Abdominal Pain In Children

Abdominal Pain in Children Pediatr Clin N Am 53(2006) 107-137

Gastroenteritis

Epidemiology • Most common GI inflammatory process • Usually viral, rotavirus being most common • Rotavirus: peak incidence between 4~23 mths • Norwalk virus more common in older children; 40% • Camphylobacter leading cause of bateria diarrhea

Presentation • Vomiting usu precedes the diarrhea by 12~24hrs • Decreased urine output late sign of dehydration • Risk for dehydration: – Younger than 12 mths old – Frequent vomiting (>2X/day) – Frequent stool (>8X/day) – Severely undernourished

Lab Data and Imaging • • • •

Blood glucose (R/O diabetic ketoacidosis) AAP: electrolytes not recommended in all Urinalysis to R/O infection Stool cultures generally not necessary

Management • Rehydration: oral vs intravenous

Appendicitis

Epidemiology • Abd pain most commonly treated surgically; 4 out of 1000 • 2.3% of all children with abd pain • Perforation rates are higher than in the general adult population(30%~60%)

Presentation • Classic presentation is seen less often • History of abd pain preceded by vomiting can be helpful • Position of appendix can vary greatly and tenderness can be found in many locations • Very young children often have diarrhea as the presenting Sx

Lab data and Imaging • WBC can be used as an adjunct • Appendicoliths are present in 10% • Ultrasonography: imaging test of choice – Inflammed appendix > 6mm – Sensitivities 85%-90% – Specificities 95%-100%

Calcified Appendicolith

Appendicitis with Appendicolith

Management • Surgical intervention • To return to ER within 8 hrs for reevaluation for those MBD

Intussusception

Epidemiology • • • • •

Mostly between 3m/o and 5y/o 60% occuring in the 1st yr Peak incidence at 6 to 11 mths Usually idiopathic in the younger age Children > 5y/o often have a pathologic “lead point”

Presentation • Classic triad: intermittent colcky pain, vomiting and bloody mucous stool • Classic triad: 20%-40% • Palpable abd mass uncommon finding • Currant jelly stool: late and unreliable sign

Target Sign

Pseudokidney Sign

Management • Emergent reduction of the obstructed bowel • Gold standard: barium enema • Newer modality: air enema • Contraindications to enema – Prolonged symptoms >24hrs – Evidence of obstruction

• Recurrence .5%~15% within 24hrs

Small Bowel Obstruction • Most common causes: adhesions • Decreased oral intake and bilious vomiting • Plan film: Paucity of air in the Abd and distended loops of bowels • Immediate surgical consultation

Incarcerated Hernia • • • •

Inguinal hernia: 1%~4% of population More common in males 6:1 More often on the Rt side 2:1 60% of incarcerated hernia occur in 1st yr of life • Reduction if no signs of incarceration • Surgical intervention

Meckel’s Diverticulum

Epidemiology • Most common congenital abnormality of the small intestine • Commonly described by “the rule of 2s” • Present in 2% of the population • 2% of affected patients become symptomatic • 45% of symptomatic p’ts are <2y/o • Most common location is 2 feet(40-100cm) from the ileocecal valve • Diverticulum typically 2 inches long

Presentation • Classic: painless or minimally painful rectal bleeding • Abdominal pain, distension and vomiting • Presenting as bowel perforation • Act as a lead point and result in intussusception

Lab data and Imaging • IV injection of technetium-pertechnetate

Management • Fluid resuscitation if active bleeding • Surgical intervention

Hypertrophic Pyloric Stenosis

Epidemiology • • • • •

Occurs in 1 of every 250 births Male to female ratio 4:1 More common in Whites Rare in Asians A child of an affected parent has an increased chance

Presentation • • • •

Presents during the 3rd and 5th wk of life Emesis is nonbilious Projectile vomiting A palpable olive mass in RUQ

Lab data and Imaging • Hypokalemic, hypochloremic, metabolic alkalosis • Ultrasonography measures the thickness of the pyloric wall (normally <2mm, HPS > 4mm), and the length of the pyloric canal (normally <10mm, HPS > 14-16mm)

Upper GI series “string sign”

Management • Hydration and correction of electrolytes abnormalities • Surgery; Ramstedt procedure

Malrotation with midgut volvulus

Epidemiology • Incidence of volvulus peaks during the 1st mth of life • Male to female ratio 2:1 • Congenital adhesions; Ladd’s bands

Presentation • Sudden onset of bilious vomiting and abd pain in a neonate • History of feeding problems with bilious vomiting; appears like bowel obstruction • Failure to thrive with feeding intolerance • Hematochezia: late sign and indicates bowel necrosis

Lab data and Imaging • Double bubble sign in plain film • Gold standard: Upper GI contrast study

Double bubble sign

Cork-screwing appearance

Management • Bilious vomiting is considered a surgical emergency until proven otherwise • Aggressive resuscitation • Broad spectrum antibiotics • Emergent surgical intervention

Necrotizing enterocolitis • Premature infants is 1st few weeks of life • Anoxic episodes at birth • Acute ill looking, lethargy, distended abd and bloody stools • Fluid resuscitation and broad spectrum antibiotics • Early surgical consultation

Pneumatosis Intestinalis