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
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
Chemistry?• Decreased chloride• Elevated bicarbonate – metabolic
alkalosis• ± Hypokalemia• Elevated BUN and creatinine• ±Elevated indirect bilirubin
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
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
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
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
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• 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
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
Surgery• Manual reduction and end-to-end
anastomosis• Indications
– Persistent filling defects– Failed nonoperative reduction– Prolonged intussusception
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