Acute Abdominal Pain
In Children
Hai Ho, M.D.
Department of Family Practice
Pathophysiology of pain
• Visceral pain
– Mechanical – stretching
– Chemical – mucosa
– Aching and dull, poorly localized
• Parietal pain
– Sharp, well-localized
Pathophysiology of pain
• Referred pain
– Somatic and visceral afferent fibers
enter the spinal close to each other
• Localization of pain
– Bilateral – most GI tract, midline pain
– Unilateral – kidney, ureter, ovary,
somatic
History
• Usual: quality, location, severity,
associated symptoms,
aggravating/alleviating factors
• Kids cannot give a history
• Dangerous signs given by parents
My history: the red flags
• Duration – acute vs. chronic
• Fever – inflammation, infection
• Vomiting – stasis, obstruction,
dehydration
• Urine output – volume depletion
• Diarrhea - bloody
Examination
• Usual: inspection, auscultation,
percussion, palpitation
• Rectal – rectocecal appendicitis,
occult blood
• Pelvic – PID
• Scrotal - torsion
Tests?
• Chemistry – electrolyte abnormality,
BUN/creatinine, liver function test
• CBC – infection, bleeding
• Plain abdominal x-ray – free air,
obstruction
• Urinalysis – pyuria, hematuria
• Pregnancy test
Pyloric stenosis
What is pyloric stenosis?
Hypertrophy of pylorus – thickening & elongation
Cause of pyloric
stenosis?
• Unknown
• Associations
– Abnormal muscle innervations
– Erythromycin in neonates for pertussis
postexposure prophylaxis
– Infant hypergastrinemia
Epidemiology
• Prevelance – 3/1000
• More common in white northern
European descents
• Male:female = 4:1 to 6:1
• Age – 1 week – 5 months but usually 3
to 6 weeks
Clinical presentation?
• Abdominal pain
• Nonbilious vomiting after feeding and
with 91% having projectile emesis
Distinguish pyloric stenosis from GER?
Clinical presentation?
• Abdominal pain
• Nonbilious vomiting after feeding and
with 91% having projectile emesis
– Hungry after feeding
– Weight loss
– Progressive symptoms
Clinical presentations
• Jaundice
– 5% of affected patients
– Indirect hyperbilirubinemia due to
decreased level of glucuronyl
transferase
Examination?
• Abdominal
distension
• Olive mass – RUQ,
after feeding
Examination
• Gastric peristaltic
wave from left to
right after feeding
Tests?
•
•
•
•
Chemistry
Plain abdominal x-ray
Ultrasound
UGI
Chemistry?
• Decreased chloride
• Elevated bicarbonate – metabolic
alkalosis
• ± Hypokalemia
• Elevated BUN and creatinine
• ±Elevated indirect bilirubin
Abdominal x-ray
Increased gastric air or fluid suggestive
gastric outlet obstruction
Ultrasound
• Pyloric length > 1519 mm
• Wall thickness > 34 mm
• Pyloric diameter
>10-14 mm
Ultrasound
Shoulder sign indentation of
pylorus into the
stomach
UGI
• String sign
• Pyloric spasm may
mimic the string
sign
Treatment?
• Medical resuscitation first
– IVF hydration with potassium
– Correction of alkalosis because of
postoperative apnea associated with general
anesthesia
• Pyloromyotomy
• Endoscopically-guided balloon dilation –
surgery is contraindicated or incomplete
pyloromyotomy
Pyloromyotomy
Pyloromyotomy
Pyloromyotomy:
laparoscopy
Postoperative
management
• May be fed within 12-24 hours, early
as 4 hours post-op in one study
• Vomiting
– Not a reason to delay feeding
– GER – up to 80% post-op
– Consider UGI if vomiting persists > 5
days
Intussusception
What is
intussusception?
Invagination of intestine into itself
Pathophysiology
• Proximal bowel
telescopes into distal
segment, dragging
along mesentery
• Compression of
mesenteric vessels &
lymphatics leads to
edema, ischemia,
mucosal bleeding,
perforation, and
peritonitis
Ileocolic intussusception
Causes of
intussusception?
• Idiopathic –
– 75% of ileocolic intussusception
– More likely in children < 5
Causes of intussusception
• Leading point
– Hyperplasia of Peyer patches in terminal
ileum
– Structural: small bowel lymphoma,
Meckel diverticulum
– Systemic: cystic fibrosis, HenochSchönlein, Crohn disease
Epidemiology
• Male:female – 3:2
• Age –
– 3 months to 6 years with 80% < age 2
– Peak at 6-12 months
• Most common - ileocolic
Clinical manifestations?
• Intermittent, severe, crampy
abdominal pain with loud cry and in
curled up position
• Vomiting
• Appear normal between attack
• Currant-jelly stool
Currant-jelly stool
Mixture of blood and mucus
Foul smelling
Tests?
• Chemistry – dehydration, electrolyte
imbalance
• CBC – infection
• X-ray: plain film & contrast or air enema
• Ultrasound
• CT scan – only if other tests are negative
X-ray : plain film
X-ray
• Contrast material
between the
intussusceptum and
the intussuscipiens is
responsible for the
coil-spring appearance
• Use water-soluble
agent prior to barium
if high risk of
perforation suspected
Ultrasound
Could detect ileoileal
intussusception
Treatment?
• Air or contrast reduction
– Air is better than barium reduction –
less perforation <1%
– Not very successful if symptoms > 24 –
48 hours or with bowel obstruction
– Successful rate – 75-90% with ileocolic
intussusception
• Surgery
Reduction
Surgery
• Manual reduction and end-to-end
anastomosis
• Indications
– Persistent filling defects
– Failed nonoperative reduction
– Prolonged intussusception
Recurrence
• 10%
• Not necessary an indication for
surgery
Malrotation & Volvulus
Normal development
Midgut volvulus
Volvulus
Cecal volvulus
Sigmoid volvulus
Clinical presentation?
• Bilious emesis
• Abdominal distension
Tests?
• UGI- duodenum not crossing the
midline
• Barium enema – malposition of cecum
Abdominal series
Gastric and duodenal bulb distention
Little air in intestine
UGI with SBFT
Cork-screw pattern – barium flowing through
restricted bowel lumen
Treatment: surgery