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ABDOMINAL PAIN IN CHILDREN

Deddy S Putra

Child Health Department


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Abdominal pain :

Common symptom

Lesion: - intra abdomen

- extra abdomen

For early diagnosis: - careful anamnesis

- physical examination

- further investigation

Surgical case or not?


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Source of abdominal pain :

Viscera abdomen

Others organ outside of abdomen

Lesion of Medulla Spinalis

Metabolic disturbance

Psychosomatic


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Pathogenesis

1. Vascular disorders

(emboli / thrombosis, rupture, occlusion causedby torsion or tension)

2. Inflammation Pain if the inflammation process are in

peritoneum parietalis somatic inervation

Local pain or general pain.

Type of pain : stabile, increase with movement ofinflammatory peritoneum


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3. Passage disorders/obstruction of luminalorgan in peritoneal or retroperitoneal cavity

Partial obstruction or total obstruction intra

lumen pressure pain

4. Traction, inflammation and stretching of

peritoneum visceralis


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Fore gut pain in upper abdomen

Mid gut pain in middle abdomen

Hind gut pain in lower abdomen

Muscle spasm colic which difficult toinvestigate the localization, not influenced withcough or abdominal pressure

Peritoneal irritation pain in the field ofirritation, stable, influenced by cough andabdominal pressure

Type of pain and source of pain


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Referred pain

Disorders of extra abdominal organ (i.e.

thorax) sensory inervation (N. Vagus)abdominal pain


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Infant commonly caused by obstruction

a. Colic

b. Constipation

c. Volvulusd. Intussusceptions/invagination

e. Strangulated hernia

f. Pyloric stenosis

g. Perforation of gastrointestinal tract

h. Appendicitis

i. Acute hydrops of gallbladder

Cause of abdominal pain by age groups(Chamberlain and Recee, 1978)


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a. Gastroenteritis

b. Appendicitis

c. Mesenteric lymphadenitis

d. Meckels diverticulume. Ileitis regional

f. Colitis ulserativa

g. Diabetic acidosis

h. Pneumonia

i. Torsion of ovarian cord

j. Constipation

Older child commonly caused by infection

k. Pyelonephritis

l. Colic Ureter

m. Lead intoxication

n. Torsion of spermatic cordo. Abdominal epilepsy

p. Sickle cell crisis

q. Mononucleosis

r. Porphiria

s. Cholecystitis andcholelytiasis

t.

Pancreatitis


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Cause of acute abdominal pain by age groups,that requirring surgical intervention

(Walker-Smith et al, 1983)

Infant / age < 2 years old

Abdomen :

Perforation of gastric ulcers

Bowel obstruction : - intusussception

- volvulus and malrotation

Appendicitis and enterocolitis necroticans

Extra abdomen :Inguinal hernia with strangulation and incarceration


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Age > 2 years old

Abdomen:a. Obstruction

Bowel obstruction caused by fibrosis, volvulus, malrotation

Perforation caused by bowel obstruction

b. Inflammation (appendicitis, primary peritonitis, peritonitiscaused by Meckels diverticle perforation, perforation ofduodenal ulcer, perforation caused by typhoid fever, Meckelsdiverticulitis, cholecystitis with or without gall stone, toxicmega colon with perforation)

c. Trauma (rupture of spleen, urinary bladder, another visceralorgans, hematoma sub serosa)

d. Bleeding (bleeding intra ovarian cyst)

e. In tropic area (perforation associated with ascariasis,strongiloidiasis, jejunitis necrotican in New Guinea, perforation

of abscess amoeba)


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Infant / age < 2 years old

Abdomen :

- Intestinal infection

Extra abdomen :

- Pneumonia

- Urinary tract infection

Cause of non surgical abdominal pain(Walker and Smith, 1983)


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Infant / age > 2 years old

Abdomen :a. Intestinal

- Infection (Salmonella, Shigella, Campylobacter,Yersinia enterocolitica)

- Food intoxication (Toxin of Staphylococcus, etc)- Purpura Henoch Schonlein (purpura anaphylactoid)- Crohns disease- Colitis ulcerative

- Colitis amoeba- Fecal impaction- Sickle cell anemia- Ileus meconeum

- Adenitis mesenterica


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b. Liver and billiary tree- Hepatitis- Cholelytiasis

c. Pancreas- Pancreatitis

d. Kidney- Urinary tract infection- Stone- Nephritis

e. Metabolic- Phorphiria- Hiperlipidemia- Diabetic keto acidosis

- Familial Mediterraneanfever

f. Gynecologic- Salphyngitis


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Cause of abdominal pain in Indonesia

Neonatal - 3 months

- Cows milk allergy- Pyloric hypertrophy

- Torsion of testis- Obstipation/with

anal fissure- Bowel malrotation

3 months2 years

- Obstipation- Gastroenteritis

- Bowel duplication- Maldigestion- Gastric mucosal

membrane

- Meckels diverticulum


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> 5 years

- Appendicitis- Gastritis

- Ovarian torsion- Menstrual cycle- Cholecystitis- Functional

abdominal pain- Urinary tract stone- Varicocele testis

2 years5 years

- Obstipation- Volvulus

- Hepatitis- Urinary tract

infection- Ascariasis

- Appendicitis- Pancreatitis


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0 - 3 months : vomiting

3 months2 years : vomiting, pitching/crying,

trauma(-) 25 years : can tell the pain, localization not

true

> 5 years : can tell the type and localization ofthe pain

Clinical manifestation by age group( Halimun 1980 )


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Diagnostic approach

1. Anamnesis

2. Physical examination

3. Laboratories and further investigation


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Anamnesis

Age

Pain (localization , type, time, frequency, other symptom)

Defecation pattern

Urination pattern Menstrual cycle

Skeletal muscle disorders

Growth and development disorders

Psychosocial aspect

Trauma

History of family disease


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Physical examination

1. Comprehensive

2. In abdomen and extra abdomen


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Therapy

Require surgical intervention?

Depend on etiology


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Surgical abdominal pain

Abdominal pain that require surgicalintervention

Symptoms

- Severe pain, stable, onset 3-4 hours

- Vomiting : green or fecal- Increase temperature


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Physical examination

Localized or generalized peritoneal sign

Sign of obstruction

- Abdominal distention

- Bowel contraction and peristaltic

Tumor mass

Anorectal bleeding


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Abdominal emergency

Rigidity of abdominal wall

Tenderness

Rebound tenderness Defense muscular


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Further investigation

Abdominal plain photo

Barium meal/follow through

Barium enema Intravenous pyelographyif suspected

urinary tract disorders

Ultrasound Endoscopy


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Therapy

Exploration/operation laparotomy


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Definition (Apley, 1975)

Recurrent abdominal pain is intermittent

abdominal pain at least 3 times whichpersists for longer than 3 months andaffects normal activity

Recurrent abdominal pain


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Etiology

Organic 5-15,6% cases

Functional 80%


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Cipto Mangunkusumo Hospital (1988)

17 cases

47% spasmophylia

11.8% gastritis

5.9% colitis

29.4% worms infection

11,8% psychological/psychiatric disorders


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Recurrent abdominal pain concept

1. Classical (2 groups)

Organic

Functional2. Barr

Organic

DisfunctionalPsychogenic

3. Levine & Rappaport


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Life style

Environment and

Inducers

BehaviorResponse pattern

Somatic predisposition

DisfunctionOrganic disorders

Levine and Rappaport1984


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Etiology of abdominal pain

Gastrointestinal

Chronic diarrheaPeptic ulcersBezoarDuplication

Intermittent volvulusMeckels diverticulumAppendicitisMesenterical adenitisAbdominal TBc

Milk protein intolerancelactose intoleranceConstipatianAscariasis

Drugs

Anti convulsionAntibioticBrochodilator

Urinary tract

HidronephrosisPyelonephritisStone

Renal neoplasmOvarian cystDismenorrheaEndometriosisiTestis torsion

Testis neoplasm

Liver, spleenand pancreas

CholecyctitisCholelithiasisPancreatitisMassive spleenomegali

Metabolic

Hypoglycemia

PhorphiriaLead intoxicationHyperlipidemiaAngioneurotic edema


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Symptoms suggested organic disorders

Persistent fever

Growth and development disturbance

Weight loss

Anemia

Hematemesis

Melena

Hematochezia Pain away from midline

Perianal disease


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Diagnostic approach

1. Careful anamnesis, Physical examination,and further investigation

2. High cost examination and commonly wasnot positive

3. Endoscopygreater probability to find theetiology


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Laboratory and further investigation

Routine ( urine, blood, feces) Ureum, creatinine

Culture

3 positions of abdominal plan photo Thorax photo (severe disease)

Barium meal/follow through

Barium enema Intravenous pyelography

Ultrasound

Endoscopy


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Therapy

Depend on etiology

Sedative and analgesic

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