1. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
Raymond G Buick
Paediatric Surgeon
Birmingham
Length: approx 55 minutes
2. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
Lecture given to
Paediatric Surgery for Specialist Trainees
Raymond G Buick
Paediatric Surgeon
Birmingham
February 2009
3. ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
•Pathophysiology
•Causes of abdominal pain
•Diagnosis of acute abdominal pain
•Acute appendicitis
•A few rare causes of acute abdominal pain
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
5. Clinically, abdominal pain falls into three categories:
• visceral (splanchnic) pain---visceral pain fibers
are bilateral and unmyelinated and enter the spinal
cord at multiple levels,
visceral pain usually is dull, poorly localized, and felt
in the midline
• parietal (somatic) pain,
• referred pain.
6. Clinically, abdominal pain falls into three categories:
• visceral (splanchnic) pain,
• parietal (somatic) pain--- Parietal pain arises from
noxious stimulation of the parietal peritoneum. Pain
resulting from ischemia, inflammation, or stretching of
the parietal peritoneum is transmitted through
myelinated afferent fibers to specific dorsal root
ganglia on the same side and at the same dermatomal
level as the origin of the pain. Parietal pain usually is
sharp, intense, discrete, and localized, and coughing or
movement can aggravate it.
• referred pain.
7. Clinically, abdominal pain falls into three categories:
• visceral (splanchnic) pain,
• parietal (somatic) pain,
• referred pain-- Referred pain has many of the
characteristics of parietal pain but is felt in remote
areas supplied by the same dermatome as the
diseased organ. It results from shared central
pathways for afferent neurons from different sites. A
classic example is a patient with pneumonia who
presents with abdominal pain because the T9
dermatome distribution is shared by the lung and the
abdomen.
11. Differential Diagnosis of Acute
Abdominal Pain by Predominant
Age
Birth to one year Two to five years Six to 11 years 12 to 18 years
Infantile colic Gastroenteritis Gastroenteritis Appendicitis
Gastroenteritis Appendicitis Appendicitis Gastroenteritis
Constipation Constipation Constipation Constipation
Urinary tract infection Urinary tract infection Functional pain Dysmenorrhoea
Intussusception Intussusception Urinary tract infection Mittelschmerz
Volvulus Volvulus Trauma Pelvic inflammatory
disease
Incarcerated hernia Trauma Pharyngitis Threatened abortion
Hirschsprung's disease Pharyngitis Pneumonia Ectopic pregnancy
Trauma Sickle cell crisis Sickle cell crisis Ovarian/testicular torsion
Henoch-Schönlein purpura Henoch-Schönlein purpura
Mesenteric lymphadenitis Mesenteric lymphadenitis
Adapted from : Acute Abdominal Pain in Children
ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
12. ABDOMINAL PAIN
Causes of ACUTE ABDOMINAL PAIN in very
young children
• Neonates – acute abdomen
• Intestinal volvulus
• Incarcerated inguinal hernia
• Hirschsprung's disease
• Intussusception
• Trauma – non-accidental
14. ADMISSIONS
363
OPERATIONS
125
35%
OTHER SURGICAL
DIAGNOSES OR NEGATIVE
24
6%
MEDICAL
129
35%
APPENDICITIS
106
29%
NON-SPECIFIC
ABDOMINAL PAIN
108
30%
OBSERVED
237
65%
Admissions with Abdominal Pain to a District General Hospital in one year
HOME
CHEMIST
NHS DIRECT
GP
16. • The most common medical cause is
gastroenteritis
• The most common surgical cause is
appendicitis.
ACUTE ABDOMINAL PAIN
17. Pain & vomiting
• In the acute surgical abdomen, pain generally
precedes vomiting, while the reverse is true in
medical conditions.
18. • The most common medical cause is
gastroenteritis – Viruses
rotavirus,
Norwalk virus,
adenovirus,
Enterovirus
Bacteria
Escherichia coli,
Yersinia,
Campylobacter,
Salmonella,
Shigella.
ABDOMINAL PAIN
19. Causes of Acute Abdominal Pain in Children
Gastrointestinal causes
Gastroenteritis
Appendicitis
Mesenteric lymphadenitis
Constipation
Flatulence
Abdominal trauma
Intestinal obstruction
Peritonitis
Food poisoning
Peptic ulcer
Meckel's diverticulum
Inflammatory bowel disease
Lactose intolerance
Hernia
Liver, spleen, and biliary tract
disorders
Hepatitis
Cholecystitis
Cholelithiasis
Splenic infarction
Rupture of the spleen
Pancreatitis
Genitourinary causes
Urinary tract infection
Urinary calculi
Dysmenorrhoea
Mittelschmerz
Pelvic inflammatory disease
Threatened abortion
Ectopic pregnancy
Ovarian/testicular torsion
Endometriosis
Hematocolpos
Metabolic disorders
Diabetic ketoacidosis
Hypoglycaemia
Porphyria
Acute adrenal insufficiency
Hematologic disorders
Sickle cell anemia
Henoch-Schönlein purpura
Haemolytic uremic syndrome
Drugs and toxins
Erythromycin
Salicylates
Lead poisoning
Venoms
Iron overdose
Soap ingestion
Pulmonary causes
Pneumonia
Diaphragmatic pleurisy
Miscellaneous
Infantile colic
Functional pain
Pharyngitis Angioneurotic oedema
Familial Mediterranean fever
Floating Rib Syndrome
Adapted from : Acute Abdominal Pain in Children
ALEXANDER K.C. LEUNG, DAVID L. SIGALET,
American Family Physician® > Vol. 67/No. 11 (June 1,
2003)
27. • Infantile colic
• Constipation
• Mesenteric adenitis
• Abdominal trauma
• Intestinal obstruction
• Pelvic inflammatory disease
• Urinary Tract Infection
• Meckel’s Diverticulum
ABDOMINAL PAIN
Chlamydia
Neisseria
infection and inflammation of the upper female genital tract, uterus, fallopian
tubes and ovaries.
infection in the vagina & cervix passing to the internal reproductive organs.
Age 15 to 24
2% female population
20% recurrent
28. • Infantile colic
• Constipation
• Mesenteric adenitis
• Abdominal trauma
• Intestinal obstruction
• Pelvic inflammatory disease
• Urinary Tract Infection
• Meckel’s Diverticulum
ABDOMINAL PAIN
Chlamydia
Neisseria
AND Pregnancy
History may be concealed
29. • Infantile colic
• Constipation
• Mesenteric adenitis
• Abdominal trauma
• Intestinal obstruction
• Pelvic inflammatory disease
• Urinary Tract Infection
• Meckel’s Diverticulum
ABDOMINAL PAIN
Chlamydia
Neisseria
AND Pregnancy
History may be concealed
PregnancyPregnancy
10% occur in 13 to 15 (7.8 per 1000)10% occur in 13 to 15 (7.8 per 1000)
52% occur in 13 to 17 (41 per 1000)52% occur in 13 to 17 (41 per 1000)
34. Meckel’s Diverticulum
• Meckel's diverticulum,
• congenital
• remnant of the vitelointestinal duct (omphalomesenteric duct)
• 2 feet (from the ileocecal valve)
• 2 inches (in length)
• 2% (of the population) have it
• 2% are symptomatic
• 2 is the most common age at clinical presentation
• 2:1 male:female
• 2 types of common ectopic tissue (gastric and pancreatic)
• first described by Fabricius Hildanus C16first described by Fabricius Hildanus C16
• named after Johann Friedrich Meckelnamed after Johann Friedrich Meckel
who described the embryological originwho described the embryological origin
of this type of diverticulum in 1809of this type of diverticulum in 1809
37. ABDOMINAL PAIN
• History
• PAIN Location
• Onset
• Character
• Change of location or character
• Severity
• Radiation
• Precipitating/relieving factors
38. ABDOMINAL PAIN
• History
• VOMITING character
• frequency
• content bile / blood
• BOWELS frequency
• consistency
• blood
• URINARY frequency/dysuria/polyuria/urgency/odour/colour
• RESPIRATORYcough/SOB/chest pain
• GENERAL temperature/headache/joint pains-swelling/rash/sore throat
• GYNAE menstruation/LMP/sexual activity/contraception/vaginal
discharge/?midcycle
• PAST MEDICAL HISTORY / DRUG HISTORY / FAMILY HISTORY
39. ABDOMINAL PAIN
• Examination
• GENERAL APPEARANCE
• GENERAL – ENT
• – Chest
• ABDOMINAL Breathing pattern
• distension
• Point to pain
• Maximum tenderness
• Muscle guarding
• Rebound tenderness
• bowel sounds
• groin / testes / introitus
• Rectal Examination
40. ABDOMINAL PAIN
• Investigations
• Tailored to symptoms and signs
• CONSIDER Full Blood Picture
• Differential White Cell Count
• Urinalysis
• CRP
• Pregnancy Test
•
• Abdominal X-Ray
• Chest x-Ray
• Ultrasound
• CT
47. • in most instances, abdominal pain can be
diagnosed through the history and physical
examination.
48. ‘THE PAIN’ in ABDOMINAL PAIN
• Use analgesia as required - it does not affect
diagnostic accuracy
Patient UK at
www.patient.co.uk/showdoc/40000523/
49. ‘THE PAIN’ in ABDOMINAL PAIN
• Traditionally, the use of analgesics is discouraged in patients with abdominal pain for fear of interfering
with accurate evaluation and diagnosis.
• However, several prospective, randomized studies have shown that judicious use of analgesics actually
may enhance diagnostic accuracy by permitting detailed examination of a more cooperative patient.
52. The approach to common abdominal diagnosis in infants and children
Irish M S et al
Pediatric Clin North Am. 1998 Aug: 45(4): 729-72
% PERFORATED % NORMAL
Age <= 8 years 33 13
Age > 8 years 18 11
Male 22 8
Female 18 17
55. APPENDICITIS
• Types of Appendicitis
pathogenesis
primary obstruction of the lumen of appendix
filled with mucus and swells.
increasing pressure within the lumen
Pressure on the wall of the appendix
resulting in thrombosis & occlusion of blood vessels
Inflammation of appendix
Pus may form within the appendix (suppuration)
stasis of lymph flow - leads to ischaemia and necrosis (gangrene)
Bacteria begin to leak out through appendix walls
Pus forms within and around the appendix
Perforation of appendix - peritonitis / abscess
Septicaemia - death
}Appendix Mass
79. A few less common causes ofA few less common causes of
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
80. Henoch-Schönlein purpura
• systemic vasculitis
• deposition of immune complexes containing
the antibody IgA in the skin and kidney
• occurs mainly in young children.
81. Henoch-Schönlein purpura
• self-limiting
• no treatment - symptom control,
• in a third of cases disease may relapse
-irreversible kidney damage in about 1% of
cases
• Cause unknown, post viral and bacterial
infections, / adverse drug reactions
