absent
-Very often mimics acute appendicitis
etc.
-High fever (103°-105°) very important
-May appear as a mass (round
pneumonia)

60. SUMMARY
Acute abdominal pain is a common problem in pediatrics.
Most of the episodes are benign and resolve with no or minimal
intervention.
However, a systemic approach is essential in distinguishing children
who have serious underlying conditions from those who do not.
Consider a benign condition despite severe pain that can be treated
at home- e.g. acute gastroenteritis, colic in infants etc.

61. Infantile colic:
3 ( min) hours of inconsolable crying
3 ( min) times a week for
3 weeks with clustering of the episodes in
the evening.
It usually starts early and resolves around
4-5 months of age. There may be a positive
family history in siblings or parents.

62. Gastroesophageal reflux: (1-8 weeks)
The esophageal symptoms of gastroesophageal reflux
cause significant irritability, crying and abdominal pain
These symptoms are likely to be caused by acid injury to the
esophageal mucosa.
Relieved by antacid preparations

63. CONCLUSION
The most common acute abdominal problems in
children are non surgical in nature.
But surgical causes must be ruled out in all.
Emergency surgery need not be the
management for all those patients !!!

64. thank you
ishadiagnsotics@gmail.comishadiagnsotics@gmail.com