Acute Abdominal Pain Acute Abdominal Pain In ChildrenIn Children

Acute Abdominal Pain Acute Abdominal Pain In ChildrenIn Children

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

Pathophysiology of pain

• Visceral pain– Mechanical – stretching– Chemical – mucosa– Aching and dull, poorly localized

• Parietal pain– Sharp, well-localized

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

History• Usual: quality, location, severity,

associated symptoms, aggravating/alleviating factors

• Kids cannot give a history• Dangerous signs given by parents

My history: the red flags

• Duration – acute vs. chronic• Fever – inflammation, infection• Vomiting – stasis, obstruction,

dehydration• Urine output – volume depletion• Diarrhea - bloody

Examination• Usual: inspection, auscultation,

percussion, palpitation• Rectal – rectocecal appendicitis,

occult blood• Pelvic – PID• Scrotal - torsion

Tests?• Chemistry – electrolyte abnormality,

BUN/creatinine, liver function test• CBC – infection, bleeding• Plain abdominal x-ray – free air,

obstruction• Urinalysis – pyuria, hematuria• Pregnancy test

Pyloric stenosisPyloric stenosisPyloric stenosisPyloric stenosis

What is pyloric stenosis?

Hypertrophy of pylorus – thickening & elongation

Cause of pyloric stenosis?

• Unknown• Associations

– Abnormal muscle innervations– Erythromycin in neonates for

pertussis postexposure prophylaxis– Infant hypergastrinemia

Epidemiology• Prevelance – 3/1000• More common in white northern

European descents• Male:female = 4:1 to 6:1• Age – 1 week – 5 months but

usually 3 to 6 weeks

Clinical presentation?• Abdominal pain• Nonbilious vomiting after feeding

and with 91% having projectile emesisDistinguish pyloric stenosis from GER?

Clinical presentation?• Abdominal pain• Nonbilious vomiting after feeding

and with 91% having projectile emesis– Hungry after feeding– Weight loss– Progressive symptoms

Clinical presentations• Jaundice

– 5% of affected patients– Indirect hyperbilirubinemia due to

decreased level of glucuronyl transferase

Examination?• Abdominal

distension• Olive mass –

RUQ, after feeding

Examination• Gastric peristaltic

wave from left to right after feeding

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

Chemistry?• Decreased chloride• Elevated bicarbonate – metabolic

alkalosis• ± Hypokalemia• Elevated BUN and creatinine• ±Elevated indirect bilirubin

Abdominal x-ray

Increased gastric air or fluid suggestive gastric outlet obstruction

Ultrasound• Pyloric length >

15-19 mm• Wall thickness >

3-4 mm• Pyloric diameter

>10-14 mm

Ultrasound

Shoulder sign - indentation of pylorus into the stomach

UGI• String sign• Pyloric spasm

may mimic the string sign

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

Pyloromyotomy

Pyloromyotomy

Pyloromyotomy: laparoscopy

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 > 5

days

IntussusceptionIntussusceptionIntussusceptionIntussusception

What is What is intussusception?intussusception?

What is What is intussusception?intussusception?

Invagination of intestine into itselfInvagination of intestine into itself

Pathophysiology• Proximal bowel

telescopes into distal segment, dragging along mesentery

• Compression of mesenteric vessels & lymphatics leads to edema, ischemia, mucosal bleeding, perforation, and peritonitis

Ileocolic intussusception

Causes of intussusception?

• Idiopathic – – 75% of ileocolic intussusception– More likely in children < 5

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

Epidemiology• Male:female – 3:2• Age –

– 3 months to 6 years with 80% < age 2

– Peak at 6-12 months

• Most common - ileocolic

Clinical manifestations?• Intermittent, severe, crampy

abdominal pain with loud cry and in curled up position

• Vomiting• Appear normal between attack• Currant-jelly stool

Currant-jelly stool

Mixture of blood and mucusFoul smelling

Tests?• Chemistry – dehydration, electrolyte

imbalance• CBC – infection• X-ray: plain film & contrast or air enema• Ultrasound• CT scan – only if other tests are negative

X-ray : plain film

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

Ultrasound

Could detect ileoileal intussusception

Treatment?• Air or contrast reduction

– Air is better than barium reduction – less perforation <1%

– Not very successful if symptoms > 24 – 48 hours or with bowel obstruction

– Successful rate – 75-90% with ileocolic intussusception

• Surgery

Reduction

Surgery• Manual reduction and end-to-end

anastomosis• Indications

– Persistent filling defects– Failed nonoperative reduction– Prolonged intussusception

Recurrence• 10%• Not necessary an indication for

surgery

Malrotation & Malrotation & VolvulusVolvulus

Malrotation & Malrotation & VolvulusVolvulus

Normal development

Midgut volvulus

Volvulus

Cecal volvulus Sigmoid volvulus

Clinical presentation?• Bilious emesis• Abdominal distension

Tests?• UGI- duodenum not crossing the

midline• Barium enema – malposition of

cecum

Abdominal series

Gastric and duodenal bulb distention

Little air in intestine

UGI with SBFT

Cork-screw pattern – barium flowing through restricted bowel lumen

Treatment: surgery