Acute abdominal pain in children

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Acute abdominal pain in children
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Age Emergent Nonemergent
03 mo old Necrotizing enterocolitis Colic
03 mo old Volvulus Acute gastroenteritis
03 mo old Testicular torsion Constipation
03 mo old Incarcerated hernia
03 mo old Trauma
03 mo old Toxic megacolon
03 mo old Tumor
3 mo3 y old Intussusception Acute gastroenteritis
3 mo3 y old Testicular torsion Constipation
3 mo3 y old Trauma Urinary tract infections
3 mo3 y old Volvulus HSP
3 mo3 y old Appendicitis
3 mo3 y old Toxic megacolon
3 mo3 y old Vaso-occlusive crisis
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3 y oldadolescence Appendicitis Constipation
3 y oldadolescence Diabetic ketoacidosis Acute gastroenteritis
3 y oldadolescence Vaso-occlusive crisis Nonspecific viral syndromes
3 y oldadolescence Toxic ingestion Streptococcus pharyngitis
3 y oldadolescence Testicular torsion Urinary tract infections
3 y oldadolescence Ovarian torsion Pneumonia
3 y oldadolescence Ectopic pregnancy Pancreatitis
3 y oldadolescence Trauma Cholecystitis
3 y oldadolescence Toxic megacolon Renal stones
3 y oldadolescence Tumor HSP
3 y oldadolescence Inflammatory bowel disease
3 y oldadolescence Gastric ulcer disease/gastritis
3 y oldadolescence Ovarian cyst
3 y oldadolescence Pregnancy
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Clinical features


Table 124-2 Historical Items for Acute Abdominal Pain
General activity (e.g., fussy, lethargic)
Characterization of the pain onset, duration, pattern, location, quality, radiation, triggers and palliative factors
Associated symptoms, including fever, vomiting, diarrhea, constipation, cough or respiratory symptoms, sore throat, and urinary symptoms
Usual diet and stool patterns
Past medical (prenatal and birth history for infants) and surgical history (especially prior abdominal surgery)
Medications tried at home
Social history, including multiple care takers, parental stress, and other possible risk factors for nonaccidental injury
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Diagnosis

• Labs
• Cbc not useful in undifferentiated abdominal pain
• Obtain glucose in altered child
• Urinalysis

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imaging

• Abdominal plain films
• intestinal obstruction (air fluid levels, dilated
  small/large bowel)
• perforation (free air)
• calcium-containing stones
• Appendicolith
• pneumatosis intestinalis (seen with NEC)
• constipation (by degree of stool present)

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imaging

• CT - appendicitis
• US
• Intussusception
• ovarian pathology
• testicular pathology
• evaluation of the gallbladder for stones and
  inflammation
• intrauterine pregnancy

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Pyloric stenosis

• pyloric muscle hypertrophy that obstructs gastric
  outflow
• Male, white race, first born, and a positive
  family history are risk factors
• Presents during 2 and 8 weeks of life as
  nonbilious projectile vomiting
• hyponatremic, hypokalemic, hypochloremic
  metabolic alkalosis
• Diagnosed with ultrasound

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intussusception

• portion of the alimentary tract telescopes into
  another segment
• Obstruction of venous return, bowel ischemia,
  bloody stools
• 6 18 month old with colicky abdominal pain
• Plain films or US (best)
• Air contrast enema both diagnostic and therapeutic

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Malrotation and volvulus

• constant abdominal pain, bilious vomiting,
  abdominal distention, and irritability
• Upper GI series Birds beak appearance of
  duodenum
• Tx surgery

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appendicitis

• Most common surgical emergency in children
• Perforation rates approach 90 in children under
  4
• vague, periumbilical pain that later localizes to
  the right side
• Nausea, anorexia, and vomiting are seen ingt80 of
  cases
• Asking a child to hop is more sensitive than
  psoas, obturator or rovsing sign

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Diagnosis and treatment

• Cbc is neither sensitive or specific
• US or CT
• Surgery
• Unasyn for unperforated
• Zosyn for perforated

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Necrotizing Enterocolitis

• Intestinal necrosis in infants, most common
  premature
• poor feeding, lethargy, abdominal distention, and
  tenderness
• Leads to sepsis
• Plain films are diagnostic
• pneumatosis intestinalis (bubbles of air within
  the walls of the bowel)
• NPO, IV fluids, antibiotics, and surgery

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Other causes

• Non specific abdominal pain number one
• Colic
• Gastroenteritis
• Cholecystitis
• Pancreatitis
• Group A strep pharyngitis
• constipation

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Table 124-5 Treatment of Constipation in Children
Osmotic laxatives polyethylene glycol (12 packs/d with 8 oz of water or juice)
Lubricants mineral oil (13 cc/kg/d) (should be used with caution in young children and those at risk for aspiration)
Stool softeners docusate sodium
Stimulant laxatives
Senna (for 26 y olds sennosides 3.75 milligrams/d maximum of 15 milligrams/d for 612 y olds sennosides 8.6 milligrams once a day, maximum of 50 milligrams/d)
Bisacodyl ( if gt6 years old) 510 milligrams at bedtime or breakfast
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References

• Tintinalli, Ch. 124