Non traumatic abdominal Non traumatic abdominal pain in childrenpain in children

ByBy

Hatem SaafanHatem SaafanMD FRCSMD FRCS

Prof. of pediatric surgeryProf. of pediatric surgeryAin-Shams universityAin-Shams university

There is considerable variation There is considerable variation among children in their perception among children in their perception and tolerance for abdominal painand tolerance for abdominal pain . .

A specific cause may be difficult to find, but the nature and location of a pain-provoking lesion can usually be determined from the

clinical description .

Two types of nerve fibers transmit Two types of nerve fibers transmit painful stimuli in the abdomen. In painful stimuli in the abdomen. In skin and muscle, A fibers mediate skin and muscle, A fibers mediate sharp localized pain; C fibers from sharp localized pain; C fibers from viscera, peritoneum, and muscle viscera, peritoneum, and muscle transmit poorly localized, dull paintransmit poorly localized, dull pain . .

Somatic painSomatic pain

Intense and is usually well localized. When the Intense and is usually well localized. When the inflamed viscus comes in contact with the somatic inflamed viscus comes in contact with the somatic

organ like the parietal peritoneum or the organ like the parietal peritoneum or the abdominal wall, pain is localized to that site. abdominal wall, pain is localized to that site.

Peritonitis gives rise to generalized abdominal Peritonitis gives rise to generalized abdominal pain with rigidity, involuntary guarding, rebound pain with rigidity, involuntary guarding, rebound tenderness, and cutaneous hyperesthesia on tenderness, and cutaneous hyperesthesia on

physical examination.physical examination.

Visceral painVisceral pain

tends to be dull and aching and is tends to be dull and aching and is experienced in the dermatome from which the experienced in the dermatome from which the

affected organ receives innervations. So, affected organ receives innervations. So, most often, the pain and tenderness is not felt most often, the pain and tenderness is not felt

over the site of the disease processover the site of the disease process..

Painful stimuli originating in the liver, pancreas, biliary tree, stomach, or upper bowel are felt in the epigastrium

Pain from the distal small bowel, cecum, appendix, or proximal colon is felt at the umbilicus

Pain from the distal large bowel, urinary tract, or pelvic organs is usually suprapubic

Pain from the cecum, ascending colon, and descending colon sometimes is felt at the site of the lesion due to the short mesocecum and corresponding mesocolon

The shifting (localization) of pain is a pointer The shifting (localization) of pain is a pointer toward diagnosis; for example; Periumbilical pain toward diagnosis; for example; Periumbilical pain

of a few hours localizing to the right lower quadrant of a few hours localizing to the right lower quadrant suggests appendicitis. suggests appendicitis.

Radiation of pain can be helpful in diagnosis;Radiation of pain can be helpful in diagnosis; for example, in biliary colic the radiation of pain is for example, in biliary colic the radiation of pain is

toward the inferior angle of the right scapula, toward the inferior angle of the right scapula, pancreatic pain radiated to the back, and the renal pancreatic pain radiated to the back, and the renal colic pain is radiated to the inguinal region on the colic pain is radiated to the inguinal region on the

same side.same side.

Referred painReferred pain

due to shared central projections with the due to shared central projections with the sensory pathway from the abdominal wall, sensory pathway from the abdominal wall,

can give rise to abdominal pain, as in can give rise to abdominal pain, as in pneumonia when the parietal pleural pain is pneumonia when the parietal pleural pain is

referred to the abdomenreferred to the abdomen . .

Pain that suggests a potentially serious Pain that suggests a potentially serious organic etiology is associated withorganic etiology is associated with

Age <5 yr; fever; weight loss; bile or blood-Age <5 yr; fever; weight loss; bile or blood-stained emesis; jaundice; stained emesis; jaundice;

hepatosplenomegaly; back or flank pain or hepatosplenomegaly; back or flank pain or pain in a location other than the umbilicus; pain in a location other than the umbilicus; awakening from sleep in pain; referred pain awakening from sleep in pain; referred pain to shoulder, groin or back; elevated ESR, to shoulder, groin or back; elevated ESR,

WBC, or CRP; anemia; edema; or a strong WBC, or CRP; anemia; edema; or a strong family history of inflammatory bowel disease family history of inflammatory bowel disease

(IBD) or celiac disease(IBD) or celiac disease..

Atypical painAtypical pain

Diagnostic dilemma Diagnostic dilemma

Clinical observationLaboratoryRadiological imagingLaparoscopy

CHRONIC ABDOMINAL PAIN IN CHRONIC ABDOMINAL PAIN IN CHILDRENCHILDREN

NONORGANIC

Functional abdominal

painNonspecific pain, often periumbilical

Hx and PE; tests as indicated

Irritable bowel

syndrome

Intermittent cramps,diarrhea, and constipation

Hx and PE

Non-ulcer dyspepsia

Peptic ulcer–like symptoms without abnormalities on evaluation of the upper

GI tract

Hx; esophagogastrod

uodenoscopy

GASTROINTESTINAL TRACT

Chronic constipation

Hx of stool retention, evidence of constipation on

examination

Hx and PE; plain x-ray of abdomen

Lactose intolerance

Symptoms may be associated with lactose ingestion; bloating, gas,

cramps, and diarrhea

Trial of lactose-free diet; lactose breath hydrogen test

Parasite infection

(especially Giardia)

Bloating, gas, cramps, and diarrhea

Stool evaluation for O&P; specific immunoassays for

Giardia

Excess fructose or

sorbitol ingestion

Nonspecific abdominal pain, bloating, gas, and diarrhea

Large intake of apples, fruit juice, or candy or chewing gum sweetened with sorbitol

Peptic ulcer

Burning or gnawing epigastric pain; worse on awakening or before meals; relieved with

antacids

Esophagogastroduodenoscopy or upper GI contrast x-rays

EsophagitisEpigastric pain with substernal burning

Esophagogastroduodenoscopy

Meckel's diverticulum

Periumbilical or lower abdominal pain; may have

blood in stoolMeckel scan

Recurrent intussusception

Paroxysmal severe cramping abdominal pain; blood may be present in stool with episode

Identify intussusception during episode or lead point in intestine between episodes with contrast

studies of GI tract

Internal, inguinal, or

abdominal wall hernia

Dull abdomen or abdominal wall pain

PE, CT of abdominal wall

Chronic appendicitis or

appendiceal mucocele

Recurrent RLQ pain; often incorrectly diagnosed, may be rare cause of abdominal pain

Barium enema, CT

GALLBLADDER AND PANCREAS

CholelithiasisRUQ pain, might

worsen with mealsUltrasound of gallbladder

Choledochal cyst

RUQ pain, mass ? elevated bilirubin

Ultrasound or CT of RUQ

Recurrent pancreatitis

Persistent boring pain, might radiate to back, vomiting

Serum amylase and lipase ? serum trypsinogen; ultrasound or CT of

pancreas

GENITOURINARY TRACT

Urinary tract infection

Dull suprapubic pain, flank pain

Urinalysis and urine culture; renal scan

HydronephrosisUnilateral abdominal or

flank painUltrasound of kidneys

UrolithiasisProgressive, severe pain; flank to inguinal region

to testicle

Urinalysis, ultrasound, IVP, CT

Other genitourinary

disorders

Suprapubic or lower abdominal pain;

genitourinary symptoms

Ultrasound of kidneys and pelvis; gynecologic

evaluation

MISCELLANEOUS CAUSES

Abdominal migraine

Nausea, family Hx migraineHx

Abdominal epilepsy

Might have seizure prodromeEEG (can require >1 study,

including sleep-deprived EEG)

Gilbert syndromeMild abdominal pain (causal or coincidental?); slightly

elevated unconjugated bilirubinSerum bilirubin

Familial Mediterranean

fever

Paroxysmal episodes of fever, severe abdominal pain, and tenderness with other evidence of polyserositis

Hx and PE during an episode, DNA diagnosis

Sickle cell crisisAnemiaHematologic evaluation

Lead poisoningVague abdominal pain ? constipationSerum lead level

Henoch-Schonlein purpura

Recurrent, severe crampy abdominal pain, occult blood in stool, characteristic rash, arthritis

Hx, PE, urinalysis

Angioneurotic edema

Swelling of face or airway, crampy painHx, PE, upper GI contrast x-rays,

serum C1 esterase inhibitor

Acute intermittent porphyria

Severe pain precipitated by drugs, fasting, or infectionsSpot urine for porphyrins

ACUTE GASTROINTESTINAL ACUTE GASTROINTESTINAL TRACT PAIN IN CHILDRENTRACT PAIN IN CHILDREN

DISEASEONSETLOCATIONREFERRALQUALITYCOMMENTS

PancreatitisAcuteEpigastric, left upper quadrant

BackConstant,

sharp, boringNausea, emesis,

tenderness

Intestinal obstruction

Acute or

gradual

Periumbilical-lower abdomen

Back

Alternating cramping

(colic) and painless periods

Distention, obstipation, emesis, increased

bowel sounds

AppendicitisAcute

Periumbilical, then localized to lower

right quadrant; generalized with

peritonitis

Back or pelvis if

retrocecalSharp, steady

Anorexia, nausea, emesis, local

tenderness, fever with peritonitis

IntussusceptionAcutePeriumbilical-lower abdomen

NoneCramping, with

painless periods

Hematochezia, knees in pulled-up position

UrolithiasisAcute, sudden

Back (unilateral)GroinSharp,

intermittent, cramping

Hematuria

Urinary tract infection

AcuteBackBladderDull to sharp

Fever, costo-vertebral angle tenderness, dysuria, urinary

frequency

Acute ScrotumAcute Scrotum(Acute Scrotal pain)(Acute Scrotal pain)

CausesCauses

1 -Testicular Torsion.

2 -Torsion Testicular Appendix

3- Epididymo-orchitis

4 -Trauma :Hematocele ; Testicular Rupture

5 -Strangulated Inguinoscrotal hernia

Inguinal HerniaInguinal Hernia

Definition of HerniaDefinition of Hernia

Descriptive: Swelling in the anatomical region of the hernias, giving expansile impulse on cough.

Pathologic: Protrusion of a sac of peritoneum together with preperitoneal fat or an organ through a congenital or acquired defect in the muscles of the abdominal wall through which they do not normally pass.

Classification of Hernias in ChildrenClassification of Hernias in Children

Congenital Inguinal Hernia

Umbilical Hernia

Diaphragmatic Hernia

Incisional Hernia

Rare Hernias : Epigastric, Lumber, Femoral and Spigellian

Congenital Inguinal Hernia Congenital Inguinal Hernia In MalesIn Males

PROCESSUS VAGINALISPROCESSUS VAGINALIS

An out-pouching of the peritoneum extending through the IR, ER and reaching the scrotum.Closes at 6 months of age.

Doesn’t mean inguinal hernia (in minority it remains patent and

assymptomatic) .Potential space.

Incidence:0.8 - 4.4% in full term

16-25% in premature infants3-10 times more than females

Type: Indirect inguinal hernia

Content: Intestine, omentum

Site:Site: Bilateral < 50%, in unilateral Bilateral < 50%, in unilateral cases: Right side predominates cases: Right side predominates

(mostly due to later descent of the (mostly due to later descent of the right testis). right testis).

Complications:Complications:

Irreducibility, Testicular atrophy, Irreducibility, Testicular atrophy, Strangulation, obstruction, Strangulation, obstruction,

HydrocoeleHydrocoele

Irreducible left inguinal Hernia

Strangulated Appendix in

Right inguinal Hernia

OperationOperationUnilateral herniotomy

Once detected (repaired as soon as possible within 4 weeks)

Contra lateral exploration:????

Congenital Inguinal Hernia Congenital Inguinal Hernia In FemalesIn Females

Incidence:

0.8 - 4.4% in full term

16-25% in premature infants

3-10 times less than males

Type: Indirect

Content: Ovary

Site: Bilateral more than 50%, in unilateral cases: Right side predominates .

Complication:Complication: Ovarian affection Ovarian affection

Operation:Operation:Herniotomy once detectedHerniotomy once detected

Contra lateral explorationContra lateral exploration??? ???

Testicular Torsion

Torsion occurs when an abnormally mobile testis twists on the spermatic cord, obstructing its blood supply.

Patients present with acute onset of severe testicular pain.

The ischemia can lead to testicular necrosis if not corrected within 5-6 hours of the onset of pain.

Torsion can be intermittent and can undergo spontaneous de-torsion.

Clinical PictureClinical Picture

Age:Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age .

Symptoms:Acute onset of painful hemiscrotum.Sometimes with nausea and vomiting.

On examination:The testis is usually elevated as a result of the torsion and the shortening of the cord itself and may be in a transverse lie .

The affected side can be larger from the other side due to:The swollen testis itself, a hydrocele or skin thickening.

Duplex may help to confirm diagnosis.Yet if in doubt or not available, explore.

Undescended Testes increase the Undescended Testes increase the liability for torsionliability for torsion

In a child with an acute scrotum, testicular torsion is not the most common condition yet the most important one.

Torsion of testicular appendices represents the more common cause of scrotal pain.

Typically, it has a more gradual onset than testicular torsion and patients may endure pain for several days before seeking medical attention.

Duplex may help

Epididymo-orchitis

The most common inflammatory process involving the scrotum.

Infections generally originate in the lower urinary tract from the bladder, urethra or

prostate .

Protocol for the diagnosis and Protocol for the diagnosis and treatment of the acute scrotumtreatment of the acute scrotum

hatemsaafan@yahoo.comhatemsaafan@yahoo.com