Acute Abdomen Flashcards
How common is abdominal pain in children?
Childhood abdominal pain is a very common reason for parents to seek medical advice. For most children the presenting abdominal pain is functional and is benign and self-limiting
Acute abdominal pain is a common complaint in childhood and it can be caused by a wide range of underlying surgical and non-surgical conditions.
What is the most common non-surgical cause of abdominal pain?
Gastroenteritis
History findings of acute abdominal pain in children
This varies according to the age of the patient.
Neonates and babies may present with crying and difficulty feeding.
Toddlers - can usually answer simple questions.
Teenagers - may be more embarrassed to talk about the pain.
Ask about duration, location, character.
Associated symptoms include vomiting, diarrhoea, fever, groin pain, urine symptoms, bloody diarrhoea, vaginal discharge.
Also enquire about recent travel history.
Gynaecological and sexual history may also be appropriate.
Physical examination findings in children presenting with acute abdominal pain
Note whether the child looks ill.
Babies may have abnormal facial expressions.
Haemodynamic status - pulse rate, blood pressure in older patients, mucous membranes, urine - eg, wet nappy.
Rash - eg, Henoch-Schönlein purpura.
Icteric
Temperature.
Note whether the child can be distracted from the pain.
Ask the patient to suck the abdomen in and blow it out.
Get them to point at the pain with one finger.
Check the abdomen for tenderness, rebound tenderness, guarding, organomegaly, loin pain, bowel sounds.
In males, check the testes for torsion.
Rectal and vaginal examinations should only be performed if they will provide significant information.
Other system examination as appropriate.
Urine dipstick.
Causes of abdominal in children less than 1 year
Gastroenteritis Constipation UTI Intussusception Volvulus Incarcerated hernia Infantile colic Hirschsprung’s disease
Causes of abdominal pain in children between the ages of 2 and 5
Gastroenteritis Constipation UTI Appendicitis Volvulus Trauma Intussusception Mesenteric lymphadenitis Henoch-Schonlein purpura DKA Sickle cell crises
Causes of abdominal pain between 6-11 years
Gastroenteritis Constipation UTI Appendicitis Pneumonia Trauma Mesenteric lymphadenitis Henoch-Schonlein purpura DKA Sickle cell crises Abdominal migraine Functional pain
Causes of abdominal pain in children between the age of 12-8
Gastroenteritis Constipation Appendicitis Ovarian torsion Testicular torsion Dysmenorrhoea Mittelschmerz Threatened abortion Ectopic pregnancy PID IBD Adrenal crisis Trauma DKA
Investigations for acute abdominal pain
These will depend upon the clinical findings and may not be needed – e.g., viral gastroenteritis.
Urinalysis - microscopy, culture, sensitivities, stone analysis.
Blood tests - capillary blood glucose, plasma glucose, FBC, renal function, liver function, inflammatory markers, amylase.
Other blood tests if indicated – e.g., paracetamol levels, TFTs.
Stool samples if there is diarrhoea - microscopy, culture and sensitivity; ova, cysts and parasites.
Abdominal imaging - abdominal X-ray (looking for obstruction), CXR (looking for pneumonia and air under the diaphragm), ultrasound scan of the abdomen and testes.
CT scan may also be appropriate.
More specialist investigations – e.g., barium enema - will depend upon preliminary findings.
BM glucose for children presenting with acute abdominal pain to rule out DKA
What is the management of acute abdominal pain?
This depends on the cause. Self-limiting causes - eg, gastroenteritis - may just require reassurance and simple advice to parents and carers.
The advice should include continued use of the child’s usual and age-appropriate diet to prevent and limit dehydration.
Clear liquids should not be substituted for oral rehydration solutions or regular diets to prevent or treat dehydration.
For other causes, more specific therapies may be required - eg, surgery in appendicitis, treatment of diabetic ketoacidosis with insulin, fluids and potassium.
What is infantile colic?
Infantile colic (gripe):
o Occurs in babies in the first few months after the birth month.
o Babies scream, draw up their knees and experience severe pain.
o Episodes can last up to three hours and occur often in a week.
o Changes in feed type and routine may help.
o Over-the-counter medicines - eg, simeticone - may help but have not been proven to be of benefit
What is mesenteric lymphadenitis?
This is associated with adenoviral infection.
It presents similarly to appendicitis but there is no peritonism.
The abdominal pain tends to be more diffuse.
There may also be generalised lymphadenopathy.
What are the pitfalls of dealing with acute abdomen in children?
The diagnosis and excluding serious underlying conditions may be particularly difficult with infants and young children.
In females, always consider gynaecological disorders and pregnancy-related disorders (you may need to speak to the patient alone).
Male patients - always consider torsion of the testes.
Consider illicit drug use.
Consider whether there is a possibility of child abuse.
Additional management may include:
- Referring the patient if you are unsure or concerned.
- Repeating the physical examination - may help.
- Using analgesia as required - it does not affect diagnostic accuracy
What are the red flag signs that should prompt consideration of further investigations in a child presenting with acute abdomen?
Age <5
Systemic symptoms such as weight loss, recurrent oral ulcers, fever; dysphagia; vomiting (especially haematemesis, bilious)
Nocturnal symptoms awakening child from sleep (be sure to differentiate waking from sleep vs stopping child from getting to sleep)
Persistent right upper or right lower abdominal pain
Dysuria/ haematuria/ flank pain
Chronic NSAID use
Family history of IBD/ coeliac/ peptic ulcer disease
growth deceleration
delayed puberty
Jaundice
pallor
rebound/ guarding/ organomegaly
perianal disease
blood in stool
What are the common causes of malaena in children?
Infective – bacterial diarrhea eg campylobacter, salmonella Inflammatory bowel disease Tearing from anal vein Polyp Intussusception – acutely unwell
