Abdominal pain in children Madesa Espana, MD Pediatric EM Section St. Joseph’s Regional Medical Center Abdominal pain: evidence-based data Incidence 5 % of patients presenting to the pediatric clinic and ED (2 – 12 years old, <72 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 Abdominal pain: evidence-based data Incidence 7.4% had return visits 1% had treatable medical conditions 0.3% needed surgical intervention on subsequent visits 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 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 Abdominal pain: evidence-based data Associated symptoms Fever Vomiting Decreased appetite Cough Headache Sorethroat 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 Historical data Associated symptoms Vomiting Diarrhea Duration Type of emesis: bile, blood bloody Fever Rash Genitourinary symptoms Physical Examination General appearance Ill-appearing or toxic Dehydrated Shock Vital signs Febrile Tachycardic Tachypneic Hypotensive Physical Examination Head/Face Fontanels Sunken Bulging Signs of inflicted injury Bruising/swelling Physical Examination Eyes Icteric sclera Abnormal eye movements Sunken appearance Periorbital swelling Physical Examination ENT Mucus membranes Moist vs dry Lesions/ulcerations Teeth and Gums Swelling Bleeding Physical Examination ENT Nose Rhinorrhea Nose bleed Throat Erythema Exudates Physical Examination Chest/Axilla Appearance Tenderness Swelling/Masses Physical Examination Cardiovascular Heart sounds Rhythm Pulses Edema Physical Examination Abdomen Appearance Distension Scars Bruises Physical Examination Abdomen Palpation Tenderness Organomegaly Masses Physical Examination Abdomen Tenderness Localized Diffuse Rebound Rovsing’s sign Guarding Voluntary Non-voluntary Physical Examination Abdomen Rectal exam Stool Guaic Other findings Psoas sign Obturator’s sign Murphy’s sign Physical Examination Pelvis/inguinal area Males Scrotum and testicles Urethral discharge Phymosis/paraphymosis Females Vaginal bleeding Speculum exam Physical Examination Skin Color Pale jaundice Rashes Signs of injury/abnormal bleeding Turgor Peripheral circulation Physical Examination Neurologic examination Mental status Cranial nerves Motor Sensorory Cerebellar Physical examination Psychiatric evaluation Mental status Depression Anxiety Suicidal ideation/attempt Homicidal ideation/attempt Hallucinations/delusions Differential diagnosis Infants Gastroenteritis Constipation Malrotation +/- Volvulos GERD Infantile Colic Intussuception Urinary tract infection Testicular torsion 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 Diferrential Diagnosis Adolescent Males Testicular torsion Varicocele Pyelonephritis Kidney stones Gallstones Pancreatitis Hepatitis Incarcerated Hernia Constipation DKA IBD STD GERD Toxic ingestions 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 Abdominal pain: evidence-based data Abdominal pain: appendicitis or not? 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) Male:female ratio: 1.4:1 Life time risk: Males: 8.6%; Females: 6.7% Perforation: 18% ; highest in < 5 and >65 y.o. Appendicitis: evidence-based data Signs and symptoms Neonates: Abdominal distension Vomiting Fever Hypothermia Respiratory distress Appendicitis: evidence-based data Signs and symptoms 3 years and under Diffuse abdominal pain Fever Vomiting Diarrhea Abdominal distension Diffuse abdominal tenderness 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 Abdominal pain: evidence-based data Laboratory studies CBC, differential ESR C-reactive protein Urinalysis Poor sensitivity and specificity Abdominal pain: evidence-based data Radiologic studies Plain films Small bowel obstruction Fecalith Pneumoperitoneum Poor sensitivity and specificity Abdominal pain: evidence-based data Radiologic studies Ultrasound Appendiceal diameter or >6 mm Target sign with 5 concentric layers Distension or obstruction of the lumen High echogenicity around the appendix Pericecal or perivesical fluid Appendix wall > 2 mm Absence of appendiceal peristalsis Can confirm but not exclude appendicitis Abdominal Pain: Evidence-based Data Radiologic studies CT scan Enlarged appendiceal diameter (> 6 mm) Appendiceal wall thickening (> 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% 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 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% Diagnostic work-up History and physical examination Serial abdominal exams Surgical consultation Laboratory data Radiologic evaluation Ultrasound CT scan Treatment of appendicitis Surgery Laparoscopic Open Conservative management Antibiotics IV hydration Treatment of appendicitis Conservative management IV and oral antibiotics Cefotaxime + (ofloxacin +tinidazole) Ciprofloxacin and metronidazole + (ciprofloxacin + tinidazole) Treatment of appendicitis Conservative management Advantages Less pain Shorter recovery time Avoid complications of surgery and anesthesia Treatment of appendicitis Conservative management Disadvantages High recurrence rate 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? 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 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 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. Thank you! Have a great day.