PAEDIATRIC

Acute abdominal emergencies in childhood

Simon E Kenny

couch. Often the child picks up parental anxieties and attempts should be made to calm their fears. The abdominal examination is often best performed in an unorthodox manner. Examination of the child on a parents lap or when he is standing up often feels safer for the child and allows clinical signs to be detected. A useful strategy with an uncooperative child is to defer examination: the fretful, tearful child in the emergency room is often more cooperative on a calm ward in a comfortable bed. Play specialists can be invaluable when assessing children and if any invasive procedures are needed. Other examinations Respiratory and ENT examinations should be performed because these are common sites of referred pain. Rebound tenderness should not be sought in the presence of localized tenderness and guarding. It is mandatory to examine the inguinal region and scrotum in boys to avoid missing strangulated herniae and testicular torsion respectively. Digital rectal examination is a contentious issue; the balance between clinical information gained versus trust lost is such that many do not practise this procedure in the evaluation of children with abdominal pain. Rectal examination may have a role in conditions such as constipation and some cases of complex appendicitis, anorectal anomalies and Hirschsprungs disease.

Abstract
Abdominal pain is a ubiquitous experience during childhood and a common presenting complaint to secondary health care facilities. Amongst the large caseload are a number of serious and / or life-threatening conditions. In this article an approach to history and examination, initial management, diagnostic categories, modes of investigation, and treatment are discussed. Common and serious causes of abdominal pain in children are discussed. The clinical skills required to differentiate between them should not be underestimated.

Keywords acute abdominal pain; appendicitis; children; paediatric

surgery

Initial management History and examination

Evaluating a child with abdominal pain is a challenge and a good relationship with the child and parents is essential. Successful evaluation requires patience and often deviates from the normal pattern of history-taking and examination. General principles Addressing the child whenever possible and allowing him time to answer questions is important; questions should give the child several options without biasing his choice of answer, for example:  Is the pain getting better, worse or staying the same?  Is the pain bad all the time or does it come and go? Showing interest in the child often helps his condence. History-taking should be age-related; a tactful gynaecological and sexual history should be taken where appropriate (this may be best achieved with the parents absent and a nurse present). Care should be taken to characterize the colour of any vomitus. Dark-green, bilious vomiting is a surgical problem until proven otherwise. Bloody mucus in the stool suggests a surgical cause (although it can also be found in bacterial gastroenteritis). Abdominal examination No information can be obtained by attempting to examine the abdomen of a crying child who is pinned to the examination Initial evaluation involves assessment of airway, breathing, circulation (ABC) protocol. In the shocked or listless child, 100% oxygen via a rebreathing circuit should be given with continuous pulse oximetry. Intravenous or intraosseous access should be obtained if there is shock or dehydration: initial crystalloid infusions should be given as a bolus of 10 ml/kg. It is not uncommon for children to require >40 ml/kg of intravenous uids: establishing an adequate capillary rell time (<2 seconds) should be used as an endpoint. Analgesics should be given via oral, rectal or intravenous routes as appropriate: intramuscular morphine should be avoided (especially in the presence of shock). Physical signs of peritonitis are not masked by the administration of opiate analgesia and analgesia should not be withheld pending surgical assessment. One must know what analgesia has been given when assessing a child (or assessing progress). Investigation Serum biochemistry should be obtained if there has been signicant vomiting. Liver function tests and serum amylase should be obtained if there are clinical indications of hepatobiliary disorders or pancreatitis. Capillary or arterial blood gases are useful in the assessment of associated acidbase disorders and their response to treatment. Metabolic acidosis is common in hypovolaemic shock, but failure of the acidosis to respond to uid resuscitation and supportive measures may suggest ischaemic or infarcted bowel (especially in the presence of raised levels of lactate in serum). C-reactive protein levels and white cell count with differential can be of use as discriminatory factors in cases where the diagnosis is uncertain. Intravenous antibiotics (e.g. cefotaxime, metronidazole) should be given preoperatively to children with obvious peritonitis.
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Simon E Kenny is a Consultant Paediatric Surgeon and Urologist at Alder Hey Childrens Hospital, Liverpool, UK. Conicts of interest: none declared.

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Common causes of abdominal pain (Table 1)

Appendicitis Appendicitis can be difcult to diagnose in the very young and neurologically impaired. Young children invariably present late with appendicitis; virtually all children aged <5 years have perforated their appendix at presentation. Abdominal signs can be subtle and true peritonism may be absent. Abdominal distension is common. A similar situation may occur in the neurologically impaired. Ultrasound and/or CT may provide useful diagnostic information in equivocal cases and prevent unnecessary surgery. Careful assessment of dehydration or shock is essential, and vigorous uid resuscitation and antibiotics should be given intravenously (if necessary). The choice between an open or a laparoscopic approach to appendicectomy in children is controversial, although a recent systematic review concluded that laparoscopic appendicectomy was likely to be benecial when performed by an experienced laparoscopist. In children aged >5 years, persistent guarding in the right iliac fossa on repeated clinical examination is the key to diagnosis. Complex appendicitis can cause pyuria or diarrhoea which can mislead the inexperienced surgeon. Non-specic abdominal pain About 60% of all children admitted to hospital in the UK with abdominal pain will be diagnosed as having non-specic abdominal pain. This category encompasses all children in whom no cause is diagnosed and who recover with no specic treatment. Anorexia is common (although less so than with appendicitis); most other symptoms are less prominent. Tenderness of the right iliac fossa may be present, although guarding and rebound are rare. Mesenteric adenitis Vague central or generalized abdominal pain often accompanies viral infections of the upper respiratory tract. The pain is

thought to result from a concomitant mesenteric lymphadenopathy. A history of vomiting is rare and children may complain of headache or sore throat. Examination may reveal a high pyrexia (>38.5C), cervical lymphadenopathy and diffuse abdominal tenderness. Management is symptomatic; if the diagnosis is in doubt, surgical exploration is indicated. Gastroenteritis Gastroenteritis typically presents with non-bilious vomiting and colicky central abdominal pain, often accompanied by diarrhoea. There may be dehydration and pyrexia. Abdominal tenderness is rare, although distension can occur. The presentation of bacterial enterocolitis can be dramatic, with high fever, listlessness, signs of hypovolaemia, abdominal distension and bloodstained diarrhoea. Occasionally, it can be difcult to differentiate between bacterial enterocolitis and a surgical cause; observation usually answers the question. Infections of the urinary tract Infections of the urinary tract are common in children, affecting 1.5% of boys and 5% of girls by the age of sixteen years in the UK. Usual symptoms are of lower abdominal or loin pain, dysuria, pyrexia and vomiting. Children with acute pyelonephritis may have renal angle tenderness. Infections of the urinary tract are typically secondary to ureterovesical reux (although acute obstruction of the urinary tract or stones should also be considered). Diagnosis is best made on nding bacteria on microscopic examination of a fresh specimen of urine followed by culture. Urine dipsticks can screen for potential infection. Trimethoprim is suitable as a rst-line antibiotic. Ureterovesical reux can lead to recurrent infections, hypertension and end stage renal failure. Children with recurrent infections, atypical symptoms / signs or family history of renal disease plus the very young will require further investigation with a renal tract ultrasound and a 99m technetium dimercaptosuccinic acid scan. (Ref: NICE guideline) Constipation Childhood constipation (the infrequent painful passage of stools, with or without soiling) is extremely common. It may be accompanied by colicky abdominal pain and soiling due to overow incontinence. Abdominal examination shows minimal tenderness and usually a rm faecal mass in the rectosigmoid or descending colon. Most cases are idiopathic, but constipation may be a presenting feature of a pelvic mass, anorectal pathology or a neurological decit. Therapy for idiopathic constipation should focus on clear explanation of the problem, with advice on diet, toileting, and the use of laxatives. Ovulatory/perimenstrual pain A menstrual history should be taken in all adolescent girls. The timing of the pains is important (especially the mittelschmertz associated with mid-cycle ovulation). Examination may show pelvic tenderness. A sexual history should be taken because pelvic inammatory disease and pregnancy may need to be excluded. Abdominal ultrasound can be useful in assessing ovarian pathology. If a large ovarian cyst is encountered at laparotomy, it should be drained and the ovary conserved (unless there is concern that
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Common causes of abdominal pain in childhood Appendicitis  Gastroenteritis Infection of the urinary tract Constipation  Mesenteric adenitis  Ovulatory/perimenstrual pain  Non-specic abdominal pain Serious causes of abdominal emergencies in childhood Appendicitis Intussusception  Malrotation/volvulus  Bleeding Meckels diverticulum  Bacterial enterocolitis  Ovarian/testicular torsion  Pancreatitis  Obstruction/strangulated hernia Table 1

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PAEDIATRIC

there may be a tumour). Laparoscopy is a useful investigative and therapeutic tool in the case of ovarian pathology. Intussusception In an intussusception, a segment of bowel (usually ileum) telescopes into distal bowel (usually colon), causing obstruction and compromising blood ow to the intussuscepted bowel (Figure1). Intussusception is most common between 2 and 24 months and most cases are idiopathic. In older children, a pathological leadpoint, such as a Meckels diverticulum (see below) or lymphoma of the small bowel may be found. Typically, infants experience colicky abdominal pain and vomiting. They draw their legs up and look pale. Rectal bleeding with mucus (redcurrant jelly) is a late sign. Most disease and death from intussusception arises from delays in diagnosis. Between bouts of colic, infants are quiet, but irritable, with evidence of hypovolaemia. A mobile abdominal mass may be palpable. Some children present atypically with lethargy but no colic; mild abdominal tenderness and mucoid rectal blood may be the clue to the cause. Vigorous uid resuscitation and supplemental oxygen is often required. The diagnosis can be conrmed by ultrasound scanning. Treatment is commonly by air reduction through a rectal Foley catheter under controlled pressure conditions managed by an experienced radiologist. Children must be adequately resuscitated and monitored by staff trained in paediatric life support during these procedures. Possible complications include intestinal perforation and tension pneumoperitoneum. Enema reduction is contraindicated in refractive shock or in children with signs of peritonitis. In a minority of patients, reduction is unsuccessful and open surgical reduction or resection is needed. Mid-gut malrotation Malrotation is where the intestine is not xed normally in the abdomen. The common form is midgut malrotation in which there are two components: the third part of the duodenum lies to the right of the vertebral column (instead of crossing to the left) and the caecum lies in the upper abdomen (adjacent to the duodenum). The mesentery of the midgut is not attached

in the usual manner across the posterior abdominal wall, but is freely suspended on a narrow pedicle from the base of the superior mesenteric artery. It can twist at any time. A volvulus of >270 may lead to midgut infarction. In the infant, acute midgut volvulus presents with dark-green bilious vomiting, abdominal distension and tenderness and rectal bleeding. With progressive midgut ischaemia, the infant rapidly deteriorates with hypovolaemia and metabolic acidosis. A plain radiograph of the abdomen shows duodenal obstruction with sparse or absent distal bowel gas. Urgent laparotomy is required after rapid resuscitation and the volvulus is derotated to permit restoration of blood ow. The bowel is placed in the non-rotated arrangement and the mesentry broadened (Ladds procedure). The risk of acute volvulus is highest during the neonatal period, but malrotation may remain asymptomatic for years.

Figure 1 Operative ndings of intussusception where the a ileum is telescoped into large bowel. The caecum and appendix are visible following partial pneumatic reduction. Also seen are the b caecum, c appendix and d dilated proximal intestine.

a Operative ndings of a Meckels diverticulum (red arrow). The ileum is represented by the white arrows. b Positive 99mtechnetium scan (lateral view) demonstrating a Meckels diverticulum (red arrow). The white arrow represents the gastric mucosa. Figure 2

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PAEDIATRIC

Recurrent volvulus may present at any age and must be suspected when there is a history of chronic intermittent abdominal pain with or without vomiting. A radiological upper gastrointestinal contrast study is usually diagnostic. Meckels diverticulum A Meckels diverticulum (Figure 2) is an embryological remnant caused by failure of regression of the vitellointestinal duct that normally occurs between the fth and seventh week of gestation.

Usually, a Meckels diverticulum is asymptomatic and found incidentally at laparotomy/autopsy. However, it can present with bleeding, intussusception, obstruction and a clinical picture similar to appendicitis. Gastric or pancreatic mucosa is present in >50% of symptomatic Meckels diverticula and is often responsible for the associated bleeding. 99mTechnetium scans label heterotopic gastric mucosa and are 85% sensitive, 95% specic and 90% accurate in the diagnosis of a bleeding Meckels diverticulum. A symptomatic Meckels diverticulum should be excised.

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