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ABDOMINAL PAIN IN CHILDRENFOR MEDICAL STUDENT

Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPS

Associate Consultant Pediatric Surgery; KAAUH_ PNU

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Abdominal pain is a common complaint in childhood.

Distinguishing between important surgical causes and self-limiting, non-surgical causes is occasionally quite difficult

This is an area where clinical skills are especially important and where examination and, indeed, repeated examination is of paramount importance.

Ensure you are familiar with the physiological differences between children and adults as well as the differences in clinical approach to history taking and examination.

INTRODUCTION

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A large number of children experience abdominal pain but less than half of these will be admitted to hospital

“One in every 500 children will experience abdominal pain sufficiently severe to warrant admission to hospital

Approximately one in two of these will require appendectomy

Introduction

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Appendicitis Non specific abdominal pain Mesenteric adenitis Intussusception Mackle's diverticulum Volvulus Medical causes Others

DD abdominal pain in children

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Urinary tract infection Enterocolitis Pneumonia Henoch-schonlein purpura Diabetic ketoacidosis Measles Others

Medical causes

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Appendicitis is the prime diagnosis to be excluded in a child presenting with abdominal pain

The commonest reason for emergency general surgical intervention in childhood

Active observation remains the most useful method of diagnosing appendicitis in children

If uncertainty exists after the first examination, a repeat examination is needed every two to three hours until the need for surgery is clarified

1-Appendicitis

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The diagnosis of appendicitis may be clear in many children, but in those under five years of age the presentation can be quite atypical and, in this age group, the incidence of perforation rises.

Incidence of perforation: <5 years = 35% >5 years = 18%

1-Appendicitis

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This condition is, to some extent, a diagnosis of exclusion

Pain usually disappears within 24 hours and, if investigated, is found not to be associated with urinary infection, systemic illness, or constipation.

There is no clear cause for this condition: viral titers are not raised, and psychological tests show no difference from controls. There may however be an association with food allergy or migraine

2-Non-specific abdominal pain

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Lymph node enlargement following antecedent viral or bacterial illness may result in gastro-intestinal dysmotility, free fluid in the peritoneal cavity, and hence abdominal pain.

The condition is typically seen after Yersinia infection, but may occur after any enteric pathogen.

Confident diagnosis of mesenteric adenitis avoids the need for abdominal exploration although some surgeons believe this to be an operative and not a clinical diagnosis.

The child will have a fever, numerous enlarged lymph nodes in the cervical chain and even in the axilla

3-Mesenteric adenitis

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A gut infection or dietary change, such as weaning, in infants aged two months to two years often results in lymphoid hyperplasia of the ileal submucosa

4-Intussusception

A submucosa nodule in the ileum may act as a bolus of food and be propelled distally, pulling the gut and associated mesentery into the distal bowel lumen and thereby producing intussusception.

Intussusception results in mucosal ischemia, colicky abdominal pain and rectal bleeding

The obstructive component produces vomiting (often reflex in nature and hence clear fluid).

If uncorrected, ischemic damage to the tip of the intussusceptum will result in eventual perforation

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M.D. is a remnant of the vitello-intestinal tract In most instances it is found in the terminal ileum as a diverticulum on

the anti-mesenteric aspect, but it can be found more proximally

It may contain ectopic gastric mucosa and hence give rise to bleeding in, or perforation of the adjacent ileum downstream from the orifice of the Mackle's diverticulum

It may also become acutely inflamed and simulate appendicitis

5-Meckel’s diverticulum (MD)

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Midgut Malrotation results in approximation of the duodenum and caecum.

This narrow pedicle may twist producing occlusion of the feeding artery of the midgut, the superior mesenteric artery

6-Midgut Volvulus

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The resultant ischemia will initially produce pain with no signs until such time as the infarction process extends to the serosa surface.

By this time the entire midgut has infarcted and survival is unlikely

Bile vomiting and intense pain with a soft abdomen are features of volvulus of the small bowel.

laparotomy must be undertaken quickly

6-Midgut Volvulus

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Should be taken from the child if possible or a parent/guardian.

Site, onset, Duration and severity of pain

Development of other symptoms

Any previous illness progression since starting

Constitutional upset

Clinical Approach; *History

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Distract the child during examination with questions about school/hobbies/ sports/music etc

In addition look at: Capillary refill time Vital signs Abdominal signs - rebound tenderness can be elicited easily by

gentle percussion of the abdomen Rectal examination (in some but not all) - It can be an upsetting

feature of the examination for younger children

Clinical Approach; *Examination

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Your investigation of abdominal pain in children will be guided by your tentative diagnosis.

“ There is no such thing as a routine investigation in a child. Every test must be considered and justified.”

Blood tests WCC & CRP in combination are useful adjuncts in helping you come to

the diagnosis of appendicitis. In isolation they are unreliable

Clinical Approach; *Laboratory

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X-Ray indicated if intestinal obstruction

is suspected.

A gasless appearance should elicit concern about possible small bowel volvulus

Fecoleth is diagnostic for appendictis

Clinical Approach; *Radiological

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Abdominal US This is a useful investigation if

intussusception is thought to be a possibility.

The cross-section of bowel during intussusception gives rise to a ‘target sign’ on ultrasound

Clinical Approach; *Radiological

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Technetium scan This will detect ectopic gastric

mucosa by uptake of the isotope in parietal cells and is useful for diagnosing Mackle's diverticulum.

Some Mackle's diverticula are diagnosed by this test but not all

Clinical Approach; *Radiological

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Fluid management is best considered in three phases:

1. Maintenance fluids 2. Replacement of continuing losses 3. Resuscitation/Restoration of deficit

Management

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The successful management of appendicitis requires:

Intravenous antibiotic given on induction, e.g. Cephalosporin and metronidazole

Appendectomy with/ without peritoneal lavage

Appendicitis

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US: To confirm diagnosis Contrast enema: Diagnostic and

Therapeutically to reduce the intussusception

Intussusception

Early diagnosis: can be treated by hydrostatic or pneumostatic reduction. The success rate is approximately 80%

Late diagnosis: with signs of peritonitis or if Radiological reduction fails, operative reduction is mandatory

The presence of a lead point, such as a polyp or Meckel’s diverticulum, is an indication for resection

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Can be treated by simple wedge resection of the Meckel’s diverticulum If bleeding has been a problem it is important to resect the adjacent

distal ileum to ensure that the bleeding point/ulcer is included in the resection

Meckel’s diverticulum

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Still unfortunately a mortality from appendicitis in UK and this usually relates to the extremes of age. Extra care therefore must be taken with the very young and the very old.

Normal appendectomy rate can be kept extremely low by adherence to active observation when performed diligently

Wound sepsis rates should not exceed 5% if care is taken with perioperative antibiotic prophylaxis and intraoperative lavage

Outcomes

Appendicitis

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Malrotation is still a potentially lethal condition and the diagnosis must be considered if intestinal infarction is to be prevented.

The ischemic process in volvulus commences with mucosal involvement. Peritonitis, indicative of serosa ischemia, will only appear when the gut is no longer viable

Outcomes

Malrotation

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Is a potential cause of death in children

Particularly in those who do not present in a classical fashion or are out with the typical age range.

The great majority of children with the above conditions however make a complete recovery

Outcomes

Intussusception

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Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPS

Associate Consultant Pediatric Surgery; KAAUH_ PNU

ABDOMINAL PAIN IN CHILDRENFOR MEDICAL STUDENT

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