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ABDOMINAL PAIN IN CHILDREN
Deddy S Putra
Child Health Department
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Abdominal pain :
Common symptom
Lesion: - intra abdomen
- extra abdomen
For early diagnosis: - careful anamnesis
- physical examination
- further investigation
Surgical case or not?
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Source of abdominal pain :
Viscera abdomen
Others organ outside of abdomen
Lesion of Medulla Spinalis
Metabolic disturbance
Psychosomatic
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Pathogenesis
1. Vascular disorders
(emboli / thrombosis, rupture, occlusion causedby torsion or tension)
2. Inflammation Pain if the inflammation process are in
peritoneum parietalis somatic inervation
Local pain or general pain.
Type of pain : stabile, increase with movement ofinflammatory peritoneum
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3. Passage disorders/obstruction of luminalorgan in peritoneal or retroperitoneal cavity
Partial obstruction or total obstruction intra
lumen pressure pain
4. Traction, inflammation and stretching of
peritoneum visceralis
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Fore gut pain in upper abdomen
Mid gut pain in middle abdomen
Hind gut pain in lower abdomen
Muscle spasm colic which difficult toinvestigate the localization, not influenced withcough or abdominal pressure
Peritoneal irritation pain in the field ofirritation, stable, influenced by cough andabdominal pressure
Type of pain and source of pain
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Referred pain
Disorders of extra abdominal organ (i.e.
thorax) sensory inervation (N. Vagus)abdominal pain
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Infant commonly caused by obstruction
a. Colic
b. Constipation
c. Volvulusd. Intussusceptions/invagination
e. Strangulated hernia
f. Pyloric stenosis
g. Perforation of gastrointestinal tract
h. Appendicitis
i. Acute hydrops of gallbladder
Cause of abdominal pain by age groups(Chamberlain and Recee, 1978)
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a. Gastroenteritis
b. Appendicitis
c. Mesenteric lymphadenitis
d. Meckels diverticulume. Ileitis regional
f. Colitis ulserativa
g. Diabetic acidosis
h. Pneumonia
i. Torsion of ovarian cord
j. Constipation
Older child commonly caused by infection
k. Pyelonephritis
l. Colic Ureter
m. Lead intoxication
n. Torsion of spermatic cordo. Abdominal epilepsy
p. Sickle cell crisis
q. Mononucleosis
r. Porphiria
s. Cholecystitis andcholelytiasis
t.
Pancreatitis
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Cause of acute abdominal pain by age groups,that requirring surgical intervention
(Walker-Smith et al, 1983)
Infant / age < 2 years old
Abdomen :
Perforation of gastric ulcers
Bowel obstruction : - intusussception
- volvulus and malrotation
Appendicitis and enterocolitis necroticans
Extra abdomen :Inguinal hernia with strangulation and incarceration
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Age > 2 years old
Abdomen:a. Obstruction
Bowel obstruction caused by fibrosis, volvulus, malrotation
Perforation caused by bowel obstruction
b. Inflammation (appendicitis, primary peritonitis, peritonitiscaused by Meckels diverticle perforation, perforation ofduodenal ulcer, perforation caused by typhoid fever, Meckelsdiverticulitis, cholecystitis with or without gall stone, toxicmega colon with perforation)
c. Trauma (rupture of spleen, urinary bladder, another visceralorgans, hematoma sub serosa)
d. Bleeding (bleeding intra ovarian cyst)
e. In tropic area (perforation associated with ascariasis,strongiloidiasis, jejunitis necrotican in New Guinea, perforation
of abscess amoeba)
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Infant / age < 2 years old
Abdomen :
- Intestinal infection
Extra abdomen :
- Pneumonia
- Urinary tract infection
Cause of non surgical abdominal pain(Walker and Smith, 1983)
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Infant / age > 2 years old
Abdomen :a. Intestinal
- Infection (Salmonella, Shigella, Campylobacter,Yersinia enterocolitica)
- Food intoxication (Toxin of Staphylococcus, etc)- Purpura Henoch Schonlein (purpura anaphylactoid)- Crohns disease- Colitis ulcerative
- Colitis amoeba- Fecal impaction- Sickle cell anemia- Ileus meconeum
- Adenitis mesenterica
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b. Liver and billiary tree- Hepatitis- Cholelytiasis
c. Pancreas- Pancreatitis
d. Kidney- Urinary tract infection- Stone- Nephritis
e. Metabolic- Phorphiria- Hiperlipidemia- Diabetic keto acidosis
- Familial Mediterraneanfever
f. Gynecologic- Salphyngitis
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Cause of abdominal pain in Indonesia
Neonatal - 3 months
- Cows milk allergy- Pyloric hypertrophy
- Torsion of testis- Obstipation/with
anal fissure- Bowel malrotation
3 months2 years
- Obstipation- Gastroenteritis
- Bowel duplication- Maldigestion- Gastric mucosal
membrane
- Meckels diverticulum
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> 5 years
- Appendicitis- Gastritis
- Ovarian torsion- Menstrual cycle- Cholecystitis- Functional
abdominal pain- Urinary tract stone- Varicocele testis
2 years5 years
- Obstipation- Volvulus
- Hepatitis- Urinary tract
infection- Ascariasis
- Appendicitis- Pancreatitis
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0 - 3 months : vomiting
3 months2 years : vomiting, pitching/crying,
trauma(-) 25 years : can tell the pain, localization not
true
> 5 years : can tell the type and localization ofthe pain
Clinical manifestation by age group( Halimun 1980 )
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Diagnostic approach
1. Anamnesis
2. Physical examination
3. Laboratories and further investigation
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Anamnesis
Age
Pain (localization , type, time, frequency, other symptom)
Defecation pattern
Urination pattern Menstrual cycle
Skeletal muscle disorders
Growth and development disorders
Psychosocial aspect
Trauma
History of family disease
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Physical examination
1. Comprehensive
2. In abdomen and extra abdomen
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Therapy
Require surgical intervention?
Depend on etiology
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Surgical abdominal pain
Abdominal pain that require surgicalintervention
Symptoms
- Severe pain, stable, onset 3-4 hours
- Vomiting : green or fecal- Increase temperature
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Physical examination
Localized or generalized peritoneal sign
Sign of obstruction
- Abdominal distention
- Bowel contraction and peristaltic
Tumor mass
Anorectal bleeding
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Abdominal emergency
Rigidity of abdominal wall
Tenderness
Rebound tenderness Defense muscular
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Further investigation
Abdominal plain photo
Barium meal/follow through
Barium enema Intravenous pyelographyif suspected
urinary tract disorders
Ultrasound Endoscopy
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Therapy
Exploration/operation laparotomy
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Definition (Apley, 1975)
Recurrent abdominal pain is intermittent
abdominal pain at least 3 times whichpersists for longer than 3 months andaffects normal activity
Recurrent abdominal pain
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Etiology
Organic 5-15,6% cases
Functional 80%
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Cipto Mangunkusumo Hospital (1988)
17 cases
47% spasmophylia
11.8% gastritis
5.9% colitis
29.4% worms infection
11,8% psychological/psychiatric disorders
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Recurrent abdominal pain concept
1. Classical (2 groups)
Organic
Functional2. Barr
Organic
DisfunctionalPsychogenic
3. Levine & Rappaport
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Life style
Environment and
Inducers
BehaviorResponse pattern
Somatic predisposition
DisfunctionOrganic disorders
Levine and Rappaport1984
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Etiology of abdominal pain
Gastrointestinal
Chronic diarrheaPeptic ulcersBezoarDuplication
Intermittent volvulusMeckels diverticulumAppendicitisMesenterical adenitisAbdominal TBc
Milk protein intolerancelactose intoleranceConstipatianAscariasis
Drugs
Anti convulsionAntibioticBrochodilator
Urinary tract
HidronephrosisPyelonephritisStone
Renal neoplasmOvarian cystDismenorrheaEndometriosisiTestis torsion
Testis neoplasm
Liver, spleenand pancreas
CholecyctitisCholelithiasisPancreatitisMassive spleenomegali
Metabolic
Hypoglycemia
PhorphiriaLead intoxicationHyperlipidemiaAngioneurotic edema
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Symptoms suggested organic disorders
Persistent fever
Growth and development disturbance
Weight loss
Anemia
Hematemesis
Melena
Hematochezia Pain away from midline
Perianal disease
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Diagnostic approach
1. Careful anamnesis, Physical examination,and further investigation
2. High cost examination and commonly wasnot positive
3. Endoscopygreater probability to find theetiology
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Laboratory and further investigation
Routine ( urine, blood, feces) Ureum, creatinine
Culture
3 positions of abdominal plan photo Thorax photo (severe disease)
Barium meal/follow through
Barium enema Intravenous pyelography
Ultrasound
Endoscopy
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Therapy
Depend on etiology
Sedative and analgesic