Objectives

 At the end of this session, participants will be

able to:
 Discuss the differential diagnosis of acute
abdominal pain in children of various ages
 Outline serious and life-threatening causes of
abdominal pain including those requiring
emergent surgical intervention
 Review an approach to the child with suspected
appendicitis
 Review an approach to the child with suspected
intussusception

 Focus on non-traumatic causes

2
Acute Abdominal Pain in Children

 Common complaint
 3.5-5% of all visits to the ED

 Causes vary depending on the patient’s age

 “Extra-abdominal” causes
 Establishing diagnosis
 Location of pain
 Accompanying signs and symptoms
Abdominal Pain in Children

 Goals of evaluation:

1. Ensure cardiovascular stability

2. Make a diagnosis; exclude serious conditions

2. Reassure patient and family

3. Relieve pain

4
Acute Abdominal Pain in Children
Common Causes by Age - Medical
 Infants
 Colic
 Gastroesophageal reflux
 Gastroenteritis
 Milk protein allergy
 Trauma
 Toddlers and Preschool
Children
 Gastroenteritis
 Urinary tract infection
 Constipation
 Henoch – Schönlein
purpura
 Trauma
 School – aged Children
 Gastroenteritis
 Urinary tract infection
 Constipation
 Asthma
 Group A streptococcal
pharyngitis
 Functional abdominal pain
 Trauma
 Adolescents
 Gastritis
 Gastroenteritis
 Gastroesophageal reflux
disease
 Constipation
 Trauma
 GU and Gyn disorders
5
Acute Abdominal Pain in Children
Surgical/Critical Causes by Age
 Infants  School – aged Children
 Malrotation,volvulus+  Appendicitis
 Intussusception  Megacolon (IBD)
 Enterocolitis (Hirschsprung)  Peritonitis
 Incarcerated/strangulated hernia  Hepatitis
 Trauma –non-accidental  Ingestion
 ALCAPA  Trauma
 DKA
 Toddlers/Preschool Children
 Intussusception  Adolescents
 Appendicitis  Appendicitis
 Incarcerated/strangulated hernia  Ovarian torsion
 Intest. Obstruction  Ectopic pregnancy
 Peritonitis  PID
 Trauma  Biliary disease
 DKA  Pancreatitis
 Myocarditis  IBD
 Meningitis  Trauma
 Diabetic ketoacidosis
 Myocarditis
 Ingestion
6
Case 1
 27 – day - old infant

 Fussy; crying more than usual

 Vomiting: clear earlier; green now

 What do you do next?

7
 Colic is a common cause of what
seems to be abdominal pain in
infants, but…
 Bilious emesis in a neonate is a
surgical emergency!
 IV access and fluid resuscitation
 Xray abdomen Upper GI series
 Surgical consultation

 Dx: malrotation with

volvulus
 > 50% of cases present in 1st
year of life

Aboagye J. J Pediatr Surg.8 2014

 Diagnosis-
Other modalities
 Ultrasound/CT:
 "Whirpool Sign” (wrapping/swirling
of the mesentery around the
superior mesenteric artery and/or
vein) seen in 22/27 (81%) patients

Esposito F. J Ped Gastro Nutr 2014

 Enhanced CT scan showing swirling of the mesentery along the
superior mesenteric artery

Zhou H et al. Emerg Med J doi:10.1136/emermed-2013-

203493

Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.
 Enhanced CT scanning revealed swirling of the mesentery along the
superior mesenteric vein

Zhou H et al. Emerg Med J doi:10.1136/emermed-2013-203493

Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.
 Infantile Colic
 Excessive crying

 10-20% of all PMD visits for infants aged 2 wks-3 mo.

 Usually benign and self-limiting; organic cause in < 5%

 Parental exhaustion and stress

 Treatment:
 Synbiotic (a mixture of seven probiotic strains plus fructo-
oligosacharide) may help
 Reassurance!

Kianifer H. J Paediatr Child Health. 2014

Akhnikh S. Pediatr Ann. 2014
“Abdominal pain” in infancy:
Other causes
 Gastroesophageal reflux disease – may be
associated with vomiting, arching

 Cow milk protein intolerance – bloody stools with

mucous

 Critical causes in infancy:

 Aberrant coronary arteries (ALCAPA) – tachycardia, S&S
of CHF, worse with feeding; ECG
 Strangulated inguinal hernia – complete exam
 Intussusception – lethargy
 Trauma – other injuries
 Enterocolitis due to Hirschsprung Disease – bloody
diarrhea and shock in first few weeks of life
13
Case 2
 9-mo old with vomiting and abdominal pain for 3 days
 Emesis-non-bloody, non-bilious
 One loose stool on first day
 Sleepy today
 Physical exam: sleepy, pale
 Mild tachycardia; mucous membranes dry
 Abdomen non-surgical
 What do you think?

14
 Intussusception

 Commonest cause of intest. Obstruction

3m – 6y
 50% of cases in the 1st year; 90% by 4 years
 Concerning features in a CDR:
 Intermittent abd pain episodes lasting <
30 minutes
 Bilious vomiting
 Blood in stool
 Tmax < 102
Aboagye J. J Pediatr Surg 2014
Maglione MA. Pediatrics 2014
Roskind 2012 15
Red Currant Jelly Stool
Intussusception
 Abdominal x-rays may be helpful
 Paucity of gas in RLQ
 Soft tissue mass in RUQ
 Features of intest. obstruction-proximal bowel loops
dilated/with air-fluid levels
 Absence of gas in distal collapsed large intestine

 Get at least 2 views

 Will be “normal” in up to 20% of cases
 Have a high index of suspicion – if concerned,
obtain an ultrasound

Roskind CG. Pediatr Emerg Care

17 2007.
Intussusception
 Further imaging:
 Ultrasound
excellent with
experienced
operator-Target
or doughnut
sign

21
Intussusception

 Contrast or air enema

is gold standard;
 Diagnostic &
therapeutic

 IV fluids

 Surgical stand – by

22
 Advances in Treatment
 Radiation-free US-guided hydrostatic
reduction:
 Good success rate: 41/47 (87%)
 May be particularly valuable in
centers that are already experienced
with using US for diagnosis

Menke J. Eur J Pediatr. 2014

(Epub ahead of print)
Recurrence rate for Intussusception after
reduction
Overall Within 24 hours Within 48 hours
% (95% CI)
Contrast enema 13 (11-14) 4 (2-7) 5 (4-8)
US-guided non- 8 (6-10) 4 (1.5-10) 7 (4-11)
contrast enema
Fluoroscopy- 8 (7-10) 2 (0.7-6) 3 (1-6)
guided air enema

Another study: D/S from ED strategy reduces hospital charges

without increasing morbidity

CONCLUSION:
Discharge home with clear instructions for follow-up after a small period
of observation and PO trial in the ED may be reasonable

Gray MP. Pediatrics. 2014

Beres AL. J Pediatr Surg. 2014
 Case-3
 10 year old boy with peri-umbilical abd. pain
& anorexia for 4 hours
 T 36° HR 77 RR 22 BP 114-70
 Uncomfortable
 Abdomen: soft; diffuse tenderness, mainly
peri-umbilical; not tender in RLQ
 X-ray abd. c/w constipation fleet
enema/miralax/home
 (RN note: Tender RLQ, guarding, pain on
walking)
 Case-cont.
 Next day: patient recalled because of
radiology read of appendicolith
 Headache, Vomiting; lethargic
 T 39°C HR 110 RR23 BP102/47
 Sick looking; abdomen diffusely tender -
max. RLQ, guarding
 WBC: 3.1; ANC 2,542; CRP 2.9; lactate: 7.1
 Diagnosis: Perforated appendicitis with
septic shock
 Epidemiology
 Commonest surgical emergency in children

 Increases with age till adolescence

 Missed appy 2nd commonest diagnosis in PEM

malpractice claims

O’Shea JS. PEC 1988

Selbst SM. PEC 2005
 ©

Locations of Appendix
 Right Lower Quadrant (85%)

 Pelvic/Retrocecal

 Retroileal

 Left Lower Quadrant

 Can we improve our diagnostic
accuracy for appendicitis?
Zero Sum Myth

Negative Laparotomy Perforation

5-20% 20-35%
 Perforation
 Higher morbidity & mortality than non-
ruptured appendicitis
 Associated with tubal infertility in girls
 Case Control Study
 279 with tubal infertility & 957 controls
 Unruptured AP - no increased risk
 Ruptured AP - relative risk 4.8

Mueller BA. NEJM 1986

 Perforation
 Associated with:
 Younger children
 Longer duration of abdominal pain
 Centers with fewer number of cases
 Poor access to care
 Obesity
 Retrocecal appendix

Smink DS. Pediatrics 2005

Bratu I. J Pediatr Surg 2008
Levas MN. Jped 2014
Blanco FC. Clin Pediatr 2012
 Perforation Sub-sample

Test for trend: OR=1.65, 95% CI (1.50, 1.82)

30% Proportion Perforation
95% Confidence Interval

20%

10%

0
<12 12-23 24-35 36-47 48-71

Duration of Abdominal Pain

Bachur RG. Ann Emerg Med 2012

Should we scan them all?
Bayes’ theorem

Pre-test Sensitivity Specificity Post-test

probability (%) (%) probability
(%) (%)

40 94 95 93
5 94 95 50
 Diagnosis
 Concordance / preponderance of evidence
 History  Examination  Labs  Imaging
 Pertinent symptoms
Symptom LR
Fever 3.4 (2.4-4.8)
RLQ pain 1.2 (1-1.5)
Mid-abd. Pain 2.5 (1.9-3-1)
migrating to RLQ
Nausea, vomiting 1.19 (1.05–1.35)
Anorexia 1.42 (1.25–1.61)

Bundy DG. JAMA 2007

Santillanes G. Acad Emerg Med 2012
 Pertinent exam findings
Sign LR
RLQ tenderness 1.3 (1.1-1.4)
Rebound tenderness 3.0 (2.3-3.9)
Guarding 2.0 (1.4-3.9)
Diffuse peritonitis 25 (1.4-414)
Pain with jumping 2.0 (1.7-2.4)
Rectal tenderness 2.3 (1.3-3.1)
Psoas sign 2.3
Obturator sign 2.2 (1.4-3.4)
Rovsing sign 1.9 (1.3-2.8)
Bundy DG. JAMA 2007
 ANC Scatter Plot
ANC result for patients with positive appendicitis
(n = 80)

35,000
30,000
25,000
ANC result

20,000
ANC
15,000
10,000
5,000
0
0 20 40 60 80 100 120 140
Duration of symptoms (hours)
 CRP Scatter Plot
CRP result for patients with positive appendicitis
(n = 78)

25
20
CRP result

15
10
5
0
0 20 40 60 80 100
Duration of symptoms (hours)

CRP for patients with + appy

 CDR to Identify Patients at Low
Risk for Appendicitis
• ANC < 6,750
• No nausea and
• No max tenderness in RLQ

 NPV 98%; LR- 0.06 (Derivation sample)

 NPV 92%; LR- 0.13 (0.1-0.2) (Multi-center
Validation study)*
Kharbanda AB. Pediatrics 2005
*Kharbanda A. Arch Ped Adol Med 2012
Test Characteristics of US in the
Diagnosis Of Appendicitis
Test Characteristic % (95% CI)

Sensitivity 72 (67-77)
Specificity 97 (95-98)
PPV 92 ( 88-95)
NPV 88 (85-90)
LR+ (Weighted for prevalence) 12.4 (8-19.1)
LR- (Weighted for prevalence) 0.14 (0.12-0.17)
Mittal MK et al. Acad Emerg Med July 2013
 Results
Restricting the analysis - appendix
specifically classified as normal or
abnormal (469 cases [49%]):
 NPV 98% (94-99)
 PPV 92% (88-95)

Mittal MK et al. Acad Emerg Med July 2013

Sensitivity and specificity of US to detect
appendicitis
Sensitivity test for trend: OR=1.39, 95% CI (1.14, 1.71)
100%

90%

80%

70%
Sensitivity, 95% Confidence Interval
Specificity, 95% Confidence Interval
60%
<12 12-23 24-35 36-47 48-71

Duration of Abdominal Pain in Hours

Bachur RG et al. Ann Emerg Med Nov. 2012

 CT
 CT with IV contrast suitable for most
cases
 Sensitivity: ≥ 93%; specificity: ≥ 92%
 Invasive, higher cost
 Ionizing radiation related cancer risk

Kharbanda A. Radiology 2007

Howell JM. Ann Emerg Med 2010
 Sensitivity and specificity of CT to detect
appendicitis
100%

90%

80%

70%
Sensitivity, 95% Confidence Interval
Specificity, 95% Confidence Interval
60%
<12 12-23 24-35 36-47 48-71

Duration of Abdominal Pain in Hours

Bachur RG et al. Ann Emerg Med Nov. 2012

 Low-dose CT
 Setting: Single-center

 Subjects: 891, age 15-44 yrs. with suspected appy

 Study type: Randomized, low-dose(median 116

mGy, effective radiation dose 2 mSv) or standard-
dose (median 521 mGy, 8mSv); IV contrast in all

 Results:
 Sens: 94.5 vs. 95; Spec: 93.3 vs. 93.8
 Similar neg. appy rate (3.5 vs. 3.2)
 Similar perf. rate (27 vs. 23)

Kim K. NEJM 2012

 Expedited MRI
 Setting: Single-center, 208 children, age 3-17 years,
with suspected appendicitis

 Methods: Expedited 4-sequence protocol; no

contrast; no sedation

 Results:
 Sens: 98%; spec 97%; PPV 89%; NPV 99%
 MRI time: median 12 min.
 Time to report (after MRI done): median 46 min

 Recent study: Equally good for those with < 24

hrs vs. > 24 hrs of abdominal pain
Moore MM. Pediatr Radiol 2012
Koning JL. Abdom Imaging. 2014
 Early Management
 NPO
 IV fluids
 Antibiotics
 Analgesia
 Surgery – appendectomy
 Early Management -
Antibiotics
 Most commonly isolated organisms: Gram
negatives and anaerobes
 Escherichia coli, Pseudomonas aeruginosa
 Streptococcus group milleri & other anaerobes

 Antibiotics:
 Ceftriaxone + metronidazole (cipro if allergic to
ceftr.)
 Piperacillin/tazobactam (Zosyn)
 Cefoxitin or ampicillin/sulbactam (Unasyn)
Pepper VK. Surg Clin North Am. 2012
Nonoperative Management
of Appendicitis
 Study Design: Prospective non-randomized
clinical trial
 Subjects: Children with uncomplicated
acute appendicitis comparing non-operative
management to urgent appendectomy
 Primary outcome: 30-day success rate of
non-operative management
 Site: Nationwide Children’s Hospital,
Columbus, Ohio Minneci PC et al. J Am Coll Surg. 2014
Nonoperative Management
of Appendicitis
Results:
 N=77; 30 non-operative
 Primary outcome
 immediate and 30-day success rates of
non-operative management were 93%
(n=28/30) and 90% (n=27/30)
 No evidence of progression of
appendicitis to rupture at the time of
surgery in the three patients that failed
non-operative management
Nonoperative Management
of Appendicitis
 Secondary outcome: Non-operative group:
 Fewer disability days (3 vs. 17) (p < .001)
 Returned to school more quickly (3 vs. 5 days,
p=0.008)
 Exhibited higher quality of life scores in both
the child (93 vs. 88, p=0.01) and the parent (96
vs. 90, p=0.03), but
 Incurred a longer LOS (38 vs. 20 hours,
p<0.0001)

 Conclusion: high early success rate and improved

patient centered outcomes in patients managed
non-operatively Minneci PC et al. J Am Coll Surg. 2014
 Comparison of Antibiotic Therapy and
appendectomy for acute uncomplicated
Appendicitis in Children – A Meta analysis

 Findings In this meta-analysis of 5

studies (including 404 patients),
antibiotic treatment was safe and
effective in 152 of 168 pediatric
patients (90.5%), but the risk for
treatment failure increased
significantly in patients with
appendicolith

Huang L, et al. JAMA Pediatr. 2017;171(5):426-434

 Appendicitis
Take-home Points
 Develop a Clinical pathway

 Use clinical evaluation, intuition, gestalt (± ANC,

CRP) to risk-stratify patients

 Imaging for equivocal patients

 US as 1st line imaging modality if available

 If US does not identify appendix, and clinical

concern persists, consider continued observation,
surgical consult &/or CT with IV contrast

 Emerging modalities: Other biomarkers, low-dose

CT, expedited MRI, non-operative management
Acute Abdominal Pain in Children
 Ovarian Torsion
 Acute onset of severe,
constant, unilateral lower
abdominal or pelvic pain
 Nausea and vomiting;
dysuria
 Post-menarche commoner
 Masses and cysts may
predispose
 Pelvic ultrasound: enlarged
ovary and “pearl necklace
sign.” Doppler helpful but
early on there may be flow
 Pancreatitis
 Upper abdominal pain,
vomiting, fever
 Elevated lipase (> 3 times
normal)
 Idiopathic, viral infections,
medications, biliary disease,
familial/anatomic
 CT and/or US – anatomic
causes and to look for
complications
 Severe cases: critically ill
due to third spacing of
fluids, hypocalcemia,
hyperglycemia
 Bowel rest initially (NG
tube?), narcotic analgesics,
fluid resuscitation
56
Acute Abdominal pain in children
 Constipation
 Common, treatable cause of
acute abdominal pain
 Pain may be severe
 Nausea or satiety may be
seen but other symptoms
are rare
 Rarely, emesis
 Fever is not due to
constipation
 Often a chronic problem
 Stool pattern, number and
character history more
accurate than x-ray
 Rectal vault may be full
 May have fecal incontinence
 Treatment varies depending
on age and degree
 Functional abdominal pain
 More often recurrent
 Initial presentation or
intercurrent illness may
present acutely
 Usually at umbilicus or
epigastric area
 Gait is usually normal
 Psychosocial features are
varied; somatization usually
not appreciated by patient
or family
 May be associated with
diarrhea or constipation
 May have other features of
somatization
57
Acute Abdominal Pain in Children:
Extra-abdominal etiologies

 Myocarditis and other cardiac etiologies

 Pneumonia
 Streptococcal pharyngitis
 Diabetic ketoacidosis
 Sickle cell disease
 Vaso-occlusive episodes
 Splenic sequestration

 Meningitis

58
 Summary
Acute Abdominal Pain in Children
 Early symptoms & signs of critical conditions can be
non-specific

 Bilious vomiting concerning for intest. Obstruction

 Consider a broad differential

 History & Exam most important

 Thoughtful use of lab tests and imaging

 Use Bayes’ principles; go with the evidence

 Thanks
Any Questions?
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