Abdominal Pain and vomiting in Children

Erick Kan

Abdominal Pain
Frequent reason for children to be taken to the doctor The causes are many and diverse
Surgery Medical origin

Abdominal pain in the first 3 months of life

Surgical causes ;
Malrotation with volvulus
Vomiting, abdominal pain, abd distention and constipation

Medical
Infantile colic
Common in the first few weeks of life The cause is poorly understood Infants; screaming, draw up the legs and is unable to be comforted No vomiting, normal bowel action, thriving well infants The colic almost invariably disappears by the fourth month of age Treatment is supportive

Gastro oesophageal Reflux

Abdominal pain later in the first year

Intussusceptions
Distal ileum telescopes into adjoining distal bowel, resulting intestinal obstruction More likely in the infants 3 18 months Suddenly develops periodic screaming attacks of pain and vomiting, The infants are pale, lethargic and unwell Congestion of the intussusceptum may lead to passage of bloodstained or red currant stool A vague mass may be felt in the right or left upper quadrants of the abdomen X ray shows unusual bowel gas distribution or features of obstruction Barium enema must be performed unless the child has peritonitis Treatment ; Gas enema is the treatment of choice Surgery : Enema reduction has failed Clinical evidence of necrotic bowel : peritonitis, sepsis Evidence of pathologic lesion DD; gastroenteritis, volvulus, band from Meckel diverticulum,Hernia strangulata

Acute abdominal pain in older children

Children in this age often present with abd pain without no specific cause is found Constipation and mesenteric adenitis are probably the most common non surgical causes

Acute abdominal pain in older children

Acute appendicitis
May occur at any age, but rare under 5 years of age The most important and consistent features is localised abd pain. The pain may be intermitten and colickly initially, situated in the epigastrium or periumbilical region, but soon shifts to the right iliac fossa. Pain in the right iliac fossa Vomitting, temp slightly eleveted PE : Tenderness and guardiang localised to the right iliac fossa Rectal examination is only indicated if a pelvic appendix or pelvic collection is suspected Lab and radiology are rarely helpful DD; Mesenteric adenitis (meckel diverticulitis), strangulated inguinal hernia, renal colic,pyelonephritis, HSP,constipation, cholecistitis, pancreatitis and UTI etc

Acute abdominal pain in older children

Gastro Oesophageal reflux
Common in infancy, sometimes persist into later childhood Symptoms of belching, acid regurgitation and intermittent vomiting Sign : substernal and epigastric pain Dx : Oesophageal PH monitoring, Oesophagoscopy and biopsy Tx : Medical : H2 receptor antagonis
Surgical correction : Fundoplication

Recurrent abdominal pain in children

Personality of the child Family environment Medical ; inflammatory bowel disease,malabsopstion Surgery

Vomiting in the neonatal period

In the early weeks of life, many normal newborn regurgitate after feeds.
Medical
Cerebral hypoxia Subdural hematoma Hypoglicemia Systemic infection Malrotation Renal disease Adrenal insuficiency Inborn metabolic error

Vomiting in the neonatal period

Surgery (Bowel obstruction) :
In doudenal obstructions, vomiting appears early and is bile stained Obstruction beyond the duodenum,vomiting commence slightly later and is associated with abd distension

TRIAD
Bile stained vomiting Failure to pass meconium Abdominal distension

Vomiting in the neonatal period

Surgery (CAUSES)
Neonatal bowel obstruction Hirschprungs disease Necrotising enterocolitis Meconium ileus Malrotation with volvulus Atresia - duodenal atresia/stenosis, jejunal atresia, ileal atresia oesophageal atresia Imperforate anus Others intestinal duplication, antral webs etc

Vomiting in infancy
A common non specific symptom in infancy Infection Malabsorption Gastroenteritis Intussusception (invagination) Strangulated inguinal hernia

Vomiting in infancy
GER :
The most common cause of vomiting in infancy These infants usually thrive well, PE reveals no abnormality Dx is made from hystory, can be confirm by barium swallow or continous 24 hours oesophageal PH monitoring Occasionaly, the child may fail to thrive or suffer repeated aspiration

Vomiting in infancy
Pyloric stenosis
The onset is sudden, between the second and sixth week of life. The vomiting is forceful and rapidly become projectile The vomitus is not bile stained, but may contain altered blood The dx is made clinically by feeling the thickened pylorus (pyloric tumor) in the midline epigastrium Pyloric stenosis can also be shown on Ultrasound and barium meal Tx ; Pyloromyotomy

Vomiting in Older children

Usually associated with infection The possibility of an intracranial neoplasm should always be considered with a child with unexplained vomiting Migraine ; pallor and vomiting Acute appendicitis and peritonitis Poisoning : vomiting and respiratory and circulatory collapse Psychologycal causes :absence of abnormal physical signs Cyclical vomiting

Management
Establish intravenous access, and measure electrolytes if the patient appears dehydrated, and cultures of blood and stool if potentially septic. Fluid resuscitation may be required (initial bolus 20ml/kg normal saline) Keep the patient fasted until surgical assessment Provide adequate analgesia Place a nasogastric tube if bowel obstruction

Notes
Acute appendicitis must be considered in any child with severe abdominal pain. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical - no laboratory or radiological tests are required.

The peak age for intussusception is 6-12 months. Plain AXR may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflations or barium enema.
Vomiting is rarely due to constipation. Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (eg. family, school issues) need to be considered. These children should be referred for general paediatric assessment.