ABDOMINAL PAIN in the

ABDOMINAL PAIN in the

PEDIATRIC PATIENT





Tim Weiner, M.D.

Dept. of Surgery

University of North Carolina

at Chapel Hill






In General





? Common





problems occur commonly

– intussusception in the infant
– appendicitis in the child


? The


differential diagnosis is age-specific


? In pediatrics most belly pain is non-surgical

– “Most things get better by themselves.
better by morning.”



Most things, in fact, are


? Bilous


emesis in the infant is malrotation

until proven otherwise

? A high rate of negative tests is OK






The History





? Pain





(location, pattern, severity, timing)

– pain as the first sx suggests a surgical problem


? Vomiting


(bile, blood, projectile, timing)


? Bowel habits (diarrhea, constipation, blood,
flatus)

? Genitourinary complaints

? Menstrual history

? Travel, diet, contact history






Diagnosis by Location



gastroenteritis
early appendicitis




biliary

PUD
pancreatitis



spleen/EBV

hepatitis



non-specific

appendicitis
enteritis/IBD
ovarian

colic
early appendicitis



constipation
UTI
pelvic appendicitis

constipation
non-specific
ovary






The Physical Examination





? Warm





hands and exam room


? Try to distract the child (talk about pets)

? A quiet, unhurried, thorough exam

? Plan to do serial exams

? Do a rectal exam






The Abdominal Examination





breath sounds
Murphy’s sign
“sausage”





Dance’s sign
rebound
tender at McBurney’s point
cecal “squish”


hernias
torsion






breath sounds
spleen edge









constipation
Rovsing’s sign






Relevant Physical Findings




? Tachycardia


? Alert


and active/still and silent


? Abdominal rigidity/softness

? Bowel sounds

? Peritoneal signs (tap, jump)

? Signs of other infection (otitis, pharyngitis,
pneumonia)

? Check for hernias






Blood in the Stool




? Newborn
– ingested maternal blood, formula intolerance, NEC, volvulus,
Hirschsprung’s

? Toddler
– anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile
polyps, HUS, IBD


? 2


to 6 years

– infectious colitis, juvenile polyps, anal fissures, intussusception,
Meckel’s, IBD, HSP


? 6


years and older

– IBD, colitis, polyps, hemorrhoids






Blood in the Vomitus




? Newborn
– ingested maternal blood, drug induced, gastritis

? Toddler
– ulcers, gastritis, esophagitis, HPS


? 2


to 6 years

– ulcers, gastritis, esophagitis, varices, FB


? 6


years and older

– ulcers, gastritis, esophagitis, varices






Further Work-up





? CBC





and differential


? Urinalysis

? X-rays (KUB, CXR)

? US

? Abdominal CT

? Stool cultures

? Liver, pancreatic function tests

? (Rehydrate, ?antibiotics, ?analgesiscs)






Relevant X-ray Findings





? Signs





of obstruction

– air/fluid levels
– dilated loops
– air in the rectum?

? Fecalith


? Paucity


of air in the right side


? Constipation






Operate NOW





? Vascular





compromise

–
–
–
–
–

malrotation and volvulus
incarcerated hernia
nonreduced intussusception
ischemic bowel obstruction
torsed gonads


? Perforated


viscus


? Uncontrolled intra-abdominal bleeding






Operate SOON





? Intestinal





obstruction


? Non-perforated appendicitis

? Refractory IBD

? Tumors






Appendicitis





? Common





in children; rare in infants


? Symptoms tend to get worse

? Perforation rarely occurs in the first 24
hours

? The physical exam is the mainstay of
diagnosis

? Classify as simple (acute, supparative) or
complex (gangrenous, perforated)






Incidental Appendectomy





? Can





be done by inversion technique


? Absolute indication
– Ladd’s procedure


? Relative


indications

–
–
–
–
–
–

Hirschsprung’s pullthrough

Ovarian cystectomy

Intussusception

Atresia repair
Wilms’ tumor excision

CDH






Intussusception





? Typically





in the 8-24 month age group


? Diagnosis is historical
– intermittent severe colic episodes
– unexplained lethargy in a previously healthy infant


? Contrast


enema is diagnostic and often

therapeutic

? Post-op small bowel intussusception





The “Medical Bellyache”




?

?

?

?

?

?

?

?

?

?

?

?




Pneumonia

Mesenteric adenitis

Henoch-Schonlein Purpura

Gastroenteritis/colitis

Hepatitis

Swallowed FB

Porphyria

Functional ileus

UTI

Constipation
IBD “flare”

rectus hematoma






Laparoscopy




? Diagnosis

–
–
–
–
–


non-specific abdominal pain

chronic abdominal pain

female patients

undescended testes

trauma


? Treatment

–
–
–
–
–


appendicitis
Meckel’s diverticulum

cholecystitis

ovarian detorsion/excision

lysis of adhesions






The Neurologically Impaired Patient





? The





physical exam is important for non-

verbal patients

? The history is important for the spinal cord
dysfunction patient

? Close observation and complementary
imaging studies are necessary

The Immunologically Impaired

Patient





? A





high index of suspicion for surgical

conditions and signs of peritonitis may
necessitate operation
– perforation
– uncontrolled bleeding
– clinical deterioration


? Blood


product replacement is essential


? Typhlitis should be considered; diagnosis is
best established by CT






The Teenage Female





? Menstrual





history

– regularity, last period, character, dysmenorrhea


? Pelvic/bimanual


exam with cultures


? Pregnancy test/urinalysis

? US

? Laparoscopy

? Differential diagnosis
– mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic
pregnancy, UTI, pyelonephritis






In Summary




“My dear surgeon, beware- haste not,

Pleads the child silently,

Listen to my mother, and then-

Examine and again examine me:

This will improve my lot
And assure you accuracy.”