acute abdominal pain in children
TRANSCRIPT
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
Raymond G BuickPaediatric Surgeon
Birmingham
Length: approx 55 minutes
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
Lecture given to
Paediatric Surgery for Specialist Trainees
Raymond G BuickPaediatric Surgeon
Birmingham
February 2009
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN•Pathophysiology•Causes of abdominal pain•Diagnosis of acute abdominal pain•Acute appendicitis•A few rare causes of acute abdominal pain
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
pathophysiology
Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain, • referred pain.
Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain---visceral pain fibers
are bilateral and unmyelinated and enter the spinal cord at multiple levels, visceral pain usually is dull, poorly localized, and felt in the midline
• parietal (somatic) pain, • referred pain.
Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain--- Parietal pain arises from
noxious stimulation of the parietal peritoneum. Pain resulting from ischemia, inflammation, or stretching of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatomal level as the origin of the pain. Parietal pain usually is sharp, intense, discrete, and localized, and coughing or movement can aggravate it.
• referred pain.
Clinically, abdominal pain falls into three categories: • visceral (splanchnic) pain, • parietal (somatic) pain, • referred pain-- Referred pain has many of the
characteristics of parietal pain but is felt in remote areas supplied by the same dermatome as the diseased organ. It results from shared central pathways for afferent neurons from different sites. A classic example is a patient with pneumonia who presents with abdominal pain because the T9 dermatome distribution is shared by the lung and the abdomen.
ABDOMINAL PAIN
• Causes of ACUTE ABDOMINAL PAIN
Causes of Acute Abdominal Pain in ChildrenGastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation FlatulenceAbdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckel's diverticulum Inflammatory bowel disease Lactose intolerance Hernia
Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis
Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhoea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Hematocolpos
Metabolic disorders Diabetic ketoacidosis Hypoglycaemia Porphyria Acute adrenal insufficiency
Hematologic disorders Sickle cell anemia Henoch-Schönlein purpura Haemolytic uremic syndrome
Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Iron overdoseSoap ingestion
Pulmonary causes Pneumonia Diaphragmatic pleurisy
Miscellaneous Infantile colic Functional painPharyngitis Angioneurotic oedema Familial Mediterranean feverFloating Rib Syndrome
Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
ABDOMINAL PAIN
• Causes of ACUTE ABDOMINAL PAIN
• AGE • SEX
Differential Diagnosis of Acute Abdominal Pain by Predominant Age
Birth to one year Two to five years Six to 11 years 12 to 18 years
Infantile colic Gastroenteritis Gastroenteritis Appendicitis
Gastroenteritis Appendicitis Appendicitis Gastroenteritis
Constipation Constipation Constipation Constipation
Urinary tract infection Urinary tract infection Functional pain Dysmenorrhoea
Intussusception Intussusception Urinary tract infection Mittelschmerz
Volvulus Volvulus Trauma Pelvic inflammatory disease
Incarcerated hernia Trauma Pharyngitis Threatened abortion
Hirschsprung's disease Pharyngitis Pneumonia Ectopic pregnancy
Trauma Sickle cell crisis Sickle cell crisis Ovarian/testicular torsion
Henoch-Schönlein purpura Henoch-Schönlein purpura
Mesenteric lymphadenitis Mesenteric lymphadenitis
Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
ABDOMINAL PAIN
Causes of ACUTE ABDOMINAL PAIN in veryyoung children• Neonates – acute abdomen• Intestinal volvulus• Incarcerated inguinal hernia• Hirschsprung's disease• Intussusception• Trauma – non-accidental
Causes of Abdominal Pain in Children Emergencies/life-threatening Other causes
Medical causes Diabetic Ketoacidosis Gastroenteritis (bacteria or viruses)
Inflammatory bowel disease ConstipationAcute adrenal failure Flatulence Mesenteric lymphadenitis Peptic ulcer disease Urinary tract infection Ureteric calculi Hepatitis Cholecystitis Pancreatitis Sickle cell anaemia/crises Henoch Schonlein purpura
Surgical causes Appendicitis
Bowel obstruction (e.g. intussusception, volvulus)
TraumaIncarcerated herniaPeritonitisTesticular torsion
Gynaecological causes DysmenorrhoeaMittelschmerzPelvic inflammatory diseaseEndometriosis
Obstetric causes Ectopic pregnancy Ovarian cyst rupture/torsionAbortion
Drugs/Toxins Paracetamol overdose Soap ingestionIron overdose ErythromycinVenoms
Referred pain PneumoniaRare causes Angioneurotic oedema
Familial Mediterranean feverUnknown aetiology Infantile colic
Functional bowel disease
ADMISSIONS363
OPERATIONS12535%
OTHER SURGICAL DIAGNOSES OR NEGATIVE
246%
MEDICAL12935%
APPENDICITIS10629%
NON-SPECIFIC ABDOMINAL PAIN
10830%
OBSERVED23765%
Admissions with Abdominal Pain to a District General Hospital in one year
HOME CHEMISTNHS DIRECTGP
Admissions with Abdominal Pain to a Paediatric Surgical Unit in one year
• The most common medical cause is gastroenteritis
• The most common surgical cause is appendicitis.
ACUTE ABDOMINAL PAIN
Pain & vomiting
• In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions.
• The most common medical cause is gastroenteritis – Viruses
rotavirus, Norwalk virus, adenovirus, Enterovirus
BacteriaEscherichia coli, Yersinia, Campylobacter, Salmonella, Shigella.
ABDOMINAL PAIN
Causes of Acute Abdominal Pain in ChildrenGastrointestinal causes Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation FlatulenceAbdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckel's diverticulum Inflammatory bowel disease Lactose intolerance Hernia
Liver, spleen, and biliary tract disorders Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis
Genitourinary causes Urinary tract infection Urinary calculi Dysmenorrhoea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Hematocolpos
Metabolic disorders Diabetic ketoacidosis Hypoglycaemia Porphyria Acute adrenal insufficiency
Hematologic disorders Sickle cell anemia Henoch-Schönlein purpura Haemolytic uremic syndrome
Drugs and toxins Erythromycin Salicylates Lead poisoning Venoms Iron overdoseSoap ingestion
Pulmonary causes Pneumonia Diaphragmatic pleurisy
Miscellaneous Infantile colic Functional painPharyngitis Angioneurotic oedema Familial Mediterranean feverFloating Rib Syndrome
Adapted from : Acute Abdominal Pain in Children ALEXANDER K.C. LEUNG, DAVID L. SIGALET, American Family Physician® > Vol. 67/No. 11 (June 1, 2003)
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
Up to 20% of infantsFirst 6 monthsScreamDraw knees up
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
Over diagnosedPain – Visceral / LIFAcute – organic causeChronic – functional causeDiagnosis of last resort
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
AdenovirusPreceding upper resp infectionMay Other lymphadenopathymimic appendicitisPain more diffuseHigher temperatureShifting tenderness
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
ACCIDENTALNON-ACCIDENTAL
Parents may conceal information
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
Includes•Malrotation•Volvulus•Intussusception•Incarcerated hernia•adhesions
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
Includes•Malrotation•Volvulus•Intussusception•Incarcerated hernia•Adhesions – ACQUIRED
-- CONGENITAL
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
ChlamydiaNeisseria
infection and inflammation of the upper female genital tract, uterus, fallopian tubes and ovaries.infection in the vagina & cervix passing to the internal reproductive organs.Age 15 to 242% female population20% recurrent
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
ChlamydiaNeisseriaAND PregnancyHistory may be concealed
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
ChlamydiaNeisseriaAND PregnancyHistory may be concealed
PregnancyPregnancy
10% occur in 13 to 15 (7.8 per 1000)10% occur in 13 to 15 (7.8 per 1000)52% occur in 13 to 17 (41 per 1000)52% occur in 13 to 17 (41 per 1000)
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
NICE Guidelines -August 2007
www.nice.org.uk/Guidance/CG54/NiceGuidance/pdf/English
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
NICE Guidelines -August 2007e
Symptoms and signs
Most common Least Common
Preverbal Fever Abdominal pain Loin tenderness Vomiting Poor feeding
Lethargy Irritability Haematuria Offensive urine Failure to thrive
Verbal Frequency Dysuria
Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness
Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine
• Infantile colic• Constipation• Mesenteric adenitis• Abdominal trauma• Intestinal obstruction• Pelvic inflammatory disease• Urinary Tract Infection• Meckel’s Diverticulum
ABDOMINAL PAIN
Meckel’s Diverticulum
Meckel’s Diverticulum
• Meckel's diverticulum, • congenital• remnant of the vitelointestinal duct (omphalomesenteric duct)
• 2 feet (from the ileocecal valve) • 2 inches (in length) • 2% (of the population) have it• 2% are symptomatic• 2 is the most common age at clinical presentation • 2:1 male:female• 2 types of common ectopic tissue (gastric and pancreatic)
• first described by Fabricius Hildanus C16 first described by Fabricius Hildanus C16 • named after Johann Friedrich Meckel who named after Johann Friedrich Meckel who
described the embryological origin of this described the embryological origin of this type of diverticulum in 1809type of diverticulum in 1809
ABDOMINAL PAIN
• diagnosis
ABDOMINAL PAIN
• History• A challenge in young children• poor sense of timing and location
ABDOMINAL PAIN
• History• PAIN Location• Onset• Character• Change of location or character• Severity• Radiation• Precipitating/relieving factors
ABDOMINAL PAIN• History• VOMITING character• frequency• content bile / blood• BOWELSfrequency • consistency• blood• URINARY frequency/dysuria/polyuria/urgency/odour/colour• RESPIRATORY cough/SOB/chest pain• GENERAL temperature/headache/joint pains-swelling/rash/sore
throat• GYNAE menstruation/LMP/sexual activity/contraception/vaginal
discharge/?midcycle• PAST MEDICAL HISTORY / DRUG HISTORY / FAMILY HISTORY
•
ABDOMINAL PAIN• Examination• GENERAL APPEARANCE• GENERAL – ENT• – Chest• ABDOMINAL Breathing pattern• distension• Point to pain• Maximum tenderness• Muscle guarding• Rebound tenderness• bowel sounds• groin / testes / introitus• Rectal Examination
ABDOMINAL PAIN
• Investigations• Tailored to symptoms and signs• CONSIDER Full Blood Picture• Differential White Cell Count• Urinalysis• CRP• Pregnancy Test•• Abdominal X-Ray• Chest x-Ray• Ultrasound• CT
ABDOMINAL PAIN
Active Observation
ABDOMINAL PAIN
“repeated physical examination by the same physician often is useful”
ABDOMINAL PAIN
repeated physical examination is MANDATORY
by the same physician is BENIFICIAL
ABDOMINAL PAIN
Active Observation
ABDOMINAL PAIN
RECORDED
Active Observation
ABDOMINAL PAIN
RecordedActive
Observation
• in most instances, abdominal pain can be diagnosed through the history and physical examination.
‘THE PAIN’ in ABDOMINAL PAIN
• Use analgesia as required - it does not affect diagnostic accuracy
Patient UK atwww.patient.co.uk/showdoc/40000523/
‘THE PAIN’ in ABDOMINAL PAIN
• Traditionally, the use of analgesics is discouraged in patients with abdominal pain for fear of interfering with accurate evaluation and diagnosis.
• However, several prospective, randomized studies have shown that judicious use of analgesics actually may enhance diagnostic accuracy by permitting detailed examination of a more cooperative patient.
APPENDICITIS
APPENDICITIS
• Age
The approach to common abdominal diagnosis in infants and childrenIrish M S et alPediatric Clin North Am. 1998 Aug: 45(4): 729-72
% PERFORATED % NORMAL
Age <= 8 years 33 13
Age > 8 years 18 11
Male 22 8
Female 18 17
Age in Years 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Acute appendicitis without perforation 2 8 17 30 33 17 43 57 97 111 137 168 144 163 104 91 178 Acute appendicitis with perforation 2 3 10 23 20 16 16 23 27 25 16 16 12 22 8 18 42Total number of patients 4 11 27 53 53 33 59 80 124 136 153 184 156 185 112 109 220Percentage perforated 50 27 37 46 38 48 27 27 22 18 10 9 8 12 7 17 19
APPENDICITIS
• What causes appendicitis
APPENDICITIS• Types of Appendicitispathogenesis
primary obstruction of the lumen of appendixfilled with mucus and swells.increasing pressure within the lumenPressure on the wall of the appendixresulting in thrombosis & occlusion of blood vesselsInflammation of appendixPus may form within the appendix (suppuration)stasis of lymph flow - leads to ischaemia and necrosis (gangrene)Bacteria begin to leak out through appendix wallsPus forms within and around the appendixPerforation of appendix - peritonitis / abscessSepticaemia - death
} Appendix Mass
APPENDICITIS
• Types of Appendicitis– Acute– Perforated
APPENDICITIS
• Types of Appendicitis– Acute
• Acute inflammatory appendicitis• Acute Suppurative appendicitis
– Perforated (complicated)• Perforated• Gangrenous
APPENDICITIS
• Types of Appendicitis– Acute
• Acute inflammatory appendicitis• Acute Suppurative appendicitis
– Perforated (complicated)• Perforated• Gangrenous
• Normal• (Registrar’s Appendicitis)
APPENDICITIS
• Types of Appendicitis– Acute
• Acute inflammatory appendicitis• Acute Suppurative appendicitis
– Perforated (complicated)• Perforated• Gangrenous
• Normal
Appendix MassAppendix Abscess
Clinical Features - Symptoms
Clinical Features - Symptoms
• Pain – Central» Vague» Crampy» Wants to move around
– Moves to Right Iliac Fossa» Acute» Sharp / constant» Wants to lie still
Anorexia
Nausia
Vomiting
Mild Pyrexia
Halitosis
Change in bowel habit – diarrhoea -- constipation
Urinary Symptoms
LOCALISED
Clinical Features - Signs
Clinical Features - Signs
• Localised Tenderness• Muscle Guarding Tachycardia
Flushed
Circum-oral pallor
Rectal Examination ?
Rovsing’s Sign
Psoas sign
Obturator sign
Caecal Gurgle
Clinical Features - Signs
• Localised Tenderness• Muscle Guarding Tachycardia
Flushed
Circum-oral pallor
Rectal Examination ?
Rovsing’s SignNiels Thorkild Rovsing Danish surgeon 1907,
Psoas sign
Obturator sign
Caecal Gurgle
Clinical Features - Signs
• Localised Tenderness• Muscle Guarding Tachycardia
Flushed
Circum-oral pallor
Rectal Examination ?
Rovsing’s Sign
Psoas sign
Obturator sign
Caecal Gurgle
Action:-Hip flexion
Pain:-Pain:-Hip ExtensionHip Extension
Clinical Features - Signs
• Localised Tenderness• Muscle Guarding Tachycardia
Flushed
Circum-oral pallor
Rectal Examination ?
Rovsing’s Sign
Psoas sign
Obturator sign
Caecal Gurgle
Action:-AbductsLat RotatesPain:-Pain:-Hip AdductionHip AdductionInternal RotationInternal Rotation
Clinical Features - Signs
• Localised Tenderness• Muscle Guarding Tachycardia
Flushed
Circum-oral pallor
Rectal Examination ?
Rovsing’s Sign
Psoas sign
Obturator sign
Caecal Gurgle
Clinical Features - Signs
• Localised Tenderness• Localised Guarding
Anatomical positions of appendix
• Retrocaecal – poor localising signs• Retroileal – diarrhoea• Pelvic – diarrhoea / Bladder
CLASSICAL CARDINAL FEATURES
• Localised Pain• Localised Tenderness• Muscle Guarding• (Rebound Tenderness)
McBurney’s PointCharles McBurney U.S. surgeon, 1845–1913
Investigations
• Blood Test– Sickle– Neutrophil leucocytosis– Lymphopenia– CRP
Investigations
• Radiology– Abdominal film
• Obstruction• faecolith• Soft tissue mass• Loaded colon
– Ultrasound• Gynaecological• Abscess/mass/thick bowel loops• stones
APPENDICITIS
• Preparation for theatre– Analgesics– Fluids– Antibiotics– Consent
APPENDICITIS
• In theatre– EUA
• Open or Laparoscopic ?
APPENDICITIS
• In theatre– EUA
• Open or Laparoscopic ?
• What if it is perforated ?
APPENDICITIS
• In theatre– EUA
• Open or Laparoscopic ?
• What if it is Crohn’s ?
APPENDICITIS
• In theatre– EUA
• Open or Laparoscopic ?
• What if it is normal ?
A few less common causes ofA few less common causes of
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
ACUTE ABDOMINAL PAIN IN CHILDRENACUTE ABDOMINAL PAIN IN CHILDREN
Henoch-Schönlein purpura
• systemic vasculitis• deposition of immune complexes containing
the antibody IgA in the skin and kidney • occurs mainly in young children.
Henoch-Schönlein purpura
• self-limiting • no treatment - symptom control, • in a third of cases disease may relapse -
irreversible kidney damage in about 1% of cases
• Cause unknown, post viral and bacterial infections, / adverse drug reactions
12th Rib Syndrome
• Floating Rib• Slipping Rib• Rib Dysfunction