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Abdominal pain in children

Madesa Espana, MD
Pediatric EM Section
St. Josephs Regional Medical
Center

Abdominal pain: evidence-based


data

Incidence
5 % of patients presenting to the pediatric clinic
and ED (2 12 years old, <72 hours duration)

1% of patients with abdominal pain had surgical


intervention
84 % of patients were diagnosed to have

URI and/or Otitis Media


Pharyngitis
Viral syndrome
Abdominal pain or uncertain etiology

Gastroenteritis

Acute febrile illness

Abdominal pain: evidence-based


data

Incidence

7.4% had return visits

1% had treatable medical conditions


0.3% needed surgical intervention on
subsequent visits

Abdominal pain: evidence-based


data

Incidence

1.7 % were hospitalized


Diagnoses when abdominal pain was first complaint

Appendicitis
Abdominal pain of uncertain etiology

Intussusception

Abdominal adhesions
Gastroenteritis

Acute Febrile Illness

Pyelonephritis
Sickle cell painful crisis

Henoch-Schonlein purpura

Abdominal pain: evidence-based


data
Incidence

1.3 % were hospitalized


Diagnoses when abdominal pain was second complaint
Gastroenteritis/Dehydration
Abdominal abscess after appendectomy
Pneumonia
Viral syndrome
Pyelonephritis
Sickle cell pain crisis and fever
Hematochezia
Hematemesis
URI and seizure
Reactive airway disease

Abdominal pain: evidence-based


data

Associated symptoms

Fever
Vomiting
Decreased appetite
Cough
Headache
Sorethroat

Historical Data

Duration of the pain


Location of the pain
Radiation of the pain
General appearance of the patient
Associated symptoms
Sick contacts
Recent travel

Historical data

Associated symptoms

Vomiting

Diarrhea

Duration
Type of emesis: bile, blood
bloody

Fever
Rash
Genitourinary symptoms

Physical Examination

General appearance

Ill-appearing or toxic
Dehydrated
Shock

Vital signs

Febrile
Tachycardic
Tachypneic
Hypotensive

Physical Examination

Head/Face

Fontanels

Sunken
Bulging

Signs of inflicted injury

Bruising/swelling

Physical Examination

Eyes

Icteric sclera
Abnormal eye movements
Sunken appearance
Periorbital swelling

Physical Examination

ENT

Mucus membranes

Moist vs dry
Lesions/ulcerations

Teeth and Gums

Swelling
Bleeding

Physical Examination

ENT

Nose

Rhinorrhea
Nose bleed

Throat

Erythema
Exudates

Physical Examination

Chest/Axilla

Appearance
Tenderness
Swelling/Masses

Physical Examination

Cardiovascular

Heart sounds
Rhythm
Pulses
Edema

Physical Examination

Abdomen

Appearance

Distension
Scars
Bruises

Physical Examination

Abdomen

Palpation

Tenderness
Organomegaly
Masses

Physical Examination

Abdomen

Tenderness

Localized
Diffuse
Rebound
Rovsings sign

Guarding

Voluntary
Non-voluntary

Physical Examination

Abdomen

Rectal exam

Stool Guaic

Other findings

Psoas sign
Obturators sign
Murphys sign

Physical Examination

Pelvis/inguinal area

Males

Scrotum and testicles


Urethral discharge
Phymosis/paraphymosis

Females

Vaginal bleeding
Speculum exam

Physical Examination

Skin

Color

Pale
jaundice

Rashes
Signs of injury/abnormal bleeding
Turgor
Peripheral circulation

Physical Examination

Neurologic examination

Mental status
Cranial nerves
Motor
Sensorory
Cerebellar

Physical examination

Psychiatric evaluation

Mental status

Depression
Anxiety

Suicidal ideation/attempt
Homicidal ideation/attempt
Hallucinations/delusions

Differential diagnosis

Infants

Gastroenteritis
Constipation
Malrotation +/- Volvulos
GERD
Infantile Colic
Intussuception
Urinary tract infection
Testicular torsion

Differential diagnosis

Children

Gastroenteritis
Constipation
Intussuception
Torsion
UTI
Kidney stones
Sickle cell crisis
DKA

Testicular torsion
Incarcerated Hernia
Pneumonia
Strep throat
Henoch-Schonlein
Purpura
Meningococcemia
Toxic ingestions

Diferrential Diagnosis

Adolescent Males

Testicular torsion
Varicocele
Pyelonephritis
Kidney stones
Gallstones
Pancreatitis
Hepatitis

Incarcerated
Hernia
Constipation
DKA
IBD
STD
GERD
Toxic ingestions

Differential diagnosis

Adolescent females

Ovarian torsion
Ruptured ovarian
cyst
PID
UTI
Gallstones
Cholecystitis
Kidney stones

DKA
Toxic ingestions
Pre-/menstrual
cramps
Complications of
pregnancy

Ectopic
Threatened AB
Missed AB

Abdominal pain: evidence-based


data
Abdominal pain: appendicitis or
not?

Abdominal pain: evidence-based


data

Appendicitis

Incidence

11/10,000 population per year


Highest in males 10-14 years (27/10,000)
Highest in females 15-19 years (20/10,000)
Male:female ratio: 1.4:1
Life time risk:

Males: 8.6%; Females: 6.7%

Perforation: 18% ; highest in < 5 and >65 y.o.

Appendicitis: evidence-based
data

Signs and symptoms

Neonates:

Abdominal distension
Vomiting
Fever
Hypothermia
Respiratory distress

Appendicitis: evidence-based
data

Signs and symptoms

3 years and under

Diffuse abdominal pain


Fever
Vomiting
Diarrhea
Abdominal distension
Diffuse abdominal tenderness

Appendicitis: evidence-based
data

Signs and symptoms

Older children

Abdominal pain
Vomiting
Fever
Anorexia
Pain with movement or cough
Localized RLQ tenderness
Diffuse/rebound tenderness

Abdominal pain: evidence-based


data

Laboratory studies

CBC, differential
ESR
C-reactive protein
Urinalysis
Poor sensitivity and specificity

Abdominal pain: evidence-based


data

Radiologic studies

Plain films

Small bowel obstruction


Fecalith
Pneumoperitoneum

Poor sensitivity and specificity

Abdominal pain: evidence-based


data

Radiologic studies

Ultrasound

Appendiceal diameter or >6 mm


Target sign with 5 concentric layers
Distension or obstruction of the lumen
High echogenicity around the appendix

Pericecal or perivesical fluid


Appendix wall > 2 mm
Absence of appendiceal peristalsis
Can confirm but not exclude appendicitis

Abdominal Pain: Evidence-based


Data

Radiologic studies

CT scan
Enlarged appendiceal diameter (> 6 mm)
Appendiceal wall thickening (> 1 mm)
Periappendiceal inflammatory changes
including fat streaks, phlegmon, fluid
collection, and/or extraluminal gas

Other findings: appendicalith, abscess,


arrowhead sign, or cecal bar
Sensitivity 87 100 %, Specificity 89
98%

Abdominal pain: evidence-based


data

Radiologic studies

CT scan

Advantages
Establish alternative diagnoses
Differentiates between perforated
and non-perforated appendicitis
Reduces length of stay and cost
of care
Reduces perforation rate
Useful in obese, uncooperative
patients

Abdominal pain: evidence-based


data

Radiologic studies

CT scan

Disadvantages
Higher cost compared to ultrasonography
Risks associated with contrast
administration
Potential need for sedation
Exposure to ionizing radiation
False negative rate 10%

Diagnostic work-up

History and physical examination

Serial abdominal exams


Surgical consultation

Laboratory data
Radiologic evaluation

Ultrasound
CT scan

Treatment of appendicitis

Surgery

Laparoscopic
Open

Conservative management

Antibiotics
IV hydration

Treatment of appendicitis

Conservative management

IV and oral antibiotics

Cefotaxime + (ofloxacin +tinidazole)


Ciprofloxacin and metronidazole +
(ciprofloxacin + tinidazole)

Treatment of appendicitis

Conservative management

Advantages
Less pain
Shorter recovery time
Avoid complications of surgery
and anesthesia

Treatment of appendicitis

Conservative management

Disadvantages

High recurrence rate

Abdominal pain: evidence-based


data

Use of analgesics in patients


with abdominal pain
Will analgesics mask the signs of acute
abdomen and cause a delay making the
diagnosis?
What medications are effective and safe?

Abdominal pain: evidence-based


data

Use of analgesics in patients


with abdominal pain

56% of patients with abdominal pain


were not given pain medication
Studies in adults show that opioids
are effective in reducing pain without
significant adverse effects or delay in
diagnosis of acute abdomen

Abdominal pain: evidence-based


data

Use of analgesics in pediatric


patients with abdominal pain

Morphine 0.1 mg/kg vs. normal


saline

Reduction of pain score by 2 points (1


10)

No change in the area(s) of tenderness

Tenderness persisted in patients with


surgical conditions

No change in the diagnostic accuracy

No significant complications

Abdominal pain: evidence-based


data

Follow up care of discharged


patients

Return or follow up visit in 8 12 hours


Will identify serious medical conditions
presenting as abdominal pain and
detect surgical conditions that may
have presented early in the disease
process.

Thank you!
Have a great day.