Acute Abdominal Pain In Children

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Acute Abdominal Pain In Children

• Hai Ho, M.D.
• Department of Family Practice

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Pathophysiology of pain

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

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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

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History

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

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My history the red flags

• Duration acute vs. chronic
• Fever inflammation, infection
• Vomiting stasis, obstruction, dehydration
• Urine output volume depletion
• Diarrhea - bloody

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Examination

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

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Tests?

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

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Pyloric stenosis
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What is pyloric stenosis?
Hypertrophy of pylorus thickening elongation
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Cause of pyloric stenosis?

• Unknown
• Associations
• Abnormal muscle innervations
• Erythromycin in neonates for pertussis
  postexposure prophylaxis
• Infant hypergastrinemia

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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

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Clinical presentation?

• Abdominal pain
• Nonbilious vomiting after feeding and with 91
  having projectile emesis

Distinguish pyloric stenosis from GER?
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Clinical presentation?

• Abdominal pain
• Nonbilious vomiting after feeding and with 91
  having projectile emesis
• Hungry after feeding
• Weight loss
• Progressive symptoms

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Clinical presentations

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

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Examination?

• Abdominal distension
• Olive mass RUQ, after feeding

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Examination

• Gastric peristaltic wave from left to right after
  feeding

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Tests?

• Chemistry
• Plain abdominal x-ray
• Ultrasound
• UGI

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Chemistry?

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

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Abdominal x-ray
Increased gastric air or fluid suggestive gastric
outlet obstruction
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Ultrasound

• Pyloric length gt 15-19 mm
• Wall thickness gt 3-4 mm
• Pyloric diameter gt10-14 mm

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Ultrasound
Shoulder sign - indentation of pylorus into the
stomach
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UGI

• String sign
• Pyloric spasm may mimic the string sign

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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

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Pyloromyotomy
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Pyloromyotomy
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Pyloromyotomy laparoscopy
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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

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Intussusception
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What is intussusception?

• Invagination of intestine into itself

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Pathophysiology

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

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Ileocolic intussusception
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Causes of intussusception?

• Idiopathic
• 75 of ileocolic intussusception
• More likely in children lt 5

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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

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Epidemiology

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

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Clinical manifestations?

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

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Currant-jelly stool
Mixture of blood and mucus Foul smelling
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Tests?

• Chemistry dehydration, electrolyte imbalance
• CBC infection
• X-ray plain film contrast or air enema
• Ultrasound
• CT scan only if other tests are negative

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X-ray plain film
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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

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Ultrasound
Could detect ileoileal intussusception
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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

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Reduction
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Surgery

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

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Recurrence

• 10
• Not necessary an indication for surgery

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Malrotation Volvulus
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Normal development
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Midgut volvulus
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Volvulus
Sigmoid volvulus
Cecal volvulus
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Clinical presentation?

• Bilious emesis
• Abdominal distension

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Tests?

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

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