Paediatric acute abdomen by sdsdfqw21


									                                          PAEDIATRIC EMERGENCIES

                        Paediatric acute abdomen
                                                       Phil Hammond, Joe Curry

INTRODUCTION                                                                           TABLE 1.
A large proportion of children assessed                                   The acute abdomen: taking a history
in hospital with abdominal pain will
                                                 Question                   Specific considerations
leave with no definitive diagnosis. The
challenge is to treat the majority of chil-      Characteristics of pain Type, position, radiation, exacerbating, relieving factors
dren with self-limiting but benign con-          Gastrointestinal           Anorexia, nausea, vomiting* (bilious or not), diarrhoea or
                                                 symptoms                   constipation
ditions and to swiftly identify and treat
the child with an uncommon but poten-            Other symptoms             Fever, headache, sore throat, cough, otalgia, dysuria
tially life-threatening cause of pain.           Other history              Recent food ingestion, foreign travel, history of illness in family
                                                                            members or class mates

CLINICAL APPROACH                                Past history               Number of previous episodes and outcome, full medical history
                                                                            including antenatal scans/diagnosis, other conditions, vaccinations
Managing acute abdominal pain in
                                                 Family                     Known illnesses (e.g. sickle cell anaemia), dynamics
children can be a major cause of stress                                     (e.g. who else is at home, who has attended with child?)
for the child, parent and clinician alike.
                                                 Other                      Menarche, dysmenorrhoea, history of unprotected sex
A calm and child-friendly dedicated
                                                 Social                     Who is primary carer? (or who has legal guardianship – do not
paediatric environment supported by                                         assume it is the parent), if multiple attendances or incompatible
specifically trained staff will enhance                                     history then check if child has social worker or is on the at-risk register
the clinician’s ability to gain the confi-       *A history of bilious (green) vomiting in infancy and childhood should always be taken to indicate intestinal
                                                 obstruction until proven otherwise.
dence of the parents and child alike.
                                                cumstances. Analgesia should be given                     INVESTIGATIONS
HISTORY                                         where appropriate to allow a thorough                     Few investigations are needed or helpful
History taking should be thorough and           and proper examination – it will not                      in the initial assessment. Inflammatory
include specific questions (Table 1).           mask the true signs of peritonitis.                       markers are non-specific and equally
                                                   The assessment of deep rebound ten-                    likely to be raised in an infective but
EXAMINATION                                     derness is probably an unfair examina-                    non-surgical cause of abdominal pain.
General considerations                          tion for a child and is virtually                         Urea and electrolyte levels should be
On entering the consultation room the           unnecessary. Rectal examination also                      measured in cases of severe dehydration
child’s disposition can be revealing. One       has little to offer over a thorough                       or prolonged losses from the gastroin-
should have a high index of suspicion           pelvic ultrasound and it is a rare proce-                 testinal tract, e.g. vomiting and diar-
for children who do not object to exami-        dure in an awake child over toddler age                   rhoea. Liver function tests are required
nation or procedures such as venesec-           in the authors’ practice. Vaginal exami-                  in the presence of jaundice and other
tion. Younger children may feel more at         nation in the awake, premenarchal girl                    tests may be required based on the his-
ease if examined on the parent’s lap.           is never indicated.                                       tory, e.g. amylase or lipase, in the pres-
Gentle distraction and engaging the                Specif ic areas need always to be                      ence of severe epigastric pain. Urinalysis
child in conversation while performing          examined in the assessment of the                         is mandatory in the initial assessment to
an abdominal examination can be useful          acute abdomen (Table 3).                                  rule out urinary tract infection (UTI).
in distinguishing a child who is contract-
ing the abdominal muscles voluntarily.                      TABLE 2.                                                    TABLE 3.
   The cardiovascular status of the child        The acute abdomen: assessment                                Examination of the paediatric
should be documented and resuscita-                   of level of hydration                                         acute abdomen
tion instituted as required (Table 2).
                                                                                                            Never forget to examine:
Pyrexia should be documented as the              Tachycardia                                                Hernial orifices
pattern can have diagnostic signifi-
                                                 Tone of fontanelle (before 12 months)                      Testes (20% of children with testicular
cance (see later).
                                                 Skin turgor                                                torsion will only have abdominal pain)
   The style and format of an examina-
                                                 Mucous membranes                                           Hip joints (pathology in the hip joint can
tion will need to vary depending on the                                                                     present with abdominal pain)
age of the child and the prevailing cir-         Peripheral perfusion
                                                                                                            The lung bases thoroughly (Ravichandran
Mr Phil Hammond is Specialist Registrar in                                                                  and Burge, 1996) (pain is referred to the
                                                 Frequency of micturition (last wet nappy)
Paediatric Surgery and Mr Joe Curry is                                                                      abdomen)
Consultant Paediatric Surgeon, Great Ormond      Fall in blood pressure is a late sign of
                                                 shock in children and must be considered                   The back of the patient for bruising or
Street Hospital for Children, London WC1N 3JH                                                               contusions (trauma, non-accidental injury)
                                                 as a potential life-threatening emergency
Correspondence to: Mr J Curry

686                                                                                                Hospital Medicine, November 2004, Vol 65, No 11
  Plain radiology is often unhelpful but       Diagnosis is conf irmed with an                  stump, and intramucosal haematoma,
should be considered in the presence of      upper gastrointestinal contrast study              e.g. Henoch–Schönlein purpura.
vomiting (especially bilious), abdomi-       showing the duodenojejunal junction                   In the early stages a high index of
nal distension or previous abdominal         to the right of the midline. Surgery to            suspicion is necessary and ultrasound
surgery. Contrast radiology should be        correct malrotation should be under-               has high sensitivity and specificity, with
requested after discussion with an           taken as an emergency before the com-              a ‘target sign’ evident on transverse sec-
appropriate specialist. Ultrasound is of     plication of volvulus occurs. Midgut               tion of the intussusception (Macdonald
most use in intussusception but is also      volvulus is a dire emergency and                   and Beattie, 1995; Carty, 2002).
useful in distinguishing the cause of an     surgery should be undertaken as early                 Early diagnosis, adequate resuscita-
abdominal mass and to assess the             as safely possible, often in the absence           tion and effective reduction of the
pelvis in children (Carty, 2002).            of any diagnostic radiology. The signif-           intussusception are key to prevent mor-
                                             icance of bilious vomiting in this con-            tality. Intravenous fluid therapy is
DIAGNOSES TO CONSIDER                        dition cannot be over-emphasized.                  guided by clinical response. Antibiotics
General considerations                                                                          are required by all until reduction is
Trauma is a major cause of morbidity         Intussusception                                    complete. Reduction is most commonly
and mortality in childhood. Immediate        This invagination of one segment of                effected by pressurized air enema, with
and early mortality usually relates to       bowel (intussusceptum) into the distal             laparotomy reserved for failure or pre-
injury sustained above the neck but          bowel (intussuscipiens) is the most                existing peritonitis or perforation. Third
poly-trauma should always be suspected.      common cause of intestinal obstruction             time recurrences as well as those out-
The most common mode is direct blunt         in infants after the neonatal period,              side the typical age range should be
injury to the abdomen leading to rupture     usually occurring between 4 and                    managed operatively as this implies a
or contusion of the solid organs, e.g.       10 months of age.                                  pathological lead point.
liver, spleen or pancreas. The gut can be      Most cases (90%) are idiopathic with
injured at points of peritoneal fixation,    the commonest site (>90%) of involve-              Inguinal hernia
e.g. duodenojejunal flexure. Computed        ment being the ileocaecal region when              Inguinal hernias have a high risk of
tomography scanning with intravenous         the intussusceptum advances into vary-             incarceration in infants (10–30%), with
and if possible enteral contrast leads to    ing lengths of the colon. Lymphoid                 the attendant risk of strangulation of the
the highest diagnostic yield.                hyperplasia in the terminal ileum is               gut and testicular atrophy from pressure
   Indications for surgery are evidence      thought to provide a lead point of the             on the testicular vessels. The impor-
of hollow visceral perforation or sus-       intussusception. A preceding viral ill-            tance of examining the groin in infants
tained haemodynamic instability              ness is implicated in 30–50% of cases.             is again emphasized. Treatment involves
(Mackway-Jones et al, 2001).                   A pathological lead point occurs                 analgesia and attempted reduction by a
                                             with an incidence of between 2 and                 doctor experienced in the technique.
INFANTS (<2 YEARS)                           12% and should be suspected in older               Urgent referral to a paediatric surgery
It is outside the scope of this review to    children, and cases of recurrent or                centre is required. Traction, elevation
discuss necrotizing enterocolitis (NEC)      ileoileal intussusception. Causes                  and the application of cold compresses
and congenital causes of gastrointestinal    include Meckel’s diverticulum, polyp,              have no place in the management of the
obstruction (mostly encountered on the       lymphoma, duplication, appendiceal                 incarcerated inguinal hernia.
neonatal intensive care unit). However,
                                                                               TABLE 4.
a history of prematurity or previous              Surgical causes of acute abdomen in children under 2 years of age
intestinal surgery may indicate a spe-
cific diagnosis, e.g. colonic stricture       Condition                 History                            Examination
secondary to NEC or Hirschsprung’s            Malrotation:             Intermittent bile vomits (can be    Without volvulus no
enterocolitis (fever, abdominal pain,         predisposing to volvulus single only presenting symptom)     specific findings
distension, constipation), or raise the       Supervening midgut      Acute abdominal pain, persistent Abdominal distension,
                                              volvulus: most commonly bile vomits                      peritonitis, blood per
possibility of adhesive intestinal            in first 6 weeks                                         rectum, shock
obstruction. Previous hepatobiliary dis-      Intussusception:          Intermittent paroxysms of          Right upper quadrant mass,
ease (biliary atresia or choledochal cyst)    usually 4–10 months       abdominal colic, drawing up        empty right iliac fossa,
may make the child susceptible to             of age                    knees, vomits (may be bilious),    ‘redcurrant jelly’ stool on per
                                                                        blood per rectum, initially well   rectum examination, shock
ascending cholangitis or pancreatitis                                   between episodes                   in later stages
(Samuel and Spitz, 1996) (Table 4).           Incarcerated inguinal     Pain, bilious vomits,              Distressed, abdominal distension,
                                              hernia                    majority boys                      mass in inguinoscrotal region
Malrotation and midgut volvulus               Hirschsprung’s disease:   Failure to pass meconium in the    Abdominal distension,
Abnormal peritoneal fixation leaves the       usually in first few      first 24–48 hours of life,         rectal examination may
                                              weeks of life             constipation, abdominal            reveal a gush of meconium
midgut prone to twisting around the                                     distension (enterocolitis may
axis of the superior mesenteric vessels,                                supervene at any stage)
resulting in volvulus of the midgut.

Hospital Medicine, November 2004, Vol 65, No 11                                                                                              687
Hirschsprung’s disease                                 low threshold for ultrasound examina-                   Untreated appendicitis may progress
This disease can rarely be diagnosed                   tion and/or laparoscopy (Williams and                 to perforation and peritonitis within
beyond the typical neonatal period. A                  Kapila, 1994; Moir, 1996).                            24 hours (less in young children). A
history of delayed passage of meconium                                                                       retrocaecal appendix may have a
(beyond 24 hours) with continuing con-                 SCHOOL-AGE CHILDREN                                   longer history with no localized rigid-
stipation should be sought. Examination                (>5 YEARS)                                            ity or rebound tenderness and with
usually reveals a healthy child with                   Appendicitis                                          pelvic appendicitis the signs are often
abdominal distension. Rectal examina-                  Acute appendicitis (Table 6) is the sin-              misdiagnosed as UTI, gynaecological
tion produces an explosive decompres-                  gle commonest surgically amenable                     problems or gastroenteritis (Davenport,
sion. Clinical suspicion should prompt                 cause of abdominal pain in children,                  1996; D’Agostino, 2002).
referral to a paediatric surgeon.                      although the cause is still unclear. It is
                                                       usually a disease of older children and               Meckel’s diverticulum
PRE-SCHOOL CHILDREN                                    adolescents, with a slightly higher                   This ileal remnant of the vitellointesti-
(2–5 YEARS)                                            prevalence in boys. Symptoms typically                nal duct, present in 2% of the popula-
Appendicitis                                           begin with vague central abdominal                    tion, may contain ectopic gastric
Acute appendicitis occurs in all ages but              pain associated with anorexia and a sin-              mucosa. Presentation is usually with
pre-schoolers account for just 5% of                   gle vomit. Pain shifts to the right iliac             painless rectal bleeding that leads to a
children with appendicitis. The low inci-              fossa and, as the overlying peritoneum                significant drop in the haemoglobin. It
dence in this group means that it is often             becomes inflamed, becomes more acute                  cause an acute abdomen as intussuscep-
overlooked (Table 5); the lack of an ade-              and localized. The child is reluctant to              tion, volvulus or diverticulitis that mim-
quate omental barrier can lead to a per-               move, cough, or in any way aggravate                  ics appendicitis can occur (D’Agostino,
foration rate as high as 50%, inversely                the pain. Localized tenderness and                    2002). A technetium scan shows
proportional to the child’s age. Atypical              involuntary guarding in an ill child, usu-            increased uptake by ectopic gastric
presentation with vomiting, diarrhoea                  ally with mild pyrexia and tachycardia,               mucosa in up to 70% of cases but diag-
and pyrexia is not uncommon.                           are the commonest signs although only                 nostic laparoscopy is increasingly used.
Abdominal pain can be insignificant. A                 a third of children have such a classic
high index of suspicion is vital with a                presentation.                                         Pancreatitis
                                                                                                             Upper abdominal pain is much less
                                    TABLE 5.
                                                                                                             common in children than in adults. If it
            Surgical causes of acute abdomen in the pre-school age
                                                                                                             recurs, particularly in older children, the
 Condition            History                                      Examination                               cause may relate to gall stones (espe-
 Incarcerated    As in Table 4                                                                               cially in children with chronic haemoly-
 inguinal hernia                                                                                             sis, e.g. sickle cell anaemia), peptic
 Acute                Symptoms may be vague including lethargy Often systemically unwell, flushed,           ulcers or pancreatitis. In childhood, pan-
 appendicitis         or poor feeding, nausea/vomiting, anorexia, pyrexia (38–38.5°C)
                      diarrhoea or constipation may occur.        not invariable, dehydrated,                creatitis is often associated with a chole-
                      Central abdominal pain, localizing to right tender in right iliac fossa,               dochal cyst or may be caused by mumps
                      iliac fossa is uncommon in this age group   may progress to peritonitis quickly
                                                                                                             or trauma. The Imrie prognostic and
                                                                                                             Ranson severity scores are of doubtful
                                                                                                             significance in children (Haddock et al,
                               TABLE 6.
                                                                                                             1994; Samuel and Spitz, 1996).
  Surgical causes of acute abdomen in school-age children (>5 years)

 Condition          History                               Examination                                        Primary acute peritonitis
 Acute              Symptoms may be vague               Often systemically unwell, flushed,                  This used to be common in young girls
 appendicitis       including lethargy or poor feeding, pyrexia not invariable, dehydrated,                  following ascent of pneumococcal or
                    central abdominal pain, localizing tender in RIF, may progress to peritonitis
                    to RIF, nausea/vomiting, anorexia, quickly                                               streptococcal infection from the genital
                    diarrhoea or constipation may occur                                                      tract. Examination of a peritoneal fluid
 Meckel’s           Varies according to mode of pathology: rectal bleeding with peptic ulceration,           sample and antibiotic therapy are the
 diverticulum       intussusception in older children, and mimics appendicitis, and volvulus
                                                                                                             main treatments but laparoscopy may
 Pancreatitis       Epigastric pain often following       Shock in severe cases, tachypnoea,                 be required to exclude a surgical cause.
                    trauma or viral illness               epigastric tenderness
 Inflammatory Chronic abdominal pain,                     Cachectic, abdominal mass especially in
 bowel disease diarrhoea (mucous and                      RIF, perianal disease, extraintestinal             Inflammatory bowel disease
               blood), weight loss, lethargy              manifestations (joints, eyes, skin)                Initial presentation of inflammatory
 Testicular         History of trauma                     Pyrexia, unilaterally tender scrotum               bowel disease (IBD) may be with an
 pathology                                                                                                   exacerbation of diarrhoea, abdominal
 Tubo-ovarian       Peri/post-menarchal, cyclical,        Suprapubic tenderness                              pain and fever, or may be with a com-
 pathology          history of unprotected sex
                                                                                                             plication such as toxic dilatation.
 RIF = right iliac fossa
                                                                                                             Consideration of IBD in the differen-

688                                                                                                     Hospital Medicine, November 2004, Vol 65, No 11
tial diagnosis of acute abdomen may               diagnosis. Antibiotics should be fol-         pneumonia, sickle cell disease,
influence the threshold and procedure             lowed by an investigation of the urogeni-     ketoacidosis, hepatitis, poisoning (e.g.
of any surgical intervention.                     tal tract, perhaps with a renal ultrasound    lead), Henoch–Schönlein purpura,
                                                  and radioisotope scan. The commonest          acute porphyria, migraine or psycho-
Testicular pathology                              anomalies identified are vesicoureteric       logical causes. The history often gives
Testicular torsion causes acute scrotal           reflux, duplex collecting systems,            signif icant clues when considering
pain, usually in adolescence, which may           hydronephrosis and ureterocoeles. Only        these diagnoses.
be associated with lower abdominal                about 8% of children with a UTI have a
pain, nausea and vomiting. The main               surgically correctable condition, but         CONCLUSIONS
differential diagnoses are infection              these are important diagnoses to reach.       Despite the myriad potential causes of
(epidydimo-orchitis) or torsion of one               Obstruction at the level of the pelvi-     acute abdomen in childhood a system-
of the vestigial testicular appendages.           ureteric junction can produce acute           atic approach will help to minimize
                                                  pain. Suspicion should prompt an              missed diagnoses and resultant compli-
Ovarian pathology                                 ultrasound scan.                              cations. Children often have atypical
In teenage girls various specific condi-                                                        presentations of common entities.
tions can mimic appendicitis: ovarian             Viral-associated abdominal pain               Even when a firm diagnosis cannot be
cysts, corpus luteal cysts, mittelschmerz,        Other causes of acute abdominal pain          made early in its course certain symp-
tubal pregnancy and salpingitis. These            are best differentiated from appendicitis     toms and signs are associated with sur-
children have traditionally had the high-         by active observation with repeat             gically correctable causes of acute
est incidence of unnecessary appen-               abdominal examination after a few             abdominal pain: vomiting of bile,
dicectomies. Pelvic ultrasound and, in            hours. Viral-associated abdominal pain        asymmetric pain, localized tenderness
selected cases, diagnostic laparoscopy            (VAAP) is a poorly defined label for a        and peritonism. Muscle guarding and
will improve accuracy in diagnosis.               symptom complex of abdominal pain,            rigidity as signs of peritoneal inflam-
                                                  pronounced fever (39–40°C), and often         mation cannot be ignored, but they can
COMMON NON-SURGICAL                               a prodromal upper respiratory tract           easily be mimicked by a quick, clumsy
CAUSES OF ABDOMINAL PAIN                          infection. Abdominal examination              palpation by an inexperienced clini-
Constipation                                      shows tenderness, often moving in loca-       cian. The early involvement of a paedi-
Children with acute or chronic consti-            tion, usually without signs of periton-       atrician or paediatric surgeon in the
pation can undoubtedly experience                 ism. It is thought that inflammation of       care of children with signif icant
abdominal pain. The physician should              mesenteric lymph nodes leads to a peri-       abdominal symptoms or findings is
be wary of returning a child home with            toneal reaction; although the condition is    always appropriate. HM
this diagnosis as the parents may toler-          self-limiting differentiation from acute      Barker PA, Jutley RS, Youngson GG (2002)
ate a worsening of the symptoms based             appendicitis requires active observation        Hospital re-admission in children with non-
                                                                                                  specif ic abdominal pain. Pediatr Surg Int
on the supposition of benign cause. It            over several hours. VAAP can only be            18(5-6): 341–3
is sensible to treat with mild laxatives          diagnosed after active observation with       Carty HM (2002) Paediatric emergencies: non-
                                                                                                  traumatic abdominal emergencies. Eur Radiol
but keep an open mind for the possibil-           repeated reassessments, preferably by           12(12): 2835–48
ity of another developing condition.              the same surgeon, to exclude a known          D’Agostino J (2002) Common abdominal emer-
                                                  surgical cause of abdominal pain                gencies in children. Emerg Med Clin North
                                                                                                  Am 20(1): 139–53
Urinary tract                                     (Davenport, 1996; Simpson and Smith,          Davenport M (1996) Acute abdominal pain in
                                                                                                  children. BMJ 312: 498–501
UTIs occur mostly in pre-school chil-             1996; Barker et al, 2002).                    Haddock G, Coupar G, Youngson GG,
dren although they may present at any                Infective gastroenteritis can cause sig-     MacKinlay GA, Raine PA (1994) Acute pan-
                                                                                                  creatitis in children: a 15-year review. J
age. The classical symptoms of dysuria,           nificant abdominal pain, usually with-          Pediatr Surg 29(6): 719–22
frequency and loin pain are rarely seen           out signs on abdominal examination.           Macdonald        IA,    Beattie TF        (1995)
                                                                                                  Intussusception presenting to a paediatric
in young children but microscopy and                                                              accident and emergency department. J Accid
culture of an uncontaminated urine sam-           Rarer causes                                    Emerg Med 12(3): 182–6
                                                                                                Mackway-Jones K, Molyneux E, Phillips B,
ple, obtained by ‘clean catch’ or supra-          Other causes of abdominal pain may              Wieteska S, eds (2001) Advanced Paediatric
pubic aspirate, will help clarify the             need to be considered. These include            Life Support: The Practical Approach. 3rd
                                                                                                  edn. BMJ Books, London
                                     KEY POINTS                                                 Moir CR (1996) Abdominal pain in infants and
                                                                                                  children. Mayo Clin Proc 71(10): 984–9
   ■ No specific diagnosis will be found in up to half of children who attend hospital with     Ravichandran D, Burge DM (1996) Pneumonia
     abdominal pain.                                                                              presenting with acute abdominal pain in chil-
                                                                                                  dren. Br J Surg 83(12): 1707–8
   ■ Specific history and clinical examination by an experienced paediatrician or paediatric    Samuel M, Spitz L (1996) Choledochal cyst: var-
     surgeon can help to distinguish those with a surgical diagnosis                              ied clinical presentations and long-term results
                                                                                                  of surgery. Eur J Pediatr Surg 6(2): 78–81
   ■ Always beware of the infant or toddler with bilious vomiting. Discussion of the child      Simpson ET, Smith A (1996) The management
     with a paediatric surgeon is mandatory.                                                      of acute abdominal pain in children. J
                                                                                                  Paediatr Child Health 32(2): 110–12
   ■ Never forget to examin the hernial orifices, testes, hips and lung bases of a child who    Williams N, Kapila L (1994) Acute appendicitis
     presents with abdominal pain.                                                                in the under-5 year old. J R Coll Surg Edinb
                                                                                                  39(3): 168–70

Hospital Medicine, November 2004, Vol 65, No 11                                                                                              689

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