Acute abdominal pain in children

Significance and epidemiology

Very common

More than 50% 0f ER admissions

Most children with abdominal pain do not come to hospital More children with abdominal pain are admitted to hospital than their counterpart adults( lack of self expression)

Significance and epidemiology

Most children admitted with abdominal pain do not require urgent surgery ANSAP: acute non specific abdominal pain makes up about 50% of discharge summaries of children admitted with abdominal pain There is no second most common cause of acute abdomen in children. Considering acute appendicitis or ANSAP as number one

Definition
Abdominal pain in a previously healthy child of less than 7 days duration, excluding trauma Acute Acute on chronic known cause Acute on chronic unknown cause

Children
Children, pediatrics- Not only they are not small adults Newborn Infants Toddlers School age Adolescents Diseases of children are age specific with great overlap

Abdomen
Anteriorly from nipple to pubis Scrotum and perineum Back and spine

History and Physical examination

Do not be in hurry Pinpoint the start of illness- when was the patient well last What was done for the pain, what was the response What made you bring the patient now Leading questions Normal activities, playing, feeding, sleeping, bowel habit, urination Do not skip more than 6 hours of history without asking about

Physical examination
Type of patient, easy to examine, acting ill V.S, Temp, Resp. rate, Pulse (resting, sleeping, crying)

Head and neck, may leave the difficult part for the last

Abdomen
Easy or difficult Examine while in mothers lap, or make mother palpate the abdomen while you observe Talk to the child while you examine Avoid the painful spot first Tenderness and rebound tenderness

Abdomen
Rigidity Guarding Localization Auscultation Percussion= rebound tenderness P/R constipation, impaction, mass, full bladder, the difficult patient

Investigations
CBC, differential, urinalysis X-Ray, plain abdomen, upright, supine Special, U/S, CT, IVP, etc

Outcome
Diagnosis made- specific treatment in or outpatient Diagnosis uncertain- consultation Diagnosis uncertain- admission with provisional diagnosis Active observation

Medical Records
Record everything you do or observe Not written (recorded) not done

Indication for admission

Specific diagnosis Acute abdomen in a known medical or surgical condition Severe associated symptoms or signs Repeated visits to clinics or hospitals for the same illness Abnormal Laboratory or radiological test Social, hospital circumstances

Recurrent Abdominal Pain

Dysfunctional 80% Psychogenic 10% Organic 10% Alimentary tract a-Peptic ulcer disease b-Gall stones c- inflammatory bowel disease d- pancreatitis e- malrotation f- recurrent intussusception g- constipation h- uropathy

Criteria
Recurrent over a period of 3 months Attacks should have occurred on more than three occasions Attacks should be severe enough to interfere with the childs normal daily activity even for a brief periods

Relative Frequency of S&S

Symptoms Central pain at onset
70% Shift of pain to RIF 65% Aggravation by movement 75% Anorexia 98% Diarrhea 18% Headache 14%

Relative Frequency of S&S

Signs Local tenderness 100% Guarding Rebound

90% 75%

Causes of Acute Abdominal Pain in Children*

Gastrointestinal
Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation Abdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckels diverticulum Inflammatory bowel disease Lactose intolerance Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Metabolic disorders Diabetic ketoacidosis Hypoglycemia Porphyria Acute adrenal insufficiency Hematologic disorders Sickle cell anemia Henoch-Schnlein purpura Hemolytic uremic syndrome

Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Pulmonary causes Pneumonia Diaphragmatic pleurisy Miscellaneous Infantile colic Functional pain Pharyngitis Angioneurotic edema Familial Mediterranean fever

-----------------------------------------------------------------------------------------------------------*(Am Fam Physician june 1,2003 volume 67)

Metabolic disorders Diabetic ketoacidosis Hypoglycemia Porphyria Acute adrenal insufficiency Hematologic disorders Sickle cell anemia Henoch-Schnlein purpura Hemolytic uremic syndrome

Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis

Differential Diagnosis of Acute Abdominal Pain by Predominant Age*

Birth to one year Infantile colic Gastroenteritis Constipation Urinary tract infection Intussusception Volvulus Incarcerated hernia Hirschsprungs disease Two to five years Gastroenteritis Appendicitis Constipation Urinary tract infection Intussusception Volvulus Trauma Pharyngitis Sickle cell crisis Henoch-Schnlein purpura Mesenteric lymphadenitis Six to 11 years Gastroenteritis Appendicitis Constipation Functional pain Urinary tract infection Trauma Pharyngitis Pneumonia Sickle cell crisis Henoch-Schnlein purpura Mesenteric lymphadenitis 12 to 18 years Appendicitis Gastroenteritis Constipation Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion

----------------------------------------------------------------------------------------------------*(Am Fam Physician june 1,2003 volume 67)

Causes of Acute Abdominal Pain in Children*

Gastrointestinal Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation Abdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckels diverticulum Inflammatory bowel disease Lactose intolerance

Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis

Differential Diagnosis of Acute Abdominal Pain by Predominant Age*

Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Pulmonary causes Pneumonia Diaphragmatic pleurisy Miscellaneous Infantile colic Functional pain Pharyngitis Angioneurotic edema Familial Mediterranean fever

Differential Diagnosis of Acute Abdominal Pain by Predominant Age*

Birth to one year Infantile colic Gastroenteritis Constipation Urinary tract infection Intussusception Volvulus Incarcerated hernia Hirschsprungs disease Two to five years Gastroenteritis Appendicitis Constipation Urinary tract infection Intussusception Volvulus Trauma Pharyngitis Sickle cell crisis Henoch-Schnlein purpura Mesenteric lymphadenitis

Differential Diagnosis of Acute Abdominal Pain by Predominant Age*

Six to 11 years Gastroenteritis Appendicitis Constipation Functional pain Urinary tract infection Trauma Pharyngitis Pneumonia Sickle cell crisis Henoch-Schnlein purpura Mesenteric lymphadenitis 12 to 18 years Appendicitis Gastroenteritis Constipation Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion