Acute abdomen in_pediatric

59
Acute abdomen in Acute abdomen in pediatric pediatric DR.MEDHAT M, IBRAHIM DR.MEDHAT M, IBRAHIM CONSULTANT PEDIA,SURGERY CONSULTANT PEDIA,SURGERY

description

 

Transcript of Acute abdomen in_pediatric

Page 1: Acute abdomen in_pediatric

Acute abdomen in Acute abdomen in pediatricpediatric

DR.MEDHAT M, IBRAHIMDR.MEDHAT M, IBRAHIM

CONSULTANT PEDIA,SURGERYCONSULTANT PEDIA,SURGERY

Page 2: Acute abdomen in_pediatric

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.

Page 3: Acute abdomen in_pediatric

EtiologyEtiology InflammatoryInflammatory Traumatic ?Traumatic ? ObstructiveObstructive VascularVascular

Page 4: Acute abdomen in_pediatric

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

Page 5: Acute abdomen in_pediatric

Age related causesAge related causes

Child age acute abdomen:Child age acute abdomen:

Page 6: Acute abdomen in_pediatric

Presentation of acute Presentation of acute abdomenabdomen

Abdominal painAbdominal pain Abdominal massAbdominal mass Organ dysfunctionOrgan dysfunction Bleeding Bleeding

Page 7: Acute abdomen in_pediatric
Page 8: Acute abdomen in_pediatric

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

Page 9: Acute abdomen in_pediatric
Page 10: Acute abdomen in_pediatric
Page 11: Acute abdomen in_pediatric

Abdominal tumors

Neuroblastoma lymphoma Willms tumors Rabdomyosarcoma

Page 12: Acute abdomen in_pediatric

Abdominal tumors (renal)Abdominal tumors (renal)

Page 13: Acute abdomen in_pediatric

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

Page 14: Acute abdomen in_pediatric

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

Page 15: Acute abdomen in_pediatric

Gut perforation secondary Gut perforation secondary peritonitisperitonitis

Page 16: Acute abdomen in_pediatric

Plain X-Ray in perforated gutPlain X-Ray in perforated gut

Page 17: Acute abdomen in_pediatric

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.

Page 18: Acute abdomen in_pediatric

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

Page 19: Acute abdomen in_pediatric

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

Page 20: Acute abdomen in_pediatric

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.

Page 21: Acute abdomen in_pediatric

Congenital band of Ladd'sCongenital band of Ladd's

Page 22: Acute abdomen in_pediatric

MalrotatioMalrotationn

MalrotatioMalrotationn

Page 23: Acute abdomen in_pediatric

MalrotationMalrotationCork screw Cork screw

upper jejunum, upper jejunum, indicative of indicative of volvulus with volvulus with partial partial obstructionobstruction

Page 24: Acute abdomen in_pediatric

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

Page 25: Acute abdomen in_pediatric

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

Page 26: Acute abdomen in_pediatric

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.

Page 27: Acute abdomen in_pediatric

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.

Page 28: Acute abdomen in_pediatric

Meconium ileusMeconium ileus

Page 29: Acute abdomen in_pediatric

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.

Page 30: Acute abdomen in_pediatric

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.

Page 31: Acute abdomen in_pediatric

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.

Page 32: Acute abdomen in_pediatric

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

Page 33: Acute abdomen in_pediatric

U.S-IntussusceptionsU.S-Intussusceptions

Page 34: Acute abdomen in_pediatric

IntussusceptionIntussusception

Page 35: Acute abdomen in_pediatric

IntussusceptioIntussusceptionsns

Page 36: Acute abdomen in_pediatric

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.

Page 37: Acute abdomen in_pediatric

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 . .

Page 38: Acute abdomen in_pediatric

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..

Page 39: Acute abdomen in_pediatric

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.

Page 40: Acute abdomen in_pediatric

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.

Page 41: Acute abdomen in_pediatric

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.

Page 42: Acute abdomen in_pediatric

Barium studyBarium study

Page 43: Acute abdomen in_pediatric

Acute appendicitisAcute appendicitis

Page 44: Acute abdomen in_pediatric

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.

Page 45: Acute abdomen in_pediatric

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.

Page 46: Acute abdomen in_pediatric

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.

Page 47: Acute abdomen in_pediatric

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%

Page 48: Acute abdomen in_pediatric

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

Page 49: Acute abdomen in_pediatric

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.

Page 50: Acute abdomen in_pediatric

--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

Page 51: Acute abdomen in_pediatric

Hydro-pyo-metrocolopsHydro-pyo-metrocolops

Page 52: Acute abdomen in_pediatric

Incidence of the NSAP ,to acute Incidence of the NSAP ,to acute appendicitis and appendicitis and

intestinal ;obstructionintestinal ;obstruction

Page 53: Acute abdomen in_pediatric

Red Flags of recurrent Red Flags of recurrent abdominal pain syndromeabdominal pain syndrome

Page 54: Acute abdomen in_pediatric

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).

Page 55: Acute abdomen in_pediatric

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

Page 56: Acute abdomen in_pediatric

SpecificSpecific

Abdominal ultrasoundAbdominal ultrasound Abdominal CTAbdominal CT Peritoneal lavagePeritoneal lavage Mesenteric angiographyMesenteric angiography Laparoscopic \ laparotomyLaparoscopic \ laparotomy

Page 57: Acute abdomen in_pediatric

Logarithm for work upLogarithm for work up

Page 58: Acute abdomen in_pediatric

Complex anomaliesComplex anomalies

Page 59: Acute abdomen in_pediatric

Thank you