Acute Abdomen in

Paediatrics
Daniel Raj
 Contents
• Case Study 1
• Case Study 2
• Malrotation/Volvulus
• Incarcerated Hernia
• Pyloric Stenosis
• Intussusception
• Acute Appendicitis
• Hirschsprung Disease
• Testicular Torsion
• Meckel’s Diverticulum
• HSP
Case Study
Case 1
• Patient J , 6 yrs old, NKMI
c/o
1.RIF pain x 2/7
-sudden onset
-colicky in nature
-unable to ambulate d/t pain
2.NBO X2/7
3.Fever
4. Vomiting
5.Reduced oral intake
Examination findings:
General ; Alert,concious,pink,not septic looking,warm
peripheries,hydration good
BP 114/80
HR 136
T 38
SPo2 100%
Per Abdomen
-Soft ,not distended
-Localised guarding at RIF

Other examinations are nil of significance

IX
1. FBC TWC 7.71/Hb 13.1/PLT 355
2. RP Urea 2.9/Creat 35/Na 131/K 4.4/CL 99
3. UFEME- No UTI picture
Imaging
Management
1. Nil by mouth with full maintenance ~ 54ml/hr
2. IV Tramadol 15mg
3. IV Flagyl 112.5 mg( 7.5mg/kg)
4. IV Cefotaxime 750mg (50mg/kg)

Patient subsequently underwent open appendicectomy and was

discharged 4 days post op.
Case 2
Patient A, 1 yr10 m old boy, NKMI
c/o
1.Abdominal distension x 3/7
-episodes of irritability in between distension.
-child then appears calm when the abdomen is less distended
2.NBO x 2/7
3. Not passing flatus
4. Less active than usual
Examination
General: Appear less active,pink,hydration good,not septic
looking,warm peripheries
BP 114/64
HR 116
T 36.5
Spo2 100%
Per Abdomen
-Soft
-Tender at right lumbar
-No palpable mass
-Bowel sounds present

Other examinations are nil by significance

IX
1.FBC TWC 10.3/Hb 10.2/ Plt 354
2.RP Urea 2.1/ Creat 24/ Na 134/ K 3.4
Imaging
Management
1. Nil by mouth with IVD 43CC/hr NSD5%
2. Syr PCM 160 mg QID

Post reduction the child was observed for 48 hours and then was
discharged with TCA
Introduction
Age Surgical Non Surgical
Neonatal -Volvulus/Malrotation -Colic
-Incarcerated Hernia -Milk Allergy
-Pyloric Stenosis -Gastroenteritis
-Intestinal Anomalies -GERD
-Hirschsprung Disease
-Intestinal Perforation
-Trauma
Infancy <2 yrs -Intussusception -Gastroenteritis
-Incarcerated Hernia -Viral Syndromme
-Trauma -Constipation
-Meckel’s Diverticulum -UTI
-Appendicitis -Sepsis
-Tumour
Childhood (2 to 10 yrs) -Appendicitis -Gastroenteritis
-Trauma -Constipation
-Meckel’s Diverticulum -Functional Pain
-Intussuception -UTI
-Tumour -Pneumonia

Adolescence -Appendicitis -Gastroenteritis

-Trauma -Viral Syndromme
-Ectopic Pregnancy -Pneumonia
-Testicular Torsion -Functional Pain
-Tumour
Malrotation with/without Volvulus
• Intestinal malrotation- congenital anatomical anomaly that results
from an abnormal rotation of the gut as it returns to the abdominal
cavity during embryogenesis.
• Volvulus occurs when a loop of intestine twists around itself and the
mesentery that supplies it, causing a bowel obstruction
• Major life threatening condition of malrotation commonly in the first
year of life.
• Leads to total gangrene of the midgut in a few hours.
• Common in the first year of life.
Clinical Features

History Examination
• Vomitting- Non BillousBillous • Septic Looking
• Abdominal distension • Pale
• Blood streaked stool. • Grunting respiration
In older children, • Rigid and discoloured abdomen
• Constant,non colicky abdominal
pain.
 Workup
Blood Ix
•FBC, elevated TWC indicates gut necrosis
•RP,electrolyte abnormalities
•VBG-metabolic acidosis
•GXM
Imaging
•AXR-coffee bean sign, Frimann Dahl sign,
Absent rectal gas
Management
1. Adequate resuscitation in key with IV 0.9% NaCl (10 to 20ml/kg)
2. Reassess circulation,repeat bolus if needed.
3. Insert NG tube and nil by mouth.
4. Urgent Surgical referral.
Incarcerated Hernia
• Abnormal protrusion of intestinal organ via a defect from one
anatomic space to another.
• Incarceration occurs when the hernia cannot be manipulated
(spontaneous or manual) through the defect.
• Risk highest during the first year of life.
 Clinical Features

History Examination
• Irritability • Inguinal or scrotal mass
• Poor feeding • May or may not have overlying skin
• Vomiting changes
Possible differential diagnosis should be excluded,
-Hydrocele
-Undescended testis
-Testicular Torsion
-Inguinal lymphadenopathy
-Inguinal node abcess
-Inguinal/Scrotal trauma
-Orchitis
Management
1. Nil by mouth with IV fluid maintenance.
2. FBC,RP,GXM.
3. Urgent surgical referral for reduction with/without sedation
4. Failure of maneuvre warrants surgical reduction.
Pyloric Stenosis
• Hypertrophy and hyperplasia of the muscular layers of the pylorus,
causing a functional gastric outlet obstruction.
Possible etiologies
• Deficiency of nitric oxide synthase containing neurons
• Abnormal myenteric plexus innervation
• Infantile hypergastrinemia
• Exposure to macrolides
• Lack of exposure to intestinal peptide in breast milk
• Motilin hypersensitivity
Clinical Features
History
• Non-Billous regurgitant
vomiting  Projectile vomiting
(after or towards the end of
feeding)
• Refeeding and hunger
• Constipation
Examination
• Dehydrated
• Failure to thrive
• Loss of weight
• Peristaltic waves from left to
right upper abdomen
• Palpation may reveal and ‘olive’
like structure near the lateral
margin of right rectus muscle.
Management
• FBC
• RP –Hyponatremia,Hypokalemia,Hypochloremia
• VBG-Metabolic Acidosis
• AXR
• Ultrasound-
Pylorus muscle thickness> 3mm
Pylorus length>13 mm
1. Adequate resuscitation based on the child’s hydration status.
2. Maintenance if no significant dehydration and bolus fluid if there are
dehydration.
IV Maintenance for infants up to 1 yr
• Day 1 60ml/kg/day  D10%
• Day 2 80ml/kg/day
• Day 3 100ml/kg/day
• Day 4 120 ml/kg/day 1/5 NS +D10%
• Day 5 to Day 28 150ml/kg/day
• 1 M to 6 M 150ml/kg/day 1/5 NS + D5%
• 6M to 1 Y 120ml/kg/day ½ NS+ D5%
3. Surgical team referral
Intussuception
• A portion of the alimentary tract is telescoped into another segment.
• It is the most common cause of intestinal obstruction between 3 months and 6
years of age.
• Male: Female ratio is 4:1
• Early diagnosis an appropriate surgical therapy reduces the mortality risk by 1 %
• Delayed diagnosis and treatment poses risk of fatality in 2-5 days
Possible Etiologies
• Meckel’s Diverticulum
• Juvenile intestinal Polyp
• Lymphosarcoma
• Complication of HSP
Clinical Features
History Examination
• Abdominal pain: • Irritable in between episodes of pain
-Intussusception is colicky, severe, and intermittent
• Pale
-The child may kick up into air with legs drawn to
abdomen during the colic. • Diaphoretic
-Calm in between episodes of pain.
• Right hypochondrium sausage-shaped
• Vomiting nonbilious Bilious( Obstruction)
mass and emptiness in the right lower
• Red currant jelly stools quadrant (Dance sign) (best palpated
• Lethargy between spasms of colic, when the
• Fever infant is quiet)
• Rigid and distended abdomen
• Involuntary guarding
Management
• FBC Leukocytosis
• RP electrolyte abnormalities
• AXR  may show absence of bowel pattern
• USG
- has a sensitivity and specificity of 97.95% to 97.8 %
- Typical appearance include target and pseudokidney signs and/or
crescent in a doughnut sign
• Contrast enema- barium or air
-Quick,reliable and has the potential to be therapeutic
-Caution when intestinal perforation or gangrene in suspected
-Air insufflation has advantage due to better control over colonic pressure
and less risk of barium spillage in the event of perforation
1. IVD drip maintenance
2. Insert RT
3. Pain Management with IV Paracetamol 15mg/kg
4. Urgent surgical referral for reduction
5. Admission to ward for observation for 48 hours
Acute Appendicitis
• Acute inflammation and infection of the vermiform appendix.
• Appendix acts as a reservoir for gut flora to aid intestinal immunity.
• Arises from the caecum with the tips assuming anatomic position in
the pelvis, retrocecal, or extraperitoneal areas.
-Gangrenous appendix has the risk of leading to perforation
-The result of perforation leads to the release of inflammatory fluid and bacteria into the
peritoneal cavity causing peritonitis
-The contents of inflammatory fluids+bacteria may wall up and form an abcess
Clinical Features

History Presentation
• Anorexia • Child may appear in pain
• Vague periumbilical pain • Lethargic
• Migratory pain from periumbilical • Septic looking
to RIF • Tachycardia
• Fever • Dehydration
• Vomitting • Tenderness over RIF
• Diarrhea • Rebound tenderness
• Voluntary guarding
• Rovsing’s sign for peritonism
• Psoas sign- high index of suspicion for retrocecal appendicitis
• Obturator sign-high index of suspicion for pelvic eppendicitis
Management
• FBC  Leukocytosis
• RP electrolyte abnormalities, pre-renal AKI in dehydration
• UFEME exclude UTI,pyelonephritis
• CXR to exclude basal pneumonia, air-under diaphragm may suggest
perforated appendicitis
• AXR Exclude intestinal obstruction,functional cause like
constipation
• USG may show
-Dsitended appendix
-Collections(hypoechoic areas) surrounding the appendix
-Thickened appendicular wall
-Perforations
1. Nil by mouth
2. Initiate bolus of patient appear dehydrated (10-20ml/kg) over 1
hours
3. IVD Maintenance if hydration is fair
4. Pain management with IV Paracetamol 15mg/kg
5. Antibiotics
-IV Cefazolin 30mg/kg every 4 H or IV Unasyn 50mg/kg every 2H
6. Urgent Surgical referral
Hirschprung Disease
• Developmental disorder characterized by the absence of ganglia in the distal colon, resulting in
a functional obstruction.
• High index of suspicion in newborn who fails to pass meconium within 24 to 48 hrs of birth.

Divided based on anatomic involvement

1.Short segment disease -75%
-rectal and distal sigmoid colonic involvement only
2.Long segment-15%
-extending to splenic flexure/transverse colon
3.Total Colonic Aganglionosis-7.5%
-extension to small bowel
4. Ultrashort
-3 to 4cm anal sphincter
Clinical Features

History Examination
• Delayed meconium passage • Dehydration
• Chronic constipation since birth • Distended Abdomen
• Abdominal distension
• Bilious vomiting
• Poor feeding
• Failure to thrive
• Diarrhea
Management
• FBC
• RP  look for AKI d/t dehydration
• AXR may show dilated bowel
• Fluoroscopy in some centers may aid the diagnosis and the length of
bowel involvement
• Definitve diagnosis via full thickness rectal biopsy with hisopathologic
findings consistent of aganglionosis.
1. Adequate hydration to correct dehydration or electrolyte disorders
2. Insertion of RT
3. Urgent Surgical referral
Testicular Torsion
• A testis torts on the spermatic cord resulting in the cutting off of blood supply

Divided based on age groups;

1.Extra-Vaginal
-At the level of inguinal ring
-Seen in neonates
2.Intra-Vaginal
-More common variety d/t bell clapper deformity
 Bell-Clapper deformity

-Abnormally high attachment of the tunica vaginalis to the spermatic

cord, allowing the testis and adjacent epididymis to move more
freely
-Risk of twisting around the spermatic cord.
-Seen in 5-16% of males and is bilateral in 66-100%.
• Torsion may impede venous outflow in the event of <360 degrees
• Gradual increase in intratesticular pressure and resistance may result
in additional twisting> 360 degrees
• May lead to arterial obstruction and testicular ischemia.
Clinical Features
History
• Abrupt onset of testicular pain
• Scrotal swelling
• Nausea and vomiting
• Precipating factors of prior genital
trauma or sudden postion change
Examination
• Appear in pain
• Irritable
• Enlarged,tender testicle that rides
higher in a transverse lie compared
to the other testicle
• Absence of cremasteric reflex
• Phren’s sign-negative
*Elevation of the affected testis may
not relieve the pain.
TWIST score
• A scoring system used to stratify the risk or torsion clinically decreasing the need
of USG
Testis swelling (2 points)
Hard testis (2)
Absent cremasteric reflex (1)
Nausea/vomiting (1)
High-riding testis (1)

Low risk 0-2

Intermediate 3-4
High risk 5-7
• Rapid diagnosis and surgical intervention minimizing the risk of
orchidectomy

• <6 hours: ~100% salvage

• 6-12 hours: 50%
• 12-24 hours: 20%
• USG may aid the diagnosis
-The whirlpool sign refers to a lamellated mass with concentric layering
of the testis representing the coiled spermatic cord components
-Alteration of blood flow ,elevated RI > 0.75
1. FBC
2. RP
3. Nil by mouth
4. Pain management with IV Paracetamol 15mg/kg
5. Urgent surgical referral for exploration and detorsion
Meckel’s Diverticulum
• Congenital intestinal diverticulum due to fibrous degeneration of
the umbilical end of the omphalomesenteric (vitelline) duct that
occurs around the distal ileum.
• 2% of the population
• 2% are symptomatic
• Common in children <2 yrs
• Twice common in males
• Meckel’s diverticulum is 2 feet from the ileocecal valve
• 2 types of mucosal lining
Clinical Features

History
• Lower Intestinal Bleeding • Dehydrated
• Hematochezia • Pallor
• Abdominal pain • Shock
• Tachycardia
• Distended,tender abdomen
• Hyoactive/Hyperactive bowel
sounds
• Palpable Abdominal pass in I/O
Management
• FBC HB levels
• RP  electrolyte abnormalities
• VBG Metabolic acidosis
• GXM
• AXR
-May show features of intestinal obstruction
• Barium study
• Technetium 99m
• CT
• Endoscope
1. Adequate resuscitation with bolus of NS 10-20ml/kg in the event of
shock,repeated if needed.
2. Blood Transfusion in acutely bleeding patient
3. Antibiotics
-IV Cefazolin 30mg/kg every 4 H or IV Unasyn 50mg/kg every 2H
1. IV Paracetamol 15mg/kg for pain management
2. Urgent Surgical referral
Henoch Schoenlein Purpura
• Acute immunoglobulin A (IgA)–mediated disorder characterized by a
generalized vasculitis involving the small vessels of the skin, the
gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the
lungs and the central nervous system (CNS)
• The circulating complexes of IgAV may deposit to end organ and may
result in a sequalae of events
 Etiologies (Infection)
• Group A streptococcal infection (most common)
• Infectious mononucleosis
• Subacute bacterial endocarditis
• Hepatitis
• Hepatitis C–related liver cirrhosis
• Mycoplasma infection
• Campylobacter enteritis
• Helicobacter pylori infection
• Yersinia infection
• Shigella infection
• Salmonella infection
• Brucellosis
• Legionella species
• Parvovirus
• Adenovirus
• Epstein-Barr virus (EBV) infection
• Varicella-zoster virus (VZV) infection
• Rotavirus
Etiologies( Vaccination)
• Typhoid and paratyphoid A and B
• Measles
• Yellow fever
• Cholera
Etiologies (Environmental exposure)
• Drugs (eg, ampicillin, erythromycin, penicillin, quinidine, quinine,
losartan, and cytarabine)
• Foods
• Horse serum
• Cold temperatures
• Insect bites
Clinical Features

History
-Prodromes
•Headache
•Anorexia
•Fever
-Post prodrome
•Rashes(legs)
•Abdominal pain
•Vomiting
•Joint pain
•Blood streaked stools
GI manifestations
-Manifests about 1 week after the appearance of the rash
•Nausea
•Vomiting
•Diarrhea with gross or occult blood
•Hematemesis
•Intussusception - This occurs in 2-3% of patients, and the lead point can be
a submucosal hematoma
•Bowel infarction, with or without perforation
•Ileal stricture
•Ileus with massive GI hemorrhage
•Acute appendicitis
Management
• FBCThrombocytosis
• RP  elevated Urea/Creatinine levels may indicate renal involvement
• UFEME
• ESR
• GXM
• AXR Helpful in the diagnosis of intestinal obstruction
• USG Intussuception
1. Adequate hydration with bolus fluids or maintenance
2. In the event of acute GI hemorrhage,blood transfusion is warranted
3. Pain management with IV Paracetamol 15mg/kg
4. Referral to surgical team in the evidence of intussusception
References
• Tintinalli's Emergency Medicine: A Comprehensive Study Guide,
9eJudith E. Tintinalli, O. John Ma, Donald M. Yealy, Garth D. Meckler,
J. Stephan Stapczynski, David M. Cline, Stephen H. Thomas
• Paediatric Protocols 4th edition
• https://radiopaedia.org/articles/meckel-diverticulum-3?lang=us
• https://radiopaedia.org/articles/testicular-torsion?lang=us
• https://radiopaedia.org/articles/meckel-diverticulum-3?lang=us
• National Microbial Guideline 2009