Abdominal Pain in Children

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

Gastroenteritis

Epidemiology

• Most common GI inflammatory process• Usually viral, rotavirus being most commo

n• Rotavirus: peak incidence between 4~23

mths• Norwalk virus more common in older childr

en; 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 re-evaluation 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