PBQ

ACUTE
ABDOMINAL
PAIN
DR NAING NAING OO
SENIOR LECTURER
 EVALUATION
HISTORY
● Pain in young children may present with intermittent unexplained screaming.
● Pallor and screaming are suggestive of intussusception.
● Older children may point to the site of pain.
● Pain migrating from periumbilical area to the right iliac fossa suggests
appendicitis.
● Sometimes, children experience referred abdominal pain with lower lobe
pneumonia.
● Blood in the stool is a serious sign and may indicate intussusception, but also
occurs in inflammatory bowel disease and  Henoch-Schönlein purpura and some
types of gastroenteritis.
● It is important to ask about associated features such as vomiting, diarrhoea,
recent viral infection, joint or urinary symptoms.
● Loss of appetite (anorexia) is a particular feature of appendicitis.
● Bile stained vomiting is highly suggestive of small bowel obstruction
 EXAMINATION

● Examination should include an assessment of how ill the

child looks and measurement of pulse and capillary refill time
and temperature.

● The abdomen should be palpated very gently at first, while

watching the child’s face for sign of pain.

● Signs of peritonism are a reluctance to move, rebound

tenderness, guarding and rigidity.

● In mesenteric adenitis, there is often palpable

lymphadenopathy elsewhere.
INVESTIGATION AND THEIR SIGNIFICANCE

Leucocytosis: Acute appendicitis

FBC UTI

Nitrite + ve in UTI
Haematuria sometimes in HSP Urine Dip

Urine Microscopy and Pyuria and presence of

organisms -- UTI
Culture
Dilated bowel loops: Intestinal obstruction Abdominal
Abnormal gas pattern: Intussusception
Faecal loading: constipation radiograph
INVESTIGATION AND THEIR SIGNIFICANCE

Abdominal To exclude renal tract abnormalities

Useful in dx of Intussusception
USS
For diagnosis and treatment of Ba enema and
Intussusception
air enema
May be elevated in infection and
CRP and ESR inflammatory bowel disease
ACUTE
APPENDICITIS
DR NAING NAING OO
SENIOR LECTURER
PRESENTATION
● 3 - 4 in 1000 children

● Can present at any age especially beyond 5-year-of

age

● Difficult to diagnose in very young children.

● In older children, pain is typically periumbilical and

moves over a few hours to the right iliac fossa due to
peritonitis.

● Often constipation, occasionally diarrhoea and

vomiting.

● Low grade fever.

 INVESTIGATION &
TREATMENT
● FBC: Leucocytosis and neutrophilia

● Urine: to exclude Infection.

● X’ray Abd: not helpful

● CT scan or USS: diagnosis is doubted

suspected appendicular abscess.

TREATMENT

● Appendicectomy: can be performed laproscopically

and excellent prognosis.

● If peritonitis has occurred, severe illness and

adhesion may later cause bowel obstruction
INTUSSUSCEP
TION
DR NAING NAING OO
SENIOR LECTURER
INTRODUCTI
ON
● Invagination of a dilated segment of bowel into an
adjacent proximal segment.

● Blood supply to the intussuscepted bowel is

compromised and will become necrotic if not
reduced rapidly.

● Usually occurs proximally to the ileo-caecal valve.

● Most common abdominal emergency in early

childhood.

● Most common 6 - 9 months of age

● Male > Female

● May have preceding viral illness.

MCQ

Association: Meckel’s diverticulum

HSP

Intestinal polyps

Lymphoma

Cystic fibrosis

inflamed Peyer’s patches

 CLINICAL FEATURES
● Previously healthy or preceding viral illness.
●  Pain: Sudden onset,
severe intermittent cramping pain lasting seconds to minutes.
pallor
● Child draws their knees up.
●  During the time in-between attacks lasting between 5 to 30 minutes, the child may be
well or quiet.
●  Vomiting – Early reflex vomiting consists of undigested food but if the child presents
late, the vomiting is bilious due to obstruction.
● Abdominal distension (late sign), abdominal tenderness, sausage shaped abdominal
mass
● Stools- Initially normal, then become dark red and mucoid (“redcurrant jelly”).
● Well- looking/drowsy/dehydrated/fitting (due to hyponatremia) depending on the
stage of presentation.
INVESTIGATI
ON
PlainX’ray Abdomen: signs of small bowel
obstruction (fluid levels, dilated loops of small
bowel)

Absence of caecal gas,

paucity of bowel gas on the right side

Abdominal USS: Useful diagnostic tool

target sign on transverse section

pseudo kidney signs on

longitudinal section

Air enema: therapeutic as well as diagnostic

 OSCE. P1
USS abdomen
 OSCE. P1
USS Abdomen
 OSCE. P1
Barium Enema
 MANAGEMENT
Resuscitation Non-operative
• 20ml/kg fluid N/S bolus if needed. • reduction
 Should be attempted in most patients,
successful reduction rate is about 80-90%.
• Do NOT proceed to hydrostatic reduction or
surgery till fully resuscitated. • Hydrostatic reduction with saline under
ultrasound guidance
• Close monitoring of vital signs and urine
output. • Air/Oxygen reduction

• Antibiotics and inotropes may be required if • Barium enema reduction

the child is septic.

• Nil by mouth, nasogastric tube, IV fluid of

normal saline + 5%DW
 Contraindication to enema reduction –IndicationsMCQ + P1
for Surgery

Failed non-operative
 Peritonitis and Bowel Perforation
reduction.

Severe Shock
 Bowel Perforation.
 

 Neonates or children more

than 4 years old (relative
 Small bowel Intussusception.
contraindication)

 History more than 48 hours  Suspected lead point.

RECURRENCE

 Rate: 5-10% with lower rates after operative

reduction.

 Success rate for non-operative reduction in

recurrent intussusception is about 30-60%.

Successful management of intussusception

depends on high index of suspicion, early
diagnosis, adequate resuscitation and prompt
reduction.
 MESENTRIC ADENITIS

● Caused by inflammation of intra-abdominal lymph nodes

following an upper respiratory tract infection or gastroenteritis.

● Enlarged nodes cause acute pain which can mimic appendicitis,

but there is no peritonism, or guarding and there may be an

evidence of infection in the throat or chest.

● It is a diagnosis of exclusion.

● Tx: simple analgesia

OTHER SURGICAL CAUSES OF ACUTE
ABDOMINAL PAIN

OVARIAN CYSTS

● can be present even in pre-pubertal children.

● Present in 20% of teenage girls.

● Usually asymptomatic, but can cause severe pain with torsion and rupture or

bleeding.
OTHER SURGICAL CAUSES OF ACUTE
ABDOMINAL PAIN

Volvulus

● Torsion of the mal-rotated intestine.

● Present with severe abdominal pain and bilious vomiting.

● Tx: urgent surgery: untwist the volvulus

treat the underlying malrotation.

● If missed, bowel may get infarction

OTHER SURGICAL CAUSES OF ACUTE
ABDOMINAL PAIN

RENAL, URETERIC AND BILIARY STONES

● Severe colicky pain.

● Relatively rare in childhood unless there is an underlying metabolic or haemolytic

disorders.
 NON-SURGICAL CAUSES OF ACUTE
ABDOMINAL PAIN

● Gastroenteritis: colicky abdominal pain.

● In sexually active girls, D/Dx – pelvic inflammatory disease and ectopic pregnancy

A pregnancy test and USS indicated.

● UTI: abdominal pain more than dysuria

● DKA: abdominal pain and vomiting

● Lower lobe pneumonia

● HSP: abdominal pain due to widespread vasculitis.

● Abdominal pain is common symptoms of anxiety and school refusal.

DIFFERENTIAL DIAGNOSIS OF ILIAC FOSSA PAIN

Mesenteric adenitis HSP

Inflammatory bowel
Gastroenteritis
disease

Constipation Ovarian pain

UTI and pyelonephritis Ectopic pregnancy

REFERENCE

01
• Paediatric Protocol for Malaysian Hospital 4 th
edition

02
• Concise Peadiatrics textbook, 2nd edition,
Rachel Sidwell

03
• Paediatrics at a Glance, 3rd edition, Lawrence
Miall
THANK YOU