Non traumatic abdominal pain in children
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Non traumatic abdominal Non traumatic abdominal pain in childrenpain in children
ByBy
Hatem SaafanHatem SaafanMD FRCSMD FRCS
Prof. of pediatric surgeryProf. of pediatric surgeryAin-Shams universityAin-Shams university
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There is considerable variation There is considerable variation among children in their perception among children in their perception and tolerance for abdominal painand tolerance for abdominal pain . .
A specific cause may be difficult to find, but the nature and location of a pain-provoking lesion can usually be determined from the
clinical description .
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Two types of nerve fibers transmit Two types of nerve fibers transmit painful stimuli in the abdomen. In painful stimuli in the abdomen. In skin and muscle, A fibers mediate skin and muscle, A fibers mediate sharp localized pain; C fibers from sharp localized pain; C fibers from viscera, peritoneum, and muscle viscera, peritoneum, and muscle transmit poorly localized, dull paintransmit poorly localized, dull pain . .
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Somatic painSomatic pain
Intense and is usually well localized. When the Intense and is usually well localized. When the inflamed viscus comes in contact with the somatic inflamed viscus comes in contact with the somatic
organ like the parietal peritoneum or the organ like the parietal peritoneum or the abdominal wall, pain is localized to that site. abdominal wall, pain is localized to that site.
Peritonitis gives rise to generalized abdominal Peritonitis gives rise to generalized abdominal pain with rigidity, involuntary guarding, rebound pain with rigidity, involuntary guarding, rebound tenderness, and cutaneous hyperesthesia on tenderness, and cutaneous hyperesthesia on
physical examination.physical examination.
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Visceral painVisceral pain
tends to be dull and aching and is tends to be dull and aching and is experienced in the dermatome from which the experienced in the dermatome from which the
affected organ receives innervations. So, affected organ receives innervations. So, most often, the pain and tenderness is not felt most often, the pain and tenderness is not felt
over the site of the disease processover the site of the disease process..
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Painful stimuli originating in the liver, pancreas, biliary tree, stomach, or upper bowel are felt in the epigastrium
Pain from the distal small bowel, cecum, appendix, or proximal colon is felt at the umbilicus
Pain from the distal large bowel, urinary tract, or pelvic organs is usually suprapubic
Pain from the cecum, ascending colon, and descending colon sometimes is felt at the site of the lesion due to the short mesocecum and corresponding mesocolon
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The shifting (localization) of pain is a pointer The shifting (localization) of pain is a pointer toward diagnosis; for example; Periumbilical pain toward diagnosis; for example; Periumbilical pain
of a few hours localizing to the right lower quadrant of a few hours localizing to the right lower quadrant suggests appendicitis. suggests appendicitis.
Radiation of pain can be helpful in diagnosis;Radiation of pain can be helpful in diagnosis; for example, in biliary colic the radiation of pain is for example, in biliary colic the radiation of pain is
toward the inferior angle of the right scapula, toward the inferior angle of the right scapula, pancreatic pain radiated to the back, and the renal pancreatic pain radiated to the back, and the renal colic pain is radiated to the inguinal region on the colic pain is radiated to the inguinal region on the
same side.same side.
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Referred painReferred pain
due to shared central projections with the due to shared central projections with the sensory pathway from the abdominal wall, sensory pathway from the abdominal wall,
can give rise to abdominal pain, as in can give rise to abdominal pain, as in pneumonia when the parietal pleural pain is pneumonia when the parietal pleural pain is
referred to the abdomenreferred to the abdomen . .
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Pain that suggests a potentially serious Pain that suggests a potentially serious organic etiology is associated withorganic etiology is associated with
Age <5 yr; fever; weight loss; bile or blood-Age <5 yr; fever; weight loss; bile or blood-stained emesis; jaundice; stained emesis; jaundice;
hepatosplenomegaly; back or flank pain or hepatosplenomegaly; back or flank pain or pain in a location other than the umbilicus; pain in a location other than the umbilicus; awakening from sleep in pain; referred pain awakening from sleep in pain; referred pain to shoulder, groin or back; elevated ESR, to shoulder, groin or back; elevated ESR,
WBC, or CRP; anemia; edema; or a strong WBC, or CRP; anemia; edema; or a strong family history of inflammatory bowel disease family history of inflammatory bowel disease
(IBD) or celiac disease(IBD) or celiac disease..
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Atypical painAtypical pain
Diagnostic dilemma Diagnostic dilemma
Clinical observationLaboratoryRadiological imagingLaparoscopy
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CHRONIC ABDOMINAL PAIN IN CHRONIC ABDOMINAL PAIN IN CHILDRENCHILDREN
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NONORGANIC
Functional abdominal
painNonspecific pain, often periumbilical
Hx and PE; tests as indicated
Irritable bowel
syndrome
Intermittent cramps,diarrhea, and constipation
Hx and PE
Non-ulcer dyspepsia
Peptic ulcer–like symptoms without abnormalities on evaluation of the upper
GI tract
Hx; esophagogastrod
uodenoscopy
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GASTROINTESTINAL TRACT
Chronic constipation
Hx of stool retention, evidence of constipation on
examination
Hx and PE; plain x-ray of abdomen
Lactose intolerance
Symptoms may be associated with lactose ingestion; bloating, gas,
cramps, and diarrhea
Trial of lactose-free diet; lactose breath hydrogen test
Parasite infection
(especially Giardia)
Bloating, gas, cramps, and diarrhea
Stool evaluation for O&P; specific immunoassays for
Giardia
Excess fructose or
sorbitol ingestion
Nonspecific abdominal pain, bloating, gas, and diarrhea
Large intake of apples, fruit juice, or candy or chewing gum sweetened with sorbitol
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Peptic ulcer
Burning or gnawing epigastric pain; worse on awakening or before meals; relieved with
antacids
Esophagogastroduodenoscopy or upper GI contrast x-rays
EsophagitisEpigastric pain with substernal burning
Esophagogastroduodenoscopy
Meckel's diverticulum
Periumbilical or lower abdominal pain; may have
blood in stoolMeckel scan
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Recurrent intussusception
Paroxysmal severe cramping abdominal pain; blood may be present in stool with episode
Identify intussusception during episode or lead point in intestine between episodes with contrast
studies of GI tract
Internal, inguinal, or
abdominal wall hernia
Dull abdomen or abdominal wall pain
PE, CT of abdominal wall
Chronic appendicitis or
appendiceal mucocele
Recurrent RLQ pain; often incorrectly diagnosed, may be rare cause of abdominal pain
Barium enema, CT
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GALLBLADDER AND PANCREAS
CholelithiasisRUQ pain, might
worsen with mealsUltrasound of gallbladder
Choledochal cyst
RUQ pain, mass ? elevated bilirubin
Ultrasound or CT of RUQ
Recurrent pancreatitis
Persistent boring pain, might radiate to back, vomiting
Serum amylase and lipase ? serum trypsinogen; ultrasound or CT of
pancreas
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GENITOURINARY TRACT
Urinary tract infection
Dull suprapubic pain, flank pain
Urinalysis and urine culture; renal scan
HydronephrosisUnilateral abdominal or
flank painUltrasound of kidneys
UrolithiasisProgressive, severe pain; flank to inguinal region
to testicle
Urinalysis, ultrasound, IVP, CT
Other genitourinary
disorders
Suprapubic or lower abdominal pain;
genitourinary symptoms
Ultrasound of kidneys and pelvis; gynecologic
evaluation
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MISCELLANEOUS CAUSES
Abdominal migraine
Nausea, family Hx migraineHx
Abdominal epilepsy
Might have seizure prodromeEEG (can require >1 study,
including sleep-deprived EEG)
Gilbert syndromeMild abdominal pain (causal or coincidental?); slightly
elevated unconjugated bilirubinSerum bilirubin
Familial Mediterranean
fever
Paroxysmal episodes of fever, severe abdominal pain, and tenderness with other evidence of polyserositis
Hx and PE during an episode, DNA diagnosis
Sickle cell crisisAnemiaHematologic evaluation
Lead poisoningVague abdominal pain ? constipationSerum lead level
Henoch-Schonlein purpura
Recurrent, severe crampy abdominal pain, occult blood in stool, characteristic rash, arthritis
Hx, PE, urinalysis
Angioneurotic edema
Swelling of face or airway, crampy painHx, PE, upper GI contrast x-rays,
serum C1 esterase inhibitor
Acute intermittent porphyria
Severe pain precipitated by drugs, fasting, or infectionsSpot urine for porphyrins
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ACUTE GASTROINTESTINAL ACUTE GASTROINTESTINAL TRACT PAIN IN CHILDRENTRACT PAIN IN CHILDREN
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DISEASEONSETLOCATIONREFERRALQUALITYCOMMENTS
PancreatitisAcuteEpigastric, left upper quadrant
BackConstant,
sharp, boringNausea, emesis,
tenderness
Intestinal obstruction
Acute or
gradual
Periumbilical-lower abdomen
Back
Alternating cramping
(colic) and painless periods
Distention, obstipation, emesis, increased
bowel sounds
AppendicitisAcute
Periumbilical, then localized to lower
right quadrant; generalized with
peritonitis
Back or pelvis if
retrocecalSharp, steady
Anorexia, nausea, emesis, local
tenderness, fever with peritonitis
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IntussusceptionAcutePeriumbilical-lower abdomen
NoneCramping, with
painless periods
Hematochezia, knees in pulled-up position
UrolithiasisAcute, sudden
Back (unilateral)GroinSharp,
intermittent, cramping
Hematuria
Urinary tract infection
AcuteBackBladderDull to sharp
Fever, costo-vertebral angle tenderness, dysuria, urinary
frequency
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Acute ScrotumAcute Scrotum(Acute Scrotal pain)(Acute Scrotal pain)
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CausesCauses
1 -Testicular Torsion.
2 -Torsion Testicular Appendix
3- Epididymo-orchitis
4 -Trauma :Hematocele ; Testicular Rupture
5 -Strangulated Inguinoscrotal hernia
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Inguinal HerniaInguinal Hernia
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Definition of HerniaDefinition of Hernia
Descriptive: Swelling in the anatomical region of the hernias, giving expansile impulse on cough.
Pathologic: Protrusion of a sac of peritoneum together with preperitoneal fat or an organ through a congenital or acquired defect in the muscles of the abdominal wall through which they do not normally pass.
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Classification of Hernias in ChildrenClassification of Hernias in Children
Congenital Inguinal Hernia
Umbilical Hernia
Diaphragmatic Hernia
Incisional Hernia
Rare Hernias : Epigastric, Lumber, Femoral and Spigellian
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Congenital Inguinal Hernia Congenital Inguinal Hernia In MalesIn Males
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PROCESSUS VAGINALISPROCESSUS VAGINALIS
An out-pouching of the peritoneum extending through the IR, ER and reaching the scrotum.Closes at 6 months of age.
Doesn’t mean inguinal hernia (in minority it remains patent and
assymptomatic) .Potential space.
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Incidence:0.8 - 4.4% in full term
16-25% in premature infants3-10 times more than females
Type: Indirect inguinal hernia
Content: Intestine, omentum
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Site:Site: Bilateral < 50%, in unilateral Bilateral < 50%, in unilateral cases: Right side predominates cases: Right side predominates
(mostly due to later descent of the (mostly due to later descent of the right testis). right testis).
Complications:Complications:
Irreducibility, Testicular atrophy, Irreducibility, Testicular atrophy, Strangulation, obstruction, Strangulation, obstruction,
HydrocoeleHydrocoele
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Irreducible left inguinal Hernia
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Strangulated Appendix in
Right inguinal Hernia
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OperationOperationUnilateral herniotomy
Once detected (repaired as soon as possible within 4 weeks)
Contra lateral exploration:????
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Congenital Inguinal Hernia Congenital Inguinal Hernia In FemalesIn Females
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Incidence:
0.8 - 4.4% in full term
16-25% in premature infants
3-10 times less than males
Type: Indirect
Content: Ovary
Site: Bilateral more than 50%, in unilateral cases: Right side predominates .
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Complication:Complication: Ovarian affection Ovarian affection
Operation:Operation:Herniotomy once detectedHerniotomy once detected
Contra lateral explorationContra lateral exploration??? ???
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Testicular Torsion
Torsion occurs when an abnormally mobile testis twists on the spermatic cord, obstructing its blood supply.
Patients present with acute onset of severe testicular pain.
The ischemia can lead to testicular necrosis if not corrected within 5-6 hours of the onset of pain.
Torsion can be intermittent and can undergo spontaneous de-torsion.
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Clinical PictureClinical Picture
Age:Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age .
Symptoms:Acute onset of painful hemiscrotum.Sometimes with nausea and vomiting.
On examination:The testis is usually elevated as a result of the torsion and the shortening of the cord itself and may be in a transverse lie .
The affected side can be larger from the other side due to:The swollen testis itself, a hydrocele or skin thickening.
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Duplex may help to confirm diagnosis.Yet if in doubt or not available, explore.
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Undescended Testes increase the Undescended Testes increase the liability for torsionliability for torsion
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In a child with an acute scrotum, testicular torsion is not the most common condition yet the most important one.
Torsion of testicular appendices represents the more common cause of scrotal pain.
Typically, it has a more gradual onset than testicular torsion and patients may endure pain for several days before seeking medical attention.
Duplex may help
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Epididymo-orchitis
The most common inflammatory process involving the scrotum.
Infections generally originate in the lower urinary tract from the bladder, urethra or
prostate .
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Protocol for the diagnosis and Protocol for the diagnosis and treatment of the acute scrotumtreatment of the acute scrotum
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