Abdominal pain in children

1
Abdominal pain in children

• Madesa Espana, MD
• Pediatric EM Section
• St. Josephs Regional Medical Center

2
Abdominal pain evidence-based data

• Incidence
• 5 of patients presenting to the pediatric
  clinic and ED (2 12 years old, lt72 hours
  duration)
• 1 of patients with abdominal pain had surgical
  intervention
• 84 of patients were diagnosed to have
• URI and/or Otitis Media
• Pharyngitis
• Viral syndrome
• Abdominal pain or uncertain etiology
• Gastroenteritis
• Acute febrile illness

3
Abdominal pain evidence-based data

• Incidence
• 7.4 had return visits
• 1 had treatable medical conditions
• 0.3 needed surgical intervention on subsequent
  visits

4
Abdominal pain evidence-based data

• Incidence
• 1.7 were hospitalized
• Diagnoses when abdominal pain was first complaint
• Appendicitis
• Abdominal pain of uncertain etiology
• Intussusception
• Abdominal adhesions
• Gastroenteritis
• Acute Febrile Illness
• Pyelonephritis
• Sickle cell painful crisis
• Henoch-Schonlein purpura

5
Abdominal pain evidence-based data

• Incidence
• 1.3 were hospitalized
• Diagnoses when abdominal pain was second
  complaint
• Gastroenteritis/Dehydration
• Abdominal abscess after appendectomy
• Pneumonia
• Viral syndrome
• Pyelonephritis
• Sickle cell pain crisis and fever
• Hematochezia
• Hematemesis
• URI and seizure
• Reactive airway disease

6
Abdominal pain evidence-based data

• Associated symptoms
• Fever
• Vomiting
• Decreased appetite
• Cough
• Headache
• Sorethroat

7
Historical Data

• Duration of the pain
• Location of the pain
• Radiation of the pain
• General appearance of the patient
• Associated symptoms
• Sick contacts
• Recent travel

8
Historical data

• Associated symptoms
• Vomiting
• Duration
• Type of emesis bile, blood
• Diarrhea
• bloody
• Fever
• Rash
• Genitourinary symptoms

9
Physical Examination

• General appearance
• Ill-appearing or toxic
• Dehydrated
• Shock
• Vital signs
• Febrile
• Tachycardic
• Tachypneic
• Hypotensive

10
Physical Examination

• Head/Face
• Fontanels
• Sunken
• Bulging
• Signs of inflicted injury
• Bruising/swelling

11
Physical Examination

• Eyes
• Icteric sclera
• Abnormal eye movements
• Sunken appearance
• Periorbital swelling

12
Physical Examination

• ENT
• Mucus membranes
• Moist vs dry
• Lesions/ulcerations
• Teeth and Gums
• Swelling
• Bleeding

13
Physical Examination

• ENT
• Nose
• Rhinorrhea
• Nose bleed
• Throat
• Erythema
• Exudates

14
Physical Examination

• Chest/Axilla
• Appearance
• Tenderness
• Swelling/Masses

15
Physical Examination

• Cardiovascular
• Heart sounds
• Rhythm
• Pulses
• Edema

16
Physical Examination

• Abdomen
• Appearance
• Distension
• Scars
• Bruises

17
Physical Examination

• Abdomen
• Palpation
• Tenderness
• Organomegaly
• Masses

18
Physical Examination

• Abdomen
• Tenderness
• Localized
• Diffuse
• Rebound
• Rovsings sign
• Guarding
• Voluntary
• Non-voluntary

19
Physical Examination

• Abdomen
• Rectal exam
• Stool Guaic
• Other findings
• Psoas sign
• Obturators sign
• Murphys sign

20
Physical Examination

• Pelvis/inguinal area
• Males
• Scrotum and testicles
• Urethral discharge
• Phymosis/paraphymosis
• Females
• Vaginal bleeding
• Speculum exam

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Physical Examination

• Skin
• Color
• Pale
• jaundice
• Rashes
• Signs of injury/abnormal bleeding
• Turgor
• Peripheral circulation

22
Physical Examination

• Neurologic examination
• Mental status
• Cranial nerves
• Motor
• Sensorory
• Cerebellar

23
Physical examination

• Psychiatric evaluation
• Mental status
• Depression
• Anxiety
• Suicidal ideation/attempt
• Homicidal ideation/attempt
• Hallucinations/delusions

24
Differential diagnosis

• Infants
• Gastroenteritis
• Constipation
• Malrotation /- Volvulos
• GERD
• Infantile Colic
• Intussuception
• Urinary tract infection
• Testicular torsion

25
Differential diagnosis

• Children
• Gastroenteritis
• Constipation
• Intussuception
• Torsion
• UTI
• Kidney stones
• Sickle cell crisis
• DKA

• Testicular torsion
• Incarcerated Hernia
• Pneumonia
• Strep throat
• Henoch-Schonlein Purpura
• Meningococcemia
• Toxic ingestions

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Diferrential Diagnosis

• Adolescent Males
• Testicular torsion
• Varicocele
• Pyelonephritis
• Kidney stones
• Gallstones
• Pancreatitis
• Hepatitis

• Incarcerated Hernia
• Constipation
• DKA
• IBD
• STD
• GERD
• Toxic ingestions

27
Differential diagnosis

• Adolescent females
• Ovarian torsion
• Ruptured ovarian cyst
• PID
• UTI
• Gallstones
• Cholecystitis
• Kidney stones

• DKA
• Toxic ingestions
• Pre-/menstrual cramps
• Complications of pregnancy
• Ectopic
• Threatened AB
• Missed AB

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Abdominal pain evidence-based data

• Abdominal pain appendicitis or not?

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Abdominal pain evidence-based data

• Appendicitis
• Incidence
• 11/10,000 population per year
• Highest in males 10-14 years (27/10,000)
• Highest in females 15-19 years (20/10,000)
• Malefemale ratio 1.41
• Life time risk
• Males 8.6 Females 6.7
• Perforation 18 highest in lt 5 and gt65 y.o.

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Appendicitis evidence-based data

• Signs and symptoms
• Neonates
• Abdominal distension
• Vomiting
• Fever
• Hypothermia
• Respiratory distress

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Appendicitis evidence-based data

• Signs and symptoms
• 3 years and under
• Diffuse abdominal pain
• Fever
• Vomiting
• Diarrhea
• Abdominal distension
• Diffuse abdominal tenderness

32
Appendicitis evidence-based data

• Signs and symptoms
• Older children
• Abdominal pain
• Vomiting
• Fever
• Anorexia
• Pain with movement or cough
• Localized RLQ tenderness
• Diffuse/rebound tenderness

33
Abdominal pain evidence-based data

• Laboratory studies
• CBC, differential
• ESR
• C-reactive protein
• Urinalysis
• Poor sensitivity and specificity

34
Abdominal pain evidence-based data

• Radiologic studies
• Plain films
• Small bowel obstruction
• Fecalith
• Pneumoperitoneum
• Poor sensitivity and specificity

35
Abdominal pain evidence-based data

• Radiologic studies
• Ultrasound
• Appendiceal diameter or gt6 mm
• Target sign with 5 concentric layers
• Distension or obstruction of the lumen
• High echogenicity around the appendix
• Pericecal or perivesical fluid
• Appendix wall gt 2 mm
• Absence of appendiceal peristalsis
• Can confirm but not exclude appendicitis

36
Abdominal Pain Evidence-based Data

• Radiologic studies
• CT scan
• Enlarged appendiceal diameter (gt 6 mm)
• Appendiceal wall thickening (gt 1 mm)
• Periappendiceal inflammatory changes including
  fat streaks, phlegmon, fluid collection, and/or
  extraluminal gas
• Other findings appendicalith, abscess, arrowhead
  sign, or cecal bar
• Sensitivity 87 100 , Specificity 89 98

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Abdominal pain evidence-based data

• Radiologic studies
• CT scan
• Advantages
• Establish alternative diagnoses
• Differentiates between perforated and
  non-perforated appendicitis
• Reduces length of stay and cost of care
• Reduces perforation rate
• Useful in obese, uncooperative patients

38
Abdominal pain evidence-based data

• Radiologic studies
• CT scan
• Disadvantages
• Higher cost compared to ultrasonography
• Risks associated with contrast administration
• Potential need for sedation
• Exposure to ionizing radiation
• False negative rate 10

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Diagnostic work-up

• History and physical examination
• Serial abdominal exams
• Surgical consultation
• Laboratory data
• Radiologic evaluation
• Ultrasound
• CT scan

40
Treatment of appendicitis

• Surgery
• Laparoscopic
• Open
• Conservative management
• Antibiotics
• IV hydration

41
Treatment of appendicitis

• Conservative management
• IV and oral antibiotics
• Cefotaxime (ofloxacin tinidazole)
• Ciprofloxacin and metronidazole (ciprofloxacin
  tinidazole)

42
Treatment of appendicitis

• Conservative management
• Advantages
• Less pain
• Shorter recovery time
• Avoid complications of surgery
• and anesthesia

43
Treatment of appendicitis

• Conservative management
• Disadvantages
• High recurrence rate

44
Abdominal pain evidence-based data

• Use of analgesics in patients with abdominal pain
• Will analgesics mask the signs of acute
• abdomen and cause a delay making the
• diagnosis?
• What medications are effective and safe?

45
Abdominal pain evidence-based data

• Use of analgesics in patients with abdominal pain
• 56 of patients with abdominal pain were not
  given pain medication
• Studies in adults show that opioids are effective
  in reducing pain without significant adverse
  effects or delay in diagnosis of acute abdomen

46
Abdominal pain evidence-based data

• Use of analgesics in pediatric patients with
  abdominal pain
• Morphine 0.1 mg/kg vs. normal saline
• Reduction of pain score by 2 points (1 10)
• No change in the area(s) of tenderness
• Tenderness persisted in patients with surgical
  conditions
• No change in the diagnostic accuracy
• No significant complications

47
Abdominal pain evidence-based data

• Follow up care of discharged patients
• Return or follow up visit in 8 12 hours
• Will identify serious medical conditions
  presenting as abdominal pain and detect surgical
  conditions that may have presented early in the
  disease process.

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• Thank you!
• Have a great day.