ACUTE ABDOMENAcute abdomen by term definition is used to describe the abdominal condition of rapid onset severe enough to warrant patients admission to hospital. The cause of this will sometime be life threatening condition that will require surgical inten… immediately or soon after rescucitation.

The cause of these can be grouped into:1 Inflammatory conditions2 Performation of hollow viscus3 Hemorrhage4 Medical conditions

DIAGNOSISDiagnosis is made from history physical findings and a few but careful chosen laboratory investigations.

HISTORYA carefully taken history is the key to a diagnosis of the cause of acute abdomen in children.

Reliance is made on history from:1. Parents for the infants2. Older child with parental input3. Old child’s own history

PAINAcute abdomen is heralded by abdominal pains. As relates to acute abdomen specific aspects of the pain are important in leading to diagnosis.

A.a. SITE OF PAIN(i). Visceral pain (colic obstruction) is vague and is referred to the region

of sometime segments of the viscus involved:1 Epigastric for foregut2 Umbilicus for midgut3 Hypogastric for hindgut

This is unreliable in young children. Older children can localize pain more accurately. It is important to ask the child to point to indicate the site of pain.(ii). Sometime pain is a result of direct stimulation of the peritoneum and

peritonitis and is referred directly to the site of origin of pain. It is

sharp will described and is associated with tenderness.

b. SHIFT OF PAIN Pain shift when perforation of the involved organ occurs and there is direct stimulation of the parietal peritoneum. E.g. the pain of acute appendicitis is initially epigastric. (Visceral pain) which later shifts to the right iliac fosa when peritonitis sets on.

c. RADIATION OF PAIN Parietal pain sometimes in felt elsewhere. This is not common in children

d. DURATION OF PAINEstablish the duration of the present pain and whether it’s a continuation of episodes of pain experienced in the past to establish whether this is an acute or chronic problem.

e. PROGRESS OF PAIN The pain that is getting better may resolve but the pain that is getting worse may require surgical intervention.

f. NATURE OF THE PAIN Progress and cresendo pain is important surgical pain as this is typical intermittent pain of intestinal, biliary or renal condition.

f. SEVERITY OF THE PAIN The severity and uniqueness of the pain is determined by asking whether a similar pain has been experienced before and whether this is the worst pain ever felt.

g. AGGREVATING FACTORS Establishing the aggrevating factors is central to making a diagnosis and the effect of abdominal movements is of particular important.

RELIEVING FACTORSAsk for the factors that make the pain less.

B. VOMITINGThe onset of vomiting and its relationship to the abdominal pain are important and relevant. Its qualities and frequency color and type reflect the level and duration of the intestinal unrest.

1 Food in early cases in the early composition of the vomitus2 Blood stained to bile staining later in the history3 Bile stained or feacal is indication lf intestinal obstruction

unless other causes can be found.

C. BOWEL HABBITIs there a genuine change in the bowel habit? Establish what is normal in the patient before concluding there is change in pattern.4 Constipation after previous abnormal surgery should alert the

possibility of adhesion causing intestinal obstruction5 Diarrhea in many surgical conditions is slightly loose and

associated with other features. Loose stool is associated with appendicitis, intusscusception.

6 Blood in stools is not common. Passage of bricks red stool without abdominal pain is indication of Meckele diverticulum. Bloody mucosal stool in a sick child is indication of pathology of upper gastrointestinal blood for varices or peptic ulceration present as rectal bleeding.

MICTURATIONSymptoms of abnormal micturation may accompany surgical diseases. Micturating pain occur with pelvic appendicitis. Dribbling of some occur with constipation.

MENSTRUATION7 Complete menstrual history in teenage girls 8 Sudden mid cycle pain is indicated if ruptured follicle.9 Amenorrhea with sudden abdominal pain may indicate ectopic

pregnancy.

PHYSICAL EXAMINATIONPhysical examination is the second part in process making a diagnosis in acute abdomen. It should yield new information that reinforces impressions made from the history.The physician should use his eyes, ears and his hands and he will achieve this by inspection, ascultation palpation, percussion and ascultation.

OBSERVE(i). Inactive of the child is most likely not having a significant surgical

problem.A quiet, silent on lying with no movement is not likely having a surgical problemRestricted abdominal thoracic movements and its indicative of acute abdomen or pneumonia.Jaundice - chillsTemperature and pulseState mucous membrane Paltor

PALPATIONWarm hands are essential for a good examinationAvoid touching sore areas as pointed out by the patients abdominal wall.Look at the child’s face while palpating the abdomen.Look for;

1. Guarding. Stiffening of the muscularal wall of the abdominal wall is indicative of local peritoneal initiation.

2. Feel for continuation of respiratory movement these are absent with in the peritonitis.

3. Rigidity. This is muscular stiffening its indicative of peritonitis.4. Masses felt on deep palpation may be abscess or intussusception.5. Emptiness with right iliac fosa indicative of intuscuception.

RECTAL EXAMINATIONThis can be informative and important to reach a diagnosis.Intuscuception: blood mucoid stool or mass is palpableAppendicitis: tenderness or mass if a bowel present.

10 Examine all hernial orifices for obvious hernia, which may be obstructed.

Ascultations

In intestinal obstructions, the bowel sounds are high pitched11 In peritonitis the bowel sounds are reduced or absent.12 In gastroenteritis, the bowel sounds are rushing

INVESTIGATIONSDiagnosis of the cause of acute abdomen in a child is often that 75% of the case make by history and physical examination in more than 75% cases.A few focused laboratory and imaging evaluation is carried out not so much as to arrive at a diagnosis but as aid with plan of management.

Laboratory evaluationComplete blood count, a shift to the left is sometimes relevant.Serum chemistryElectrolytesBlood, urea nitrogenBlood gas.All are none specifications for diagnosis and useful in management of patients with dehydration, acid basis and electrolyte imbalance and may indicate the presence of bacterial infection.

URINEUrinalysis: of low diagnostic value but can confirm the presence of urinary tract infections or suspicion of a ureter stone.

Pregnancy testRule out ectopic pregnancy.

Imagingi. Plain x-rays

Useful in intestinal obstructionUseful in appendicolithUseful in urinary stone.Useful in perforation infection.

ii. UltrasonographyCan visualize change in outline of solid organs.Can visualize vascular supply to organsUsed more often in many cases of acute abdomen

iii. Upper and lower intestinal Contrast StudiesThese are often used for different diagnosis in children as in malformation or intuscuseption. Contrast used is either barren, watersoluble gastrograffin or air.

iv. Computerised tormographyv. Magnetic resonance imaging are of no immediate use in acute

abdomen.

Other measures.LaparotomyIncreasingly diagnostic laparotomy is being used in the absent of acute abdomen. In particular patients suspected of appendicitis and management of lower abdominal pains in young females.Laparotomy

Laparotomy remains the mainstay of treatment in acute abdomen.Exploratory laparotomy requires an incision that will expose the whole part of the abdominal cavity to the surgeon. This is a transverse abdominal incision in children and infants. In old children, a midline incision may be enough. Systemic exploration of the abdominal cavity is carried out unless the cause is immediately obvious. TABLE 1. PROMPT SURGICAL INTERVENTION REQUIRED

Vascular compromiseMalrotation with VolvulusOther intestinal torsion (eg, lymphangioma, colon)Irreducible incarcerated herniasNon-reduced intruscuceptionLate adhesive bowel obstructionSolid organ torsion (eg, gonad, spleen)

Perforated viscusAcute appendicitisNecrotizing enterocolitisIdiopathic or drug-induced lesions (eg, steroids)Peptic ulcer diseaseMeckel’s diverticulumTraumaForeign bodies

Acute hemorrhageTrauma to solid viscus (unstable patient)Trauma to major vesselsMeckel’s diverticulumEctopic pregnancy

TABLE 2. RELATIVE SURGICAL URGENCY REQUIREDIntestinal obstruction

Congenital lesions (eg, atresia, bands, megacolon)Adhesive bowel obstruction (early stages)Postoperative intussuceptionInflammatory bowel diseaseTumor (eg, lymphoma)

Infection/parasitosisEarly acute appendicitis Walled-off abscessesComplications owing to intestinal infections or parasites

TraumaPancreatic injuryHemobiliaBladder rupture

Non-life threatening hemorrhageInflammatory bowel diseaseIntra-tumoral hemorrage

TumorsIntra-abdominal lesions (eg, lymphangioma, lymphoma, teratoma0Rectro-peritoneal lesions (eg, Wilm’s tumor, neuroblastoma)

MiscelaneousCholedocholithiasis with obstruction

Table 3. Pathologies Suitable for (Initial) Non-surgical ManagementTrauma

Hepatic, splenic, renal injuryDuodenal hematomaPancreatic pseudocysts

Infection/parasitosisPelvic inflammatory diseaseAmebiasis, YersiniosisAscariasis

Intra-peritoneal/foreign body infections (manageable by removal)Ventriculo-peritoneal shuntsPeritoneal dialysis catheters

MiscelaneousEarly necrotizing entrocolitisPancreatitis (non-hemorrhagic or necrotizing)Omental torsionSplenic infarct in sickle cell diseaseUrinary tract pathology

Table 4. Surgical Intervention Not IndicatedInfection

Gastroenteritis (multiple viral, bacteria, protozoal, or parasitic agents)“Mesenteric adenitis)Basal pneumoniaHerpes zosterPrimary peritonitisHepatitis

Intestinal luminal abnormalities

ConstipationAerophagiaSwallowed foreign bodies

Systemic and metabolic diseasesHenoch-Scoenlein purpuraDiabetesPorhyriaUremiaHyperlipidemaiAddisonian crisis

Circulatory diseasesCardiac failureMicroemboli

IntoxicationLeadThalliumFungiCertain insect and snake bites

MiscelaneousPneumoperitoneum secondary to mediastinal emphysemaParalytic ileusLabor (pregnancy)Muscle strain (exercise, coughing)Idiopatic conditions

Table 5. Differential Diagnosis Between Intestinal Strangulation and ObstructionStrangulation Obstruction Sudden onset Gradual onset, often accompanied bySevere pain prodrome and/or associated diseaseEarly onset of emesis (usually colorless, processFormy, “nagging,” not followed by relief) Oveflow emesis (bilious,fouls smellingShock floccular, perceived as providing relief)0Blood and mucus in stool No flatus or stool abdominal distension

May be absent with high obstruction)Aspiration pneumonia Danger of adynamic ileus, dehydration,Heat loss, aspiration.

Urgent prompt action required Adequate preparation required

Table 6. Factors That Influence the Timing of OperationThe patient

Heemodynamic, ventilatory, electrolyte status, associated conditions and risk factors, medication, allergies pain.

The surgeonExperience, availability of help, stress, other commitments, sleep deprivation

The environmentThe operating team, availability, hour of dayAnaesthesia: experience, availabilitySupport services: blood banks, pathology, radiologyOther: Intensive care unit and expert postoperative nursing availability, child’s family, medico-legal issues.