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Acute Abdominal Pain In Children

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Acute Abdominal Pain In Children Hai Ho, M.D. Department of Family Practice Pathophysiology of pain Visceral pain Mechanical stretching Chemical mucosa Aching ... – PowerPoint PPT presentation

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Title: Acute Abdominal Pain In Children


1
Acute Abdominal Pain In Children
  • Hai Ho, M.D.
  • Department of Family Practice

2
Pathophysiology of pain
  • Visceral pain
  • Mechanical stretching
  • Chemical mucosa
  • Aching and dull, poorly localized
  • Parietal pain
  • Sharp, well-localized

3
Pathophysiology of pain
  • Referred pain
  • Somatic and visceral afferent fibers enter the
    spinal close to each other
  • Localization of pain
  • Bilateral most GI tract, midline pain
  • Unilateral kidney, ureter, ovary, somatic

4
History
  • Usual quality, location, severity, associated
    symptoms, aggravating/alleviating factors
  • Kids cannot give a history
  • Dangerous signs given by parents

5
My history the red flags
  • Duration acute vs. chronic
  • Fever inflammation, infection
  • Vomiting stasis, obstruction, dehydration
  • Urine output volume depletion
  • Diarrhea - bloody

6
Examination
  • Usual inspection, auscultation, percussion,
    palpitation
  • Rectal rectocecal appendicitis, occult blood
  • Pelvic PID
  • Scrotal - torsion

7
Tests?
  • Chemistry electrolyte abnormality,
    BUN/creatinine, liver function test
  • CBC infection, bleeding
  • Plain abdominal x-ray free air, obstruction
  • Urinalysis pyuria, hematuria
  • Pregnancy test

8
Pyloric stenosis
9
What is pyloric stenosis?
Hypertrophy of pylorus thickening elongation
10
Cause of pyloric stenosis?
  • Unknown
  • Associations
  • Abnormal muscle innervations
  • Erythromycin in neonates for pertussis
    postexposure prophylaxis
  • Infant hypergastrinemia

11
Epidemiology
  • Prevelance 3/1000
  • More common in white northern European descents
  • Malefemale 41 to 61
  • Age 1 week 5 months but usually 3 to 6 weeks

12
Clinical presentation?
  • Abdominal pain
  • Nonbilious vomiting after feeding and with 91
    having projectile emesis

Distinguish pyloric stenosis from GER?
13
Clinical presentation?
  • Abdominal pain
  • Nonbilious vomiting after feeding and with 91
    having projectile emesis
  • Hungry after feeding
  • Weight loss
  • Progressive symptoms

14
Clinical presentations
  • Jaundice
  • 5 of affected patients
  • Indirect hyperbilirubinemia due to decreased
    level of glucuronyl transferase

15
Examination?
  • Abdominal distension
  • Olive mass RUQ, after feeding

16
Examination
  • Gastric peristaltic wave from left to right after
    feeding

17
Tests?
  • Chemistry
  • Plain abdominal x-ray
  • Ultrasound
  • UGI

18
Chemistry?
  • Decreased chloride
  • Elevated bicarbonate metabolic alkalosis
  • Hypokalemia
  • Elevated BUN and creatinine
  • Elevated indirect bilirubin

19
Abdominal x-ray
Increased gastric air or fluid suggestive gastric
outlet obstruction
20
Ultrasound
  • Pyloric length gt 15-19 mm
  • Wall thickness gt 3-4 mm
  • Pyloric diameter gt10-14 mm

21
Ultrasound
Shoulder sign - indentation of pylorus into the
stomach
22
UGI
  • String sign
  • Pyloric spasm may mimic the string sign

23
Treatment?
  • Medical resuscitation first
  • IVF hydration with potassium
  • Correction of alkalosis because of postoperative
    apnea associated with general anesthesia
  • Pyloromyotomy
  • Endoscopically-guided balloon dilation surgery
    is contraindicated or incomplete pyloromyotomy

24
Pyloromyotomy
25
Pyloromyotomy
26
Pyloromyotomy laparoscopy
27
Postoperative management
  • May be fed within 12-24 hours, early as 4 hours
    post-op in one study
  • Vomiting
  • Not a reason to delay feeding
  • GER up to 80 post-op
  • Consider UGI if vomiting persists gt 5 days

28
Intussusception
29
What is intussusception?
  • Invagination of intestine into itself

30
Pathophysiology
  • Proximal bowel telescopes into distal segment,
    dragging along mesentery
  • Compression of mesenteric vessels lymphatics
    leads to edema, ischemia, mucosal bleeding,
    perforation, and peritonitis

31
Ileocolic intussusception
32
Causes of intussusception?
  • Idiopathic
  • 75 of ileocolic intussusception
  • More likely in children lt 5

33
Causes of intussusception
  • Leading point
  • Hyperplasia of Peyer patches in terminal ileum
  • Structural small bowel lymphoma, Meckel
    diverticulum
  • Systemic cystic fibrosis, Henoch-Schönlein,
    Crohn disease

34
Epidemiology
  • Malefemale 32
  • Age
  • 3 months to 6 years with 80 lt age 2
  • Peak at 6-12 months
  • Most common - ileocolic

35
Clinical manifestations?
  • Intermittent, severe, crampy abdominal pain with
    loud cry and in curled up position
  • Vomiting
  • Appear normal between attack
  • Currant-jelly stool

36
Currant-jelly stool
Mixture of blood and mucus Foul smelling
37
Tests?
  • Chemistry dehydration, electrolyte imbalance
  • CBC infection
  • X-ray plain film contrast or air enema
  • Ultrasound
  • CT scan only if other tests are negative

38
X-ray plain film
39
X-ray
  • Contrast material between the intussusceptum and
    the intussuscipiens is responsible for the
    coil-spring appearance
  • Use water-soluble agent prior to barium if high
    risk of perforation suspected

40
Ultrasound
Could detect ileoileal intussusception
41
Treatment?
  • Air or contrast reduction
  • Air is better than barium reduction less
    perforation lt1
  • Not very successful if symptoms gt 24 48 hours
    or with bowel obstruction
  • Successful rate 75-90 with ileocolic
    intussusception
  • Surgery

42
Reduction
43
Surgery
  • Manual reduction and end-to-end anastomosis
  • Indications
  • Persistent filling defects
  • Failed nonoperative reduction
  • Prolonged intussusception

44
Recurrence
  • 10
  • Not necessary an indication for surgery

45
Malrotation Volvulus
46
Normal development
47
Midgut volvulus
48
Volvulus
Sigmoid volvulus
Cecal volvulus
49
Clinical presentation?
  • Bilious emesis
  • Abdominal distension

50
Tests?
  • UGI- duodenum not crossing the midline
  • Barium enema malposition of cecum

51
Abdominal series
Gastric and duodenal bulb distention Little air
in intestine
52
UGI with SBFT
Cork-screw pattern barium flowing through
restricted bowel lumen
53
Treatment surgery
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