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Abdominal Pain in Children

Updated 5/2/2015Arjun Rao

+Outline

Clinical evaluation – tips and tricks Appendicitis Ovarian Torsion Intussusception “Constipation” Medical Causes Extra-abdominal causes

+Epidemiology of Abdominal Pain ~ 5% of all presentations to PED Surgery only required in 1-7% No specific diagnosis in up to 15%

+History – the basics 1

Maintain empathy at all times, no matter how tired you are

Parents are anxious and worried – don’t let this frustrate you

Open ended questions to start – let the parents speak, don’t interrupt early

Acknowledge that they might be exhausted, especially if they have been transferred from another hospital and have had a long day

Age appropriate engagement of child

+History – the basics 2

History of pain – if child is old enough can ask them

Temporal history important

Associated symptoms

Red flagsBile stained vomitingFlank or back painWaking at nightNot walking

+History – tips

Ask about journey to hospital – when the car went over bumps

When asking about nature and severity let the child know that the questions are hard and not to worry too much if they can’t answer

If the history is long try to establish if they had any days when they were well

Ask about stool frequency (beware assuming “constipation”)

Ask about family history of appendicits

+Examination – the basics

Distraction, be non-threatening, keep parents close

Positioning

Observation – RR (measure yourself), work of breathing, movement, level of distress “well v unwell”, Sa02 if monitored

Vital signs – measure HR, CR

All systems including ENT

Inspection, Palpation, Percussion, Auscultation

+Examination - tips

Don’t stand over child, kneel or sit next to bed

Keep arm horizontal, palpate with palm not tips of fingers

Look at their face

Distraction Ask about age, siblings, school, movies, parents, pets

If you think the abdomen is distended measure

Don’t forget hernia, testes

Mobility, don’t be afraid to try to walk them but don’t push

+Examination – the abdomen

Superficial palpation away from site of reported pain – look at face

Deep palpation

Liver, spleen, kidneys

Masses

Percussion

+Appendicitis in Children

Most common non-traumatic surgical emergency

Peak 12-18 yrs Classic appendicitis easy “Atypical” appendicitis common in

children Beware false localising signs – diarrhoea,

dysuria

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+Appendicitis - Investigations

No single diagnostic test

Aim: high sensitivity/specificity minimise missed appendicitis minimise normal appendicectomy rate minimise delay to OT

+Appendicitis - Investigations

• Urinalysis– Pyuria in ~ 30%

• FBC– Neither sensitive nor specific

• U/S– Sensitivity 87%, Specificity 89%– Not visualised 10%

• CT– Sensitivity 91%, Specificity 94%– RIM risk (single CT in 5yo -> 20-25:100000)

•Klein, M. D. (2007). "Clinical approach to a child with abdominal pain who might have appendicitis." Pediatric Radiology 37(1): 11-14•Doria, A. (2009). "Optimizing the role of imaging in appendicitis." Pediatric Radiology 39(Suppliment 2): S144-148.

+ Appendicitis scores – Alvarado Score

Clinical Feature Score

M Migration of pain to RIF 1

A Anorexia 1

N Nausea 1

T Tenderness in RLQ 2

R Rebound pain 1

E Elevated temperature 1

L Leukocytosis 2

S Shift to left of WBC 1

10

<5: Rule out>7: Rule in

Probably - good at ruling out, not great at ruling in, overestimates appendicitis in children with intermediate scores

+Intussusception

Telescopic invagination of one section of the bowel into another

Usually ileo-colic

Can be a great “mimic”

Image Definition

http://yoursurgery.com

+Intussusception

• Mostly idiopathic but consider lead point • Vomit / pain / blood [classic triad < 30%]• Most common 5-10mths – “any age”• M:F 3:1, 1-4:1000• X-ray may show signs• US (sensitivity ~ 100%)• Air enema

• Consider pathological lead point in very young or older children

Del-Pozzo et al (1996). “Intussusception: US findings with pathologic correlation – the cresent in doughnut sign. Radiology 199: 688-792

+ Intussusception

Liver edge not well defined“Cresent” in right upper quadrantPaucity of gas on right side of abdomenDistended loop of transverse colon

+Meckel’s Diverticulum

• Omphalomesenteric duct vestige (vitelline duct)• Contain gastric mucosa• Can mimic appendicitis

http://www.health.act.gov.au

+Meckel’s Diverticulum

“Rule of 2s” 2% population 2% symptomatic (actually ~ 4%) 2 inches long 2 ft prox to terminal ileum 2 times more common in boys 2 types of ectopic tissue (gastric and pancreatic)

Pain, bleed, perforation, obstruction Classic presentation -> painless bleeding Can be lead point for intussusception Meckel’s scan

~ 80% sensitivity, 95% specific Surgical excision

+Ovarian Torsion

• Rare in children• Usually seen with ovarian pathology• Usually colicky lower pain• Acute onset• Right > Left• May be associated nausea, vomiting,

raised WCC• Ultrasound has high specificity /

sensitivity

+Formulating a provisional and differential diagnosis

Be systematic

Most likely to least likely

Anatomical

Most serious

Surgical v Non-surgical

Abdominal v extra-abdominal

PnemonicV Vascular

I Inflammatory/infectious

N NeoplasticD Drugs

I Iatrogenic

C Congenital

A Autoimmune

T TraumaticE Endocrine / Environmental

M Metabolic

+Formulating a provisional and differential diagnosis

Constipation is not a diagnosis

Rare but serious Discitis ALL Intra-abdominal abcess Tumour

Anatomical approach

Systems approach

+Differential

AppendicitisUTI/PyelonephritisTesticular torsionCholecystitisPneumoniaPancreatitisIntussusceptionBowel obstructionMeckel’s DiverticulumPoor diet -> constipation

http://www.lifescript.com

+Extra-abdominal causes

• Tonsillitis / pharyngitis• Pneumonia• Pericarditis

+“Medical” causes

• DKA• HSP• HUS• Iron ingestion• FMF• Abdominal migraine

+Neonates and Infants

• Hernia• Torsion• Appendicitis• NEC• Volvulus• Intussusception• Hirschprung

+Management in ED - Analgesia

Assessment of pain• Can be difficult – pain vs anxiety• Age dependent • Pain scales, Visual analogue scale

+Management in ED - Analgesia

• Simple analgesia as appropriate• Are opioids contra-indicated?• No RCT• Practice is to not withhold analgesia• Intranasal Fentanyl (1-2mcg/kg)• Intravenous Morphine (0.1-0.2mg/kg)

Sharwood, L. N. and F. E. Babl (2009). "The efficacy and effect of opioid analgesia in undifferentiated abdominal pain in children: a review of four studies." Paediatric Anaesthesia 19(5): 445-451.

+Disposition

Admission v Discharge

Solid plan for discharge and follow up

“Obs admit” – try to avoid prolonged observation admission

Admission for observation and serial examination is a good option in equivocal cases

+Guidelines

SCH

CHW

RCH

NSW Health

+Essentials

1. Only a small percentage have surgical cause

2. Age influences diagnostic possibilities3. Abdominal examination critical4. Don’t withhold analgesia5. Aetiology may be intra or extra abdominal6. Serial examination useful7. Definitive diagnosis not always possible8. Clear follow up important