Acute abdomen in_pediatric
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Transcript of Acute abdomen in_pediatric
Acute abdomen in Acute abdomen in pediatricpediatric
DR.MEDHAT M, IBRAHIMDR.MEDHAT M, IBRAHIM
CONSULTANT PEDIA,SURGERYCONSULTANT PEDIA,SURGERY
Definition of the acute Definition of the acute abdomenabdomen
This is an abdominal condition which This is an abdominal condition which interfere with the normal live and interfere with the normal live and make patient ask the medical advice make patient ask the medical advice with in few hours. with in few hours.
Emergent abdominal condition is the Emergent abdominal condition is the abdominal condition need for abdominal condition need for immediate interference with out any immediate interference with out any delay. delay.
EtiologyEtiology InflammatoryInflammatory Traumatic ?Traumatic ? ObstructiveObstructive VascularVascular
Age related causeAge related cause
Neonatal causesNeonatal causes:: Necrotizing enter Necrotizing enter
colitiscolitis Obstructive causesObstructive causes Mega colonMega colon Meconieum plugsMeconieum plugs Atresia and its typesAtresia and its types malrotatinmalrotatin Birth injuriesBirth injuries
Infant causesInfant causes:: GastroenteritisGastroenteritis Nonspecific Nonspecific
abdominal painabdominal pain Complicated herniaComplicated hernia IntussusceptionsIntussusceptions malrotationmalrotation Volvulus and Volvulus and
vascular vascular insufficienciesinsufficiencies
Age related causesAge related causes
Child age acute abdomen:Child age acute abdomen:
Presentation of acute Presentation of acute abdomenabdomen
Abdominal painAbdominal pain Abdominal massAbdominal mass Organ dysfunctionOrgan dysfunction Bleeding Bleeding
Upper G I T bleedingUpper G I T bleeding
Endoscopic images from children with (a) a normalesophagus, (b) an esophagus with erosive reflux esophagitis, and(c) an esophagus affected by eosinophilic esophagitis. Eosinophilicesophagitis, distinct from GERD, often appears as in thisimage, with furrowing of the esophageal mucosa, and whitespecks on the surface resembling candidiasis
Abdominal tumors
Neuroblastoma lymphoma Willms tumors Rabdomyosarcoma
Abdominal tumors (renal)Abdominal tumors (renal)
Intestinal lymphomaIntestinal lymphoma
Tumor induce abdominal pain ,mass,and Tumor induce abdominal pain ,mass,and intestinal obstractionintestinal obstraction
Obstractin is the indecation of surgeryObstractin is the indecation of surgery
Inflammatory causesInflammatory causes
Primary bacterial peritonitisPrimary bacterial peritonitis• spontaneous bacterial peritonitisspontaneous bacterial peritonitis• spontaneous bacterial peritonitis in healthy spontaneous bacterial peritonitis in healthy
patientspatients
Secondary bacterial peritonitisSecondary bacterial peritonitis• visceral perforation, inflammation, tumor visceral perforation, inflammation, tumor
(pathology) (pathology)
Tertiary bacterial peritonitisTertiary bacterial peritonitis• most bad prognosis it is usually occur in ICU most bad prognosis it is usually occur in ICU
patientspatients
Gut perforation secondary Gut perforation secondary peritonitisperitonitis
Plain X-Ray in perforated gutPlain X-Ray in perforated gut
TraumaticTraumatic
That abdominal condition is not That abdominal condition is not including the abdominal trauma including the abdominal trauma which was need for specific different which was need for specific different management.management.
Bleeding and Gut contents caused Bleeding and Gut contents caused peritonitis. peritonitis.
ObstructiveObstructive
Hollow organ obstructive disordersHollow organ obstructive disorders Most common colon (spastic colon Most common colon (spastic colon
and irritable bowel syndrome)and irritable bowel syndrome) Obstructive type of acute Obstructive type of acute
appendicitisappendicitis Intestinal obstructionIntestinal obstruction Obstructive uropathyObstructive uropathy Bilary colicBilary colic
VascularVascular
Acute ischemiaAcute ischemia Necrotizing enter colitis is the most Necrotizing enter colitis is the most
common cause in neonatecommon cause in neonate The entropic drugs become the most The entropic drugs become the most
common cause in the childrencommon cause in the children Intussusceptions and VolvulusIntussusceptions and Volvulus Strangulated herniaStrangulated hernia
MalrotationMalrotation The commonest features of malrotation are: The commonest features of malrotation are: (1)the D-J flexure lies right of midline,(1)the D-J flexure lies right of midline, (2) the dorsal mesenteric attachment is narrow(2) the dorsal mesenteric attachment is narrow (3) peritoneal folds cross from colon and Caecum (3) peritoneal folds cross from colon and Caecum
to duodenum, liver and gallbladder (Laddto duodenum, liver and gallbladder (Ladd’’s bands), s bands), thus possibly obstructing the duodenum. Whether thus possibly obstructing the duodenum. Whether LaddLadd’’s bands are substantial enough to cause s bands are substantial enough to cause mechanical obstruction is debatable. The narrowed mechanical obstruction is debatable. The narrowed mesenteric base can lead to midgut volvulus, mesenteric base can lead to midgut volvulus, bowel obstruction and mesenteric vessel occlusion. bowel obstruction and mesenteric vessel occlusion.
Congenital band of Ladd'sCongenital band of Ladd's
MalrotatioMalrotationn
MalrotatioMalrotationn
MalrotationMalrotationCork screw Cork screw
upper jejunum, upper jejunum, indicative of indicative of volvulus with volvulus with partial partial obstructionobstruction
outcomeoutcome
The outcome of patients The outcome of patients undergoing Laddundergoing Ladd’’s procedure s procedure for isolated malrotation is for isolated malrotation is very good and thevery good and the
majority make a full recovery. majority make a full recovery. The commonest The commonest postoperative complication is postoperative complication is adhesion obstruction occurs adhesion obstruction occurs in 45in 45––65% of children with 65% of children with malrotation and still carries a malrotation and still carries a mortality rate of 7mortality rate of 7––15%; 15%; necrosis of more than 75% of necrosis of more than 75% of the midgut short bowel the midgut short bowel syndromesyndrome
Meconieum IleusMeconieum Ileus
symptoms include abdominal symptoms include abdominal distension (96%), bilious distension (96%), bilious vomiting (50%) and delayed vomiting (50%) and delayed passage From a clinical point passage From a clinical point of view, it is possible to of view, it is possible to recognize two different recognize two different conditions:conditions:
a simple, uncomplicated and a simple, uncomplicated and non-surgical type, and non-surgical type, and
a complicated, severe type, a complicated, severe type, with a mortality of at leastwith a mortality of at least
25% of all cases.25% of all cases. In the first type (58%), signs In the first type (58%), signs
and symptoms of a distal and symptoms of a distal ileal obstruction are seen not ileal obstruction are seen not later than 48 h after birthlater than 48 h after birth
Meconium IleusMeconium Ileus
When meconium has a very high When meconium has a very high protein content and is particularly protein content and is particularly sticky, it can cause distal ileal sticky, it can cause distal ileal obstruction. obstruction.
For practical purposes, meconium ileus For practical purposes, meconium ileus means cystic fibrosis and 10% to 20% of means cystic fibrosis and 10% to 20% of cystic fibrosis patients present in this cystic fibrosis patients present in this way in the neonatal period. way in the neonatal period.
As with ileal atresia, the neonate As with ileal atresia, the neonate presents with bilious vomiting and presents with bilious vomiting and abdominal distension, and failure to abdominal distension, and failure to pass meconium.pass meconium.
Gas in inspisated Gas in inspisated MeconieumMeconieum
Besides the Besides the nonspecific signs of nonspecific signs of obstruction seen on obstruction seen on plain film, the most plain film, the most characteristic characteristic evidence is of a evidence is of a Frothy Frothy bubbly bubbly pattern of bowel pattern of bowel gas in the right gas in the right lower quadrantlower quadrant which indicates gas which indicates gas in inspesiated in inspesiated meconium.meconium.
Meconium ileusMeconium ileus
MECONIUM ILEUSMECONIUM ILEUS
A contrast enema with water-soluble and hyperorA contrast enema with water-soluble and hyperoriso-osmolar contrast is the medical treatment ofiso-osmolar contrast is the medical treatment ofchoice and mucosal safe, for uncomplicated cases. choice and mucosal safe, for uncomplicated cases.
AArecent study that used various enema solutions recent study that used various enema solutions
administeredadministeredin a mouse model showed that surfactantin a mouse model showed that surfactantand Gastrografin were the most efficacious for the and Gastrografin were the most efficacious for the
ininvivo relief of constipation in comparison with vivo relief of constipation in comparison with
perflubron,perflubron,Tween-80, Golytely, DNase, Tween-80, Golytely, DNase, NN-acetylcysteine-acetylcysteineand Viokase.and Viokase.
ATRESIAATRESIA Neonatal obstructive pathology due to Neonatal obstructive pathology due to
loss of the gut lumen continuity.loss of the gut lumen continuity. Intra-uterin vascular insult is the cause.Intra-uterin vascular insult is the cause. Ante natal ultra sound is diagnostic.Ante natal ultra sound is diagnostic. There is several types, the contrast There is several types, the contrast
study post natal is corner stone of the study post natal is corner stone of the diagnosis.diagnosis.
Prognosis is variable depending on Prognosis is variable depending on several factors as the neonate general several factors as the neonate general assessment +and type of atresia. assessment +and type of atresia.
Dr Magda Shady Clinic
Dr. Magda Shady Clinic
Dr Magda Shady Clinic
Collapsed lower Collapsed lower bowelbowel
Dr Magda Shady Clinic
LaddLadd’’s band at DJJ.s band at DJJ.
Presentation of Presentation of intussusceptionsintussusceptions''
Typical symptoms pattern. In an early state initial vomiting – found
in 80%. lethargy are caused by tearing
of the mesentery; obstruction, as well as no
abdominal distension. Colicky, intermittent abdominal
pain. initially around every 20 min – but with increasing frequencies. on examination?? palpable abdominal mass
U.S-IntussusceptionsU.S-Intussusceptions
IntussusceptionIntussusception
IntussusceptioIntussusceptionsns
ManagementManagement
Hydrostatic Hydrostatic reduction under reduction under radiological guide radiological guide is the modern is the modern way for ttt.way for ttt.
Open manual Open manual reduction after it reduction after it is failure or if it is is failure or if it is not available.not available.
N.E.CN.E.C--1-31-3 cases per 1000 cases per 1000
live birthlive birth, ,
-Mortality 10% to -Mortality 10% to 70%.70%.
- - it is the disease of it is the disease of prematurityprematurity..
- - infant below infant below 1500gm have high 1500gm have high significant mortalitysignificant mortality..
- - Bell staging system Bell staging system of N.E.C. to 3 stagesof N.E.C. to 3 stages..
- - peritoneal lavage in peritoneal lavage in a new method for ttta new method for ttt . .
PNEUMATOSIS PNEUMATOSIS INTESTINALISINTESTINALIS..
THERE ARE ALSO THERE ARE ALSO
SUBTLE AIR DENSITIES SUBTLE AIR DENSITIES OVER THE LIVER. THIS OVER THE LIVER. THIS SUGGESTS THAT SUGGESTS THAT THERE IS AIR IN THE THERE IS AIR IN THE PORTAL CIRCULATION PORTAL CIRCULATION (INTRAPORTAL AIR).(INTRAPORTAL AIR).
BOTH FINDINGS BOTH FINDINGS INDICATE INDICATE NECROTIZING NECROTIZING ENTEROCOLITISENTEROCOLITIS..
PNEUMATOSIS PNEUMATOSIS INTESTINALIS.INTESTINALIS.
NOTE THE AIR IN NOTE THE AIR IN THE BOWEL WALL.THE BOWEL WALL.
DOUBLE LINED DOUBLE LINED APPEARANCE APPEARANCE (ie., (ie., RAILROAD RAILROAD TRACKS WITHOUT TRACKS WITHOUT TIESTIES).).
NECROTIZING NECROTIZING ENTEROCOLITIS.ENTEROCOLITIS.
Hypertrophic pyloric Hypertrophic pyloric stenosisstenosis
The ultrasound is The ultrasound is diagnostic , contrast diagnostic , contrast study is performed study is performed only in d doubtful.only in d doubtful.
Correction of the Correction of the electrolytes and pH, electrolytes and pH, and hydration is and hydration is mandatory before mandatory before OR.OR.
Hypertrophic pyloric Hypertrophic pyloric stenosisstenosis Common in male 4-1.Common in male 4-1.
First born at 2w-7w.First born at 2w-7w. Projectile non bile Projectile non bile
stain ,increase in stain ,increase in severity and severity and frequency with time.frequency with time.
Constant hunger just Constant hunger just after the vomiting.after the vomiting.
Hypo cl alkalosis .Hypo cl alkalosis . Olive mass at the rt Olive mass at the rt
hypo chondriam. hypo chondriam.
Barium studyBarium study
Acute appendicitisAcute appendicitis
Acute app,Acute app,Gradual onset Gradual onset generalized abdominal generalized abdominal pain , which become pain , which become localized to rt iliac foss. localized to rt iliac foss. associated with nausea associated with nausea and vomiting.and vomiting.
--the use of medication --the use of medication change this picture.change this picture.
--the advance in the --the advance in the radiological diagnosis radiological diagnosis make it is diagnosis by make it is diagnosis by U.S and C.T more U.S and C.T more accurate .accurate .
--laparoscopic or open --laparoscopic or open appendectomy is the ttt.appendectomy is the ttt.
AppendicitisAppendicitis
an appendix with a diameter an appendix with a diameter ofof more than 6 mm . more than 6 mm . periappendiceal inflammation, conventional periappendiceal inflammation, conventional CTCT criteria have efficacy in differentiating criteria have efficacy in differentiating appendicitisappendicitis from a normal appendix. However, from a normal appendix. However, the new the new CTCT criterion based on a maximum depth criterion based on a maximum depth ofof the intraluminal appendiceal fluid the intraluminal appendiceal fluid ofof more than more than 2.6 mm is helpful in this differentiation. 2.6 mm is helpful in this differentiation.
Acute pancreatiatsAcute pancreatiats
Pancreatitis is uncommon during Pancreatitis is uncommon during childhood.childhood.
It should be considered in every child It should be considered in every child with unexplained acute abdominal pain.with unexplained acute abdominal pain.
The prognosis is generally good.The prognosis is generally good. C.T scan and serum amylase C.T scan and serum amylase
+abdominal pain is the golden stone +abdominal pain is the golden stone for diagnosis .for diagnosis .
Management will directed to the cause.Management will directed to the cause.
Distribution of clinical presentation
Symptoms /Signs (%) Abdominal pain 11 (91.7%) Upper (41.7%) Central (33.3%) Lower Generalised (16.7%) Vomiting (58.3%) Fever (16.7%) Abdominal tenderness (100%) Upper (75.0%) Central (8.3%) Lower (8.3%) Generalised (16.7%) Abdominal distension (8.3%) Abdominal mass (16.7%
Complicated herniaComplicated hernia
The inguinal hernia The inguinal hernia is the most common is the most common obstructive obstructive pathology in infants pathology in infants and children in pre-and children in pre-school age.school age.
Groin swelling Groin swelling +abdominal pain + +abdominal pain + vomiting are vomiting are diagnosticdiagnostic
Scrotal causesScrotal causes
Testicular torsion Testicular torsion , and a testicular , and a testicular appendiceal appendiceal torsion are an torsion are an important causes important causes of abdominal of abdominal pain in children.pain in children.
Clinical +u.s Clinical +u.s =diagnosis.=diagnosis.
--ACUTE ABDOMINAL PAIN.ACUTE ABDOMINAL PAIN.-COMPLEX ADENEXIAL MASS -COMPLEX ADENEXIAL MASS (U.S).(U.S).-ELEVATED W.B.C-ELEVATED W.B.C
Ovarian torsion or Ovarian torsion or tumortumor
Hydro-pyo-metrocolopsHydro-pyo-metrocolops
Incidence of the NSAP ,to acute Incidence of the NSAP ,to acute appendicitis and appendicitis and
intestinal ;obstructionintestinal ;obstruction
Red Flags of recurrent Red Flags of recurrent abdominal pain syndromeabdominal pain syndrome
InvestigationsInvestigations
What is the general condition of the What is the general condition of the patient? (Essential investigation for patient? (Essential investigation for all acute abdomens).all acute abdomens).
What is the primary cause of the What is the primary cause of the acute abdomen? (specific acute abdomen? (specific investigation).investigation).
EssentialEssential
Haemoglobin,WCC,PCVHaemoglobin,WCC,PCV Urea and electrolytes, amylase.Urea and electrolytes, amylase. Chest X-ray, supine and erect Chest X-ray, supine and erect
abdominal X-rayabdominal X-ray Blood CulturesBlood Cultures Group and save cross matchGroup and save cross match
SpecificSpecific
Abdominal ultrasoundAbdominal ultrasound Abdominal CTAbdominal CT Peritoneal lavagePeritoneal lavage Mesenteric angiographyMesenteric angiography Laparoscopic \ laparotomyLaparoscopic \ laparotomy
Logarithm for work upLogarithm for work up
Complex anomaliesComplex anomalies
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