acute abdominal pain in children

ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN

Raymond G BuickPaediatric Surgeon

Birmingham

Length: approx 55 minutes

ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN

Lecture given to

Paediatric Surgery for Specialist Trainees

Raymond G BuickPaediatric Surgeon

Birmingham

February 2009

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

pathophysiology

Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain, • referred pain.

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.

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.

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.

ABDOMINAL PAIN

• Causes of ACUTE ABDOMINAL PAIN

Causes of Acute Abdominal Pain in ChildrenGastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation FlatulenceAbdominal 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 overdoseSoap ingestion

Pulmonary causes Pneumonia Diaphragmatic pleurisy

Miscellaneous Infantile colic Functional painPharyngitis Angioneurotic oedema Familial Mediterranean feverFloating 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)

ABDOMINAL PAIN

• Causes of ACUTE ABDOMINAL PAIN

• AGE • SEX

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)

ABDOMINAL PAIN

Causes of ACUTE ABDOMINAL PAIN in veryyoung children• Neonates – acute abdomen• Intestinal volvulus• Incarcerated inguinal hernia• Hirschsprung's disease• Intussusception• Trauma – non-accidental

Causes of Abdominal Pain in Children  Emergencies/life-threatening Other causes

Medical causes Diabetic Ketoacidosis Gastroenteritis (bacteria or viruses)

Inflammatory bowel disease ConstipationAcute adrenal failure Flatulence  Mesenteric lymphadenitis  Peptic ulcer disease  Urinary tract infection  Ureteric calculi  Hepatitis  Cholecystitis  Pancreatitis  Sickle cell anaemia/crises  Henoch Schonlein purpura

Surgical causes Appendicitis  

Bowel obstruction (e.g. intussusception, volvulus)

TraumaIncarcerated herniaPeritonitisTesticular torsion

Gynaecological causes   DysmenorrhoeaMittelschmerzPelvic inflammatory diseaseEndometriosis

Obstetric causes Ectopic pregnancy  Ovarian cyst rupture/torsionAbortion

Drugs/Toxins Paracetamol overdose Soap ingestionIron overdose ErythromycinVenoms  

Referred pain   PneumoniaRare causes   Angioneurotic oedema

Familial Mediterranean feverUnknown aetiology   Infantile colic

Functional bowel disease

ADMISSIONS363

OPERATIONS12535%

OTHER SURGICAL DIAGNOSES OR NEGATIVE

246%

MEDICAL12935%

APPENDICITIS10629%

NON-SPECIFIC ABDOMINAL PAIN

10830%

OBSERVED23765%

Admissions with Abdominal Pain to a District General Hospital in one year

HOME CHEMISTNHS DIRECTGP

Admissions with Abdominal Pain to a Paediatric Surgical Unit in one year

• The most common medical cause is gastroenteritis

• The most common surgical cause is appendicitis.

ACUTE ABDOMINAL PAIN

Pain & vomiting

• In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions.

• The most common medical cause is gastroenteritis – Viruses

rotavirus, Norwalk virus, adenovirus, Enterovirus

BacteriaEscherichia coli, Yersinia, Campylobacter, Salmonella, Shigella.

ABDOMINAL PAIN

Causes of Acute Abdominal Pain in ChildrenGastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation FlatulenceAbdominal 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 overdoseSoap ingestion

Pulmonary causes Pneumonia Diaphragmatic pleurisy

Miscellaneous Infantile colic Functional painPharyngitis Angioneurotic oedema Familial Mediterranean feverFloating 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)

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

Up to 20% of infantsFirst 6 monthsScreamDraw knees up

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

Over diagnosedPain – Visceral / LIFAcute – organic causeChronic – functional causeDiagnosis of last resort

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

AdenovirusPreceding upper resp infectionMay Other lymphadenopathymimic appendicitisPain more diffuseHigher temperatureShifting tenderness

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

ACCIDENTALNON-ACCIDENTAL

Parents may conceal information

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

Includes•Malrotation•Volvulus•Intussusception•Incarcerated hernia•adhesions

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

Includes•Malrotation•Volvulus•Intussusception•Incarcerated hernia•Adhesions – ACQUIRED

-- CONGENITAL

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

ChlamydiaNeisseria

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 242% female population20% recurrent

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

ChlamydiaNeisseriaAND PregnancyHistory may be concealed

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

ChlamydiaNeisseriaAND PregnancyHistory 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)

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

NICE Guidelines -August 2007

www.nice.org.uk/Guidance/CG54/NiceGuidance/pdf/English

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

NICE Guidelines -August 2007e

Symptoms and signs

Most common Least Common

Preverbal Fever Abdominal pain Loin tenderness Vomiting Poor feeding

Lethargy Irritability Haematuria Offensive urine Failure to thrive

Verbal Frequency Dysuria

Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness

Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine

• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum

ABDOMINAL PAIN

Meckel’s Diverticulum

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 C16 first described by Fabricius Hildanus C16 • named after Johann Friedrich Meckel who named after Johann Friedrich Meckel who

described the embryological origin of this described the embryological origin of this type of diverticulum in 1809type of diverticulum in 1809

ABDOMINAL PAIN

• diagnosis

ABDOMINAL PAIN

• History• A challenge in young children• poor sense of timing and location

ABDOMINAL PAIN

• History• PAIN Location• Onset• Character• Change of location or character• Severity• Radiation• Precipitating/relieving factors

ABDOMINAL PAIN• History• VOMITING character• frequency• content bile / blood• BOWELSfrequency • consistency• blood• URINARY frequency/dysuria/polyuria/urgency/odour/colour• RESPIRATORY cough/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

•

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

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

ABDOMINAL PAIN

Active Observation

ABDOMINAL PAIN

“repeated physical examination by the same physician often is useful”

ABDOMINAL PAIN

repeated physical examination is MANDATORY

by the same physician is BENIFICIAL

ABDOMINAL PAIN

Active Observation

ABDOMINAL PAIN

RECORDED

Active Observation

ABDOMINAL PAIN

RecordedActive

Observation

• in most instances, abdominal pain can be diagnosed through the history and physical examination.

‘THE PAIN’ in ABDOMINAL PAIN

• Use analgesia as required - it does not affect diagnostic accuracy

Patient UK atwww.patient.co.uk/showdoc/40000523/

‘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.

APPENDICITIS

APPENDICITIS

• Age

The approach to common abdominal diagnosis in infants and childrenIrish M S et alPediatric 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

Age in Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Acute appendicitis without perforation 2 8 17 30 33 17 43 57 97 111 137 168 144 163 104 91 178 Acute appendicitis with perforation 2 3 10 23 20 16 16 23 27 25 16 16 12 22 8 18 42Total number of patients 4 11 27 53 53 33 59 80 124 136 153 184 156 185 112 109 220Percentage perforated 50 27 37 46 38 48 27 27 22 18 10 9 8 12 7 17 19

APPENDICITIS

• What causes appendicitis

APPENDICITIS• Types of Appendicitispathogenesis

primary obstruction of the lumen of appendixfilled with mucus and swells.increasing pressure within the lumenPressure on the wall of the appendixresulting in thrombosis & occlusion of blood vesselsInflammation of appendixPus may form within the appendix (suppuration)stasis of lymph flow - leads to ischaemia and necrosis (gangrene)Bacteria begin to leak out through appendix wallsPus forms within and around the appendixPerforation of appendix - peritonitis / abscessSepticaemia - death

} Appendix Mass

APPENDICITIS

• Types of Appendicitis– Acute– Perforated

APPENDICITIS

• Types of Appendicitis– Acute

• Acute inflammatory appendicitis• Acute Suppurative appendicitis

– Perforated (complicated)• Perforated• Gangrenous

APPENDICITIS

• Types of Appendicitis– Acute

• Acute inflammatory appendicitis• Acute Suppurative appendicitis

– Perforated (complicated)• Perforated• Gangrenous

• Normal• (Registrar’s Appendicitis)

APPENDICITIS

• Types of Appendicitis– Acute

• Acute inflammatory appendicitis• Acute Suppurative appendicitis

– Perforated (complicated)• Perforated• Gangrenous

• Normal

Appendix MassAppendix Abscess

Clinical Features - Symptoms

Clinical Features - Symptoms

• Pain – Central» Vague» Crampy» Wants to move around

– Moves to Right Iliac Fossa» Acute» Sharp / constant» Wants to lie still

Anorexia

Nausia

Vomiting

Mild Pyrexia

Halitosis

Change in bowel habit – diarrhoea -- constipation

Urinary Symptoms

LOCALISED

Clinical Features - Signs

Clinical Features - Signs

• Localised Tenderness• Muscle Guarding Tachycardia

Flushed

Circum-oral pallor

Rectal Examination ?

Rovsing’s Sign

Psoas sign

Obturator sign

Caecal Gurgle

Clinical Features - Signs

• Localised Tenderness• Muscle Guarding Tachycardia

Flushed

Circum-oral pallor

Rectal Examination ?

Rovsing’s SignNiels Thorkild Rovsing Danish surgeon 1907,

Psoas sign

Obturator sign

Caecal Gurgle

Clinical Features - Signs

• Localised Tenderness• Muscle Guarding Tachycardia

Flushed

Circum-oral pallor

Rectal Examination ?

Rovsing’s Sign

Psoas sign

Obturator sign

Caecal Gurgle

Action:-Hip flexion

Pain:-Pain:-Hip ExtensionHip Extension

Clinical Features - Signs

• Localised Tenderness• Muscle Guarding Tachycardia

Flushed

Circum-oral pallor

Rectal Examination ?

Rovsing’s Sign

Psoas sign

Obturator sign

Caecal Gurgle

Action:-AbductsLat RotatesPain:-Pain:-Hip AdductionHip AdductionInternal RotationInternal Rotation

Clinical Features - Signs

• Localised Tenderness• Muscle Guarding Tachycardia

Flushed

Circum-oral pallor

Rectal Examination ?

Rovsing’s Sign

Psoas sign

Obturator sign

Caecal Gurgle

Clinical Features - Signs

• Localised Tenderness• Localised Guarding

Anatomical positions of appendix

• Retrocaecal – poor localising signs• Retroileal – diarrhoea• Pelvic – diarrhoea / Bladder

CLASSICAL CARDINAL FEATURES

• Localised Pain• Localised Tenderness• Muscle Guarding• (Rebound Tenderness)

McBurney’s PointCharles McBurney U.S. surgeon, 1845–1913

Investigations

• Blood Test– Sickle– Neutrophil leucocytosis– Lymphopenia– CRP

Investigations

• Radiology– Abdominal film

• Obstruction• faecolith• Soft tissue mass• Loaded colon

– Ultrasound• Gynaecological• Abscess/mass/thick bowel loops• stones

APPENDICITIS

• Preparation for theatre– Analgesics– Fluids– Antibiotics– Consent

APPENDICITIS

• In theatre– EUA

• Open or Laparoscopic ?

APPENDICITIS

• In theatre– EUA

• Open or Laparoscopic ?

• What if it is perforated ?

APPENDICITIS

• In theatre– EUA

• Open or Laparoscopic ?

• What if it is Crohn’s ?

APPENDICITIS

• In theatre– EUA

• Open or Laparoscopic ?

• What if it is normal ?

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

Henoch-Schönlein purpura

• systemic vasculitis• deposition of immune complexes containing

the antibody IgA in the skin and kidney • occurs mainly in young children.

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

12th Rib Syndrome

• Floating Rib• Slipping Rib• Rib Dysfunction