PEDIATRIC EMERGENCY MEDICINE: CURRENT CONCEPTS AND CONTROVERSIES

07338627/02 $15.00 .00

COMMON ABDOMINAL EMERGENCIES IN CHILDREN

James DAgostino, MD

Pediatric abdominal complaints are common presentations in emergency departments (EDs), and emergency physicians are challenged every day with a vast array of gastrointestinal disorders. Because young children with abdominal disorders cannot fully describe their pain or how they feel, the emergency physician must use clinical experience, accurate history taking, diligent physical examinations, and diagnostic studies to help differentiate well children from children with signicant illness. This article facilitates the emergency physicians understanding of common abdominal emergencies in children. GENERAL APPROACH TO CHILDREN WITH ABDOMINAL EMERGENCIES Pain is probably the most common reason that patients visit EDs to seek medical advice.18 Abdominal pain is a common complaint in children and is associated with a large number of gastrointestinal disorders. Nearly one third of children presenting to an ED with abdominal pain did not receive a specic diagnosis.41 Determining exact causes can be difcult. The emergency physician must be aware of stoic children who deny pain in fear of further medical intervention, and histrionic children who demonstrate exaggerated pain. Infants demonstrate pain reaction as a change in behavior: persistent crying, irritability, inability to be consoled, fussiness,45, 55 sleeplessness,

From the Department of Emergency Medicine, State University of New York Upstate Medical University, Syracuse, New York

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

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and poor feeding. Older children, adolescents and even toddlers describe pain with words such as aching, awful, or horrible.59 It is interesting to note that many children with the same pathophysiology can have divergent pain severity and medication requirements.26 The child writhing in pain from a benign condition such as intestinal colic from constipation can appear similar to the child in pain from a potentially life-threatening condition such as intestinal obstruction from intussusception. Anxiety, which is most likely experienced by nearly all pediatric emergency patients,46 has a tendency to increase the painful stimuli,16 and, like pain, it also should be addressed and controlled. Differentiating the child with a benign abdominal process from the child with a more serious condition can be difcult. The emergency physician must obtain a thorough history of the present illness and use patience in examining young patients; often, waiting for the right moment to examine anxious patients and even repeating their examinations. Coupled with specic laboratory and radiologic studies, a thoughtful, thorough evaluation can allow the emergency physician to diagnose abdominal disorders more accurately. APPENDICITIS Appendicitis is the most common nontraumatic surgical emergency in children.15 There is a slight male predominance, with a peak incidence of 9 to 12 years of age.35 Although uncommon in infants and children under 2 years, neonatal cases have been reported.32 Diagnosis is particularly challenging in this younger age group. Clinical Presentation The classic signs and symptoms of appendicitis are periumbilical visceral pain (after obstruction of the appendix), followed by nausea, vomiting, and anorexia, with the development of right lower quadrant abdominal parietal pain. This progression can be noted in up to 50% of adults but is less common in children younger than 12 years of age43 and can account for the initial misdiagnosis in this age group of 28% to 57%.13 For ages 2 years and younger, the most common symptoms are vomiting (85%90%), pain (35%77%), diarrhea (18%46%), and fever (40%60%).3, 22 Misleading clinical signs in this age group have included irritability (34%40%), grunting respirations (8%23%), cough or rhinitis (40%), and right hip complaints, such as refusal to walk or limping (3%23%).3, 22, 37, 50 Localized right lower abdominal tenderness is noted in fewer than 50% of infants3, 22 and the inability of this age group to verbalize their complaints, coupled with misleading clinical signs, have led to perforation rates of 82% to 92%.23, 35 In children ages 2 to 5 years, the incidence of appendicitis is still

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low (fewer than 5% of all pediatric appendicitis cases20) and in contrast to infants, right lower abdominal tenderness is more common (58%85%) than diffuse tenderness (19%28%).60 Abdominal pain (89%100%), vomiting (66%100%), fever (80%87%), and anorexia (53%60%) predominate in this age group.22, 60 Vomiting is often the rst symptom preceding pain that is noted by the parent.43 The incidence of appendicitis increases in school-aged children and peaks in adolescence and the late teenage years. In children 6 to 12 years of age vomiting occurs in 68% to 95% of children with appendicitis (with up to 18% preceding or concurrent with pain). Anorexia (47% 75%), diarrhea (9%16%), constipation (5%28%), and dysuria (4%20%) are also seen in children with appendicitis.42 Fevers above 103F (39.5C) are uncommon,35 although temperatures up to 102F (38.9C) to 103F (39.5C) can occur after perforation.23 One study found that temperatures above 100.4F (38.0C) were found in 4% of school-aged children with symptom duration less than 24 hours, 64% with symptoms lasting 24 to 48 hours, and 63% with symptoms lasting over 48 hours.14 Nearly all the children in this age group have right lower quadrant tenderness, although the entire abdomen can be tender or diffusely tender in 15% of children without perforation, and up to 83% with perforation.39 Diagnostic Studies Although no single laboratory test is diagnostic for appendicitis, patients in whom the physician is considering this diagnosis should have a complete blood count (CBC), urinalysis, and in menstruating adolescents a -human chorionic gonadotropin level performed. The white blood cell (WBC) count is insensitive and nonspecic for appendicitis, and, with the advent of ultrasonography (US) and focused abdominal computed tomography (CT) scan, less reliance should be placed on this test for decision making.42 WBC counts greater than 10,000 occur in 62% of normal patients, 89% of patients with appendicitis, and 93% of patients with perforated appendicitis.35 Abnormal urinalyses ( 5 WBC/ hpf or RBCs) can be found in 7% to 25% of children with appendicitis.43 Although abdominal radiographs frequently are ordered on nearly all patients with a differential diagnosis of appendicitis, their true value in the diagnostic work-up is questionable.31 Some advocate the use of abdominal radiographs in children to evaluate selectively for intraabdominal free air, intestinal obstruction, fecalith, lower lobe pneumonia, intussusception, and renal and biliary calculi.58 The nding of small bowel obstruction on the abdominal radiograph in children younger than 3 years of age should alert one to the high possibility of a perforated appendix.17 Where the diagnosis of appendicitis is not secured with history and physical alone, US is used increasingly. There is a reported sensitivity of 80% to 92% and specicity of 86% to 98%.10, 12, 21, 27 The use of abdominal CT scans for the diagnosis of appendicitis has been thought not to be

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cost effective,23 although its accuracy has been prospectively studied and the sensitivities and specicities range from 87% to 100% and 83% to 97%, respectively.38 The abdominal CT scan can reveal the distended appendix, fecaliths, focal thickening of the cecal wall, and uid collections in cases of appendiceal rupture. In some institutions, CT scan of the right lower quadrant is used if US ndings are equivocal or if an abscess is suspected.58 a and her colleagues have shown improved diagnosis, as Garcia-Pen well as a high degree of diagnostic accuracy and cost-effectiveness with a protocol using both US and CT scans.19 Patients with equivocal clinical ndings have an US. If the US ndings are positive, they are taken directly to the operating room (OR). If the US ndings are negative or equivocal, a CT scan with rectal contrast is performed. If the CT scan is positive the patient is taken to the OR. More than 60% of children in this series had a benecial change in management, and there was a projected cost savings of $565 per patient.19 Differential Diagnosis The most common diagnoses confused with appendicitis are acute bacterial enterocolitis (particularly Yersinia enterocolitica and Campylobacter jejuni, both of which can present with focal right lower quadrant pain, fever, diarrhea, and visible rectal blood), mesenteric lymphadenitis (although the pain is less severe, and peritoneal signs are usually not present), pelvic inammatory disease (and other gynecologic disorders), urinary tract infections, Meckels diverticulitis, intussusception, and right lower lobe pneumonia. Management If an acute abdomen is considered, the emergency physician must act appropriately to stabilize the patients with intravenous uid support and immediate surgical consultation. Patients should receive nothing by mouth and broad-spectrum intravenous antibiotics are administered if obvious perforation is suspected (e.g., febrile, diffuse tenderness, rigid abdomen, or ill-appearing patients). There is controversy over administering intravenous antibiotics in uncomplicated pediatric appendicitis.51 In equivocal cases, admission is sometimes warranted to observe patients for progression of signs and symptoms. HYPERTROPHIC PYLORIC STENOSIS Pyloric stenosis, an idiopathic hypertrophy of the pyloric muscle, is the most common pediatric surgical condition that causes emesis.23 The etiology is unknown. Pyloric stenosis occurs in about 1 in 250 births;

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rst-born boys are at increased risk.25 There is a male-to-female ratio of 4 : 1. Clinical Presentation The infant with pyloric stenosis usually presents in the third week of life with a range of 1 to 10 weeks.23 It is uncommon in the rst few days of life.4 Vomiting is the primary complaint and after several days lethargy and dehydration occur. The vomiting occurs near the end of or within 30 minutes of a feeding, is always nonbilious, and is projectile. Projectile emesis is a common complaint. The physician often must clarify what the parent is describing. Patients with pyloric stenosis usually have true, forceful projectile emesis. The physical examination usually reveals a hungry infant who eats again after vomiting. The infant should be evaluated for signs of dehydration by examining the anterior fontanelle in the sitting position and assessing the rate and intensity of the distal pulses. The infants level of consciousness, perfusion of the extremities, and condition of the mucous membranes also can aid in determining hydration status. The abdomen is generally soft and nondistended. Gentle examination of the midepigastrium while the infant is eating can allow the examiner to palpate deeply and feel an olive-like mass; however, in the authors experience, this mass is palpated infrequently, and a similar experience is reported in the literature.4 The emergency physician must observe the infant during and after feeding. Assessment of the sucking mechanisms, the infants eagerness to eat, and the nature of vomiting can be made. Early in the course of this disorder, patients are often well hydrated, with an excellent sucking mechanism, and make vigorous attempts to eat. As dehydration ensues, the patient becomes increasingly lethargic, and feeding activity and tone are diminished. Late in the course of the illness, the patient can experience periods of apnea because of severe metabolic alkalosis. Diagnostic Studies Serum electrolyte levels should be taken and can reveal the hypokalemic, hypochloremic metabolic alkalosis commonly found in advanced cases of this disorder. If an olive-like mass is palpated, the diagnosis is most ensured, but if not, further studies are warranted. An abdominal radiograph can reveal a large gastric bubble, suggesting a gastric outlet obstruction; however, US of the pylorus is the preferred study in most institutions and is highly sensitive and specic.1, 58 Pyloric stenosis is present if the pylorus muscle thickness is equal to or exceeds 4 mm.6 In cases in which US is inconclusive, an upper gastrointestinal series is done to evaluate for possible gastroesophageal reux, duodenal atresia, or malrotation.23 Pyloric stenosis can appear as a lling defect in the

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distal stomach and duodenal bulb, or as a string of contrast through the stenotic pyloric channel. Differential Diagnosis A common disorder confused with pyloric stenosis is gastroesophageal reux disease (GERD), which generally causes nonforceful, nonprojectile regurgitation. Again, the examiner should observe the infant during and after feedings. An upper gastrointestinal (UGI) series can sometimes but not always demonstrate gastroesophageal reux. UGI has a low specicity for GERD. Many normal patients demonstrate reux with a barium meal. Admission for pH probe testing can further conrm GERD. US usually does demonstrate pyloric stenosis if it is present. Other diagnoses to consider are gastroenteritis, intestinal malrotation with obstruction, duodenal atresia, and an annular pancreas. Management Pyloric stenosis is not a surgical emergency but can be a medical emergency because of electrolyte disturbances and signicant dehydration. The key to management of these infants is rapid volume replacement and judicial electrolyte correction. A surgical consult should be obtained once the diagnosis is suspected, further oral intake withheld, a nasogastric tube placed to decompress the stomach, and the patient should be admitted. Restoration of circulating blood volume with intravenous uids is warranted. Isotonic uids should be given. Initially, 0.9% normal saline solution should be given as a 20 mL/kg bolus infusion if dehydration or signs of poor perfusion are present. Lactated Ringers solution is not indicated because the patient is already alkalotic and the alkalosis can precipitate apnea. The infants serum glucose level should be checked and monitored closely. Continued uid therapy is usually with solutions containing 5% dextrose and 0.9% sodium chloride. Potassium chloride (35 mEq/kg/day) should be added when urine output is established. Adequate rehydration and stabilization is associated with decreased surgical, anesthetic, and postoperative complications. Surgery is often delayed for 1 to 2 days while rehydration and normalization of electrolytes is achieved. Pyloromyotomy (e.g., Ramstedt procedure) is curative. INTUSSUSCEPTION Intussusception, an invagination of the proximal portion of the bowel into an adjacent distal bowel segment, is a common cause of intestinal obstruction in infants,24 second only to an incarcerated inguinal hernia as the cause of intestinal obstruction in infants.51 The peak incidence of

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intussusception is at 10 months of age, with a range of 3 months to 2 years. Pathologic lead points are commonly noted in older children, with Meckels diverticulum being the most common.29 In children younger than 2 years of age, a pathologic lead point is found in less than 5% to 10% of cases. Other causes of lead points are submucosal hemorrhage from Henoch-Scho lein purpura, lymphomas, and intestinal polyps.23 Clinical Presentation The classic triad of intermittent colicky abdominal pain, vomiting, and bloody stools full of mucus (currant jelly stools) is seen infrequently (about 20%). More infants present with only two symptoms.9 It is common for these infants to have a history of severe intermittent abdominal pain every 20 to 30 minutes, with periods of relief lasting 10 to 20 minutes, during which they can appear calm and healthy.23 Other patients become extremely lethargic and pale.29 In those infants without bloody stools, occult blood is present in up to 75% of cases.28 Therefore, the emergency physician should Hemoccult test the stool in all infants with altered mental status. Although the nding of a sausage-like mass in the right upper quadrant with absence of bowel in the right lower quadrant (Dances sign) is pathognomonic of intussusception, this nding is present in only 85% of cases and might not be palpated in crying infants, who can have tense abdominal muscles. The physician should try to examine the abdomen with the infant asleep (not uncommon after paroxysmal attacks), which gives a softer and more revealing abdominal examination. Diagnostic Studies Plain abdominal radiographs, including at plate, upright, and cross-table lateral lms, are the initial studies in children with possible intussusception. These lms can be normal particularly in infants who present early in their disease,23 and therefore normal plain lms of the abdomen should not be used to exclude the diagnosis.48 Radiographic ndings suggestive of intussusception include a paucity of intestinal gas, little or no stool in the colon,58 and small bowel obstruction. Intraperitoneal air should be ruled out with upright or decubitus lms. A soft tissue mass can be seen in the right upper quadrant in up to 50% of cases5 and at times in the rectum. The barium enema is the gold standard study for the diagnosis of and therapy for intussusception. Aircontrast enemas have been used for many years in some countries and have been shown to be as effective as barium enemas in the diagnosis and treatment of intussesception.47 Air contrast decreases the risks associated with perforation during barium enemas in this disease. US has been used increasingly in diagnosis of this condition.

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Differential Diagnosis Disorders that cause intestinal obstruction, abdominal pain, and blood in the stool should be considered, such as malrotation with midgut volvulus, Meckels diverticulum (although this classically causes painless bleeding), and incarcerated inguinal hernia (although the inguinal mass should help differentiate from intussusception). Henoch-Scho nlein purpura can coincide with (ie, and be the cause for the intussusception) and despite the purpuric rash and joint involvement, a barium or aircontrast enema can be unavoidable. Management Once intussusception is suspected, a surgical consultation should be obtained, oral intake withheld, and intravenous uid resuscitation provided prior to attempts at barium or air-contrast reduction. One can place a nasogastric tube into the stomach if obstruction is present. The air-contrast enema has been shown to be as effective as barium in reducing the intussusceptum.34, 47 And has replaced the barium enema as the study of choice at most major centers in the United States. Successful reduction of intussusception occurs in 60% to 80% of cases.58 MALROTATION AND MIDGUT VOLVULUS Volvulus results from an incomplete rotation and an abnormal xation of the bowel during embryonic development. This malrotation predisposes the bowel to twist on itself, leading to bowel obstruction and vascular compromise. Volvulus occurs in 68% to 71% of neonatal malrotation cases.56 Patients with malrotation may have obstructing brous bands (Ladds bands) that can cause proximal intestinal obstruction. Unfortunately, complete volvulus can lead to bowel necrosis in 1 to 2 hours,15 and therefore clinical and radiographic evaluation of suspected volvulus cases must be done promptly. The incidence of malrotation is 1 in 500 births.23 Nearly two thirds of midgut volvulus cases present in the rst month of life, 75% by 1 year23, 58 and the remaining cases any time later in life.58 Clinical Presentation Midgut volvulus has a sudden onset of vomiting, abdominal pain, and feeding intolerance in the otherwise healthy young infant. Bilious emesis, the hallmark, is present in 77% to 100% of cases.44, 56 Symptoms are more vague in the older child and malrotation without volvulus can occur even in adulthood. The older child can display symptoms of chronic, intermittent vomiting, crampy abdominal pain, failure to thrive,

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constipation, bloody diarrhea, and hematemesis.30 The frequency of volvulus complicating malrotation in the older child ranges from 14% to 65%.44, 56 Unfortunately for the emergency physician, malrotation and even early volvulus have few, if any, abnormal physical ndings.7, 44 In a review of 22 patients undergoing surgery for malrotation, Torres found that 50% of patients had normal abdominal examinations and 32% had abnormal distension without tenderness.56 The obstruction in midgut volvulus is usually high, and proximal and abdominal distention might not be present. A high index of suspicion is therefore necessary to diagnose this disease especially early in its course. With midgut volvulus, intestinal ischemia progresses to gangrene, and virtually all patients develop abdominal pain and peritoneal signs. At this stage, tachycardia and hypovolemia are present40 and, as infarction ensues peritonitis, abdominal distention, profound dehydration and shock occur.23 When the diagnosis is delayed, the patients may be pale and grunting.37 Diagnostic Studies CBC, electrolytes, blood-urea-nitrogen (BUN), and creatinine levels, as well as blood type and cross match are performed in these patients but should not be used in the diagnostic evaluation of infants with malrotation and midgut volvulus. Radiographs vary in patients with midgut volvulus. The upright, at-plate and cross-table lateral abdominal lms can demonstrate small bowel obstruction, abdominal paucity of gas distally, and a markedly dilated duodenum and stomach.54 At times, a normal bowel gas pattern can be seen because the obstruction is usually in the proximal bowel.58 In patients suspected of having malrotation and midgut volvulus, particularly when the abdominal radiographs are equivocal, the diagnostic study of choice is the upper gastrointestinal study.23, 58 Malrotation with midgut volvulus is suspected when the duodenojejunal junction is in an abnormal location (ie, not to the left of the vertebral column), and the contrast material either ends abruptly or tapers like a corkscrew, indicating abdominal proximal intestinal obstruction.23 If US is used for the vomiting infant (as in pyloric stenosis), any abnormal relationship between the superior mesenteric artery and vein warrants an upper gastrointestinal study.58 Differential Diagnosis Duodenal webs, duodenal stenosis, and duodenal atresia can result in a clinical picture similar to that of midgut volvulus. Lower intestinal obstruction usually causes abdominal distention. Adynamic ileus can result in bilious vomiting; however, unexplained bilious vomiting in a young infant is malrotation and midgut volvulus until proved otherwise.

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Management When midgut volvulus is suspected, surgical consultation for immediate laparotomy is required to decrease morbidity and mortality. Intravenous uids are begun, and, if vascular collapse is present, rapid normal saline boluses are given until adequate perfusion is attained. A nasogastric tube should be inserted into the stomach and intravenous antibiotics started.

MECKELS DIVERTICULUM Meckels diverticulum, a vestige of the omphalomesenteric duct, occurs in 2% of the population. Two percent of patients with a Meckels diverticulum manifest symptoms. The diverticulum is usually 2 feet proximal to the terminal ileum. Forty-ve percent of symptomatic patients are younger than 2 years old.2 This nding is known as Meckels rule of twos.

Clinical Presentation Meckels diverticuli are the most common cause of signicant lower gastrointestinal bleeding in children.2, 36 Most patients with bleeding have peptic ulceration within the diverticulum or adjacent ileum. The bleeding can be intermittent or massive. It is classically painless,36 although some patients do experience pain.8 The stools appear bright red or tarry, depending on the briskness of the bleeding and the location of the diverticulum.2 In a total of 830 cases of Meckels diverticulum of all ages, Amoury found intestinal obstruction and intussusception in 35% of patients, bleeding in 32%, diverticulitis in 22%, and umbilical stula in 10%.2 Although bleeding occurs in young patients, diverticulitis occurs more frequently in older patients.2, 8

Diagnostic Studies In addition to CBC, electrolytes, BUN, and creatinine levels, if one suspects Meckels diverticulum, a blood type and cross match should be done. Abdominal radiographs are usually normal, although they can demonstrate obstruction or perforation. The Meckels scan, using intravenous technetium 99m, is 75% to 85% sensitive for identifying heterotopic gastric tissue when bleeding is present.11

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Differential Diagnosis Other causes for lower GI bleeding include intestinal polyps, intussusception, anal ssures, midgut volvulus, bacterial enteritis, and perianal streptococcal disease. Management Patients should be given adequate intravenous uid support, and oral intake should be withheld. With massive bleeding, a blood transfusion is sometimes necessary. In stable but bleeding patients, a Meckels scan can be done, and, if positive, a surgical consultation obtained. In unstable patients, or if peritoneal signs are present, surgery should not be delayed. INCARCERATED INGUINAL HERNIA Inguinal hernia repair is the most common surgical procedure in children. One to two percent of children have an inguinal hernia (approaching 30% in premature infants) and 10% of inguinal hernias eventually are complicated by incarceration.33 Seventy percent of incarcerations occur in infants younger than 1 year of age,57 with the greatest risk occurring during the rst 6 months of life.49 If left undiagnosed and untreated, incarcerated inguinal hernias can have serious and even lifethreatening consequences.23 The prevalence of inguinal hernias occurs in a male-to-female ratio of 6 : 1. Clinical Presentation Many parents bring children to the ED after noting a bulge or swelling in the groin area. These masses can be noted during diaper changing, or during crying or other Valsalva maneuvers. Gradual swelling of the bowel in boys and bowel or ovary in girls causes incarceration. Signs and symptoms of vomiting, lack of bowel movements, abdominal distention, and poor feeding can indicate the presence of intestinal obstruction. Prolonged incarceration manifests itself as an erythematous, rm, immobile, tender mass. Diagnostic Studies Transillumination of the scrotum, using an otoscope, can help to differentiate a hydrocele from an incarcerated inguinal hernia. Abdominal radiographs should not be necessary to diagnose an incarcerated inguinal hernia, although signs of intestinal obstruction can be present.

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With an inguinal hernia, the neck of the groin mass should emanate from the distal ring of the inguinal canal. Differential Diagnosis Hydroceles can be confused with inguinal hernias, particularly communicating hydroceles, in which the size changes with Valsalva maneuvers or with recumbence. Lymphadenopathy can be palpated in the inguinal area; however, a swollen lymph node is usually smaller than an inguinal hernial mass, is not mobile, and does not involve the inguinal canal. Undescended or retracted testicles can appear to be inguinal hernias. The emergency physician should be sure to palpate both testicles in the scrotum prior to diagnosing an inguinal hernia. Management If intestinal obstruction is present (e.g., bilious vomiting, abdominal tenderness and distention, bloody stools, and a hypovolemic state), one should resuscitate with intravenous uids, place a nasogastric tube into the stomach, and obtain laboratory studies and emergent surgical consultation. If an incarcerated inguinal hernia is present without obstruction or shock, one should attempt a manual reduction. Nearly 95% of inguinal hernias can be reduced by gentle constant upward pressure on the hernia sac.52 With more resistant incarcerated inguinal hernias, sedation and a Trendelenburg position are helpful. Once the patient is sedated, one should apply rm, constant upward pressure on the hernia sac with one hand while milking the neck of the hernial mass into the distal ring of the inguinal canal with the other hand. If the inguinal hernia is reduced successfully, one should consult with a pediatric surgeon for outpatient follow-up. Depending on the duration of the incarceration and the difculty in reduction, some pediatric surgeons do admit these patients for observation. If reduction is unsuccessful, then immediate surgical consultation is warranted. Entrapped ovaries can be difcult to reduce. Some pediatric surgeons delay surgery if the ovary appears normal, nonerythematous, and nontender.33 All patients with inguinal hernias eventually require surgery, and followup consultation with a pediatric surgeon must be arranged prior to ED discharge. SUMMARY Because young children often present to EDs with abdominal complaints, emergency physicians must have a high index of suspicion for the common abdominal emergencies that have serious sequelae. At the

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same time, they must realize that less serious causes of abdominal symptoms (e.g., constipation or gastroenteritis) are also seen. A gentle yet thorough and complete history and physical examination are the most important diagnostic tools for the emergency physician. Repeated examinations and observation are useful tools. Physicians should listen carefully to parents and their children, respect their concerns, and honor their complaints. Ancillary tests are inconsistent in their value in assessing these complaints. Abdominal radiographs can be normal in children with intussusception and even malrotation and early volvulus. Unlike the classic symptoms seen in adults, young children can display only lethargy or poor feeding in cases of appendicitis or can appear happy and playful between paroxysmal bouts of intussusception. The emergency physician therefore, must maintain a high index of suspicion for serious pathology in pediatric patients with abdominal complaints. Eventually, all signicant abdominal emergencies reveal their true nature, and if one can be patient with the child and repeat the examinations when the child is quiet, one will be rewarded with the correct diagnosis.

References
1. Allen AE: Ultrasound investigation of pyloric stenosis. Radiogr Today 54:49, 1988 2. Amoury RA: Meckels diverticulum. In Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, CV Mosby, 1986 3. Barker AP, Davey RB: Appendicitis in the rst three years of life. Aust NZJ Surg 58:491494, 1988 4. Benson CD: Infantile hypertrophic pyloric stenosis. In Welch KJ, Randolph JG, Ravitch MM, et al [eds]: Pediatric Surgery, Chicago, CV Mosby, 1986 5. Bisset GS III, Kirks DR: Intussusception in infants and children: Diagnosis and therapy. Radiology 168:141145, 1988 6. Blumhagen JD, Maclin L, Krauter D, et al: Sonographic diagnosis of hypertrophic pyloric stenosis. AJR Am J Radiol 150:13671370, 1988 7. Bonadio WA, Clarkson T, Naus J: The clinical features of children with malrotation of the intestine. Pediatr Emerg Care 7:348, 1991 8. Brophy C, Seashore J: Meckels diverticulum in the pediatric surgical population. Conn Med 53:203, 1989 9. Bruce J, Huh YS, Cooney DR, et al: Intussusception: Evolution of current management. J Pediatr Gastroenterol Nutr 6:663, 1987 10. Carrico CW, Fenton LZ, Taylor GA, et al: Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults. AJR Am J Radiol 172:513516, 1991 11. Caty MG, Azizkhan RG: Gastrointestinal bleeding. In Oldman KT, Colombani PM, Foglia RP (eds): Surgery of Infants and Children: Scientic Principles and Practice. Philadelphia, LippincottRaven, 1997, pp 11251131 12. Crady SK, Jones JS, Wyn T, et al: Clinical validity of ultrasound in children with suspected appendicitis. Ann Emerg Med 22:1125, 1993 13. Curran TJ, Muenchow SK: The treatment of complicated appendicitis in children using peritoneal drainage: Results from a public hospital. J Pediatr Surg 28:204208, 1993 14. Doraiswamy NW: Progress of acute appendicitis: A study in children. Br J Surg 65:877879, 1978 15. Felter RA: Nontraumatic surgical emergencies in children. Emerg Med Clin North Am 9:589610, 1991

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