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| ACUTE ABDOMEN |
Dr Ira Shah
M.D, DCH(Gold Medalist), FCPS, DNB
Abdominal pain is one of the most common presentations in the pediatric emergency department. The most important concern is to decide if the condition requires surgical intervention or can be managed medically.
What is important is to note whether the pain is constant or colicky
and the site and radiation of pain. Also, other associated features such
as nausea, vomiting, bowel or urinary complaints, vaginal bleeding aid
in the diagnosis. Clinical examination findings such as presence of fever,
tenderness, rigidity (indicates peritoneal inflammation), organomegaly,
increased/decreased bowel sounds, pallor, jaundice usually helps to determine
the cause of pain.
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Causes of acute abdomen |
In first few years of life –
- Congenital abnormalities
- Incarcerated inguinal hernia
- Intussuception
- Intestinal volvulus
- GI perforation
- NEC in preterm neonates
In older children-
Trauma
- Pancreatitis
- Meckel’s diverticulum
- Primary peritonitis
- Intestinal worm infestation
In adolescents –
- Acute appendicitis
- Cholecystitis (acalculous)
- Testicular torsion
- Rupture of ovarian cyst
Non- surgical causes of abdominal pain –
Hyperthyroidisin
- Addison’s disease
- Diabetic ketoacidosis
- Hypercalcemia
- Lead poisoning
- Porphyria
Non-specific abdominal pain
It is the most common cause of abdominal pain in late childhood and early
adolescence. It is a colicky pain with some localization that becomes
worse after meals. Bowel sounds may be increased and a palpable mass of
feces may be present in right or left iliac fossa. The causes commonly
are constipation, irritable bowel and chronic spasm.
The treatment consists of antispasmodics.
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Investigations in a child with acute abdomen: |
- Abdominal X-Ray/Chest X-Ray erect – Look for bowel obstruction calcification, free air and lower lobe pneumonia. Also soft tissue mass may be seen
- Ultrasound of both pelvis and upper abdomen – For hepatobiliary, renal and gynaecological pathology.
- Complete blood count Increased in case of necrosis, bacterial infection, abscess
- Peripheral smear for HUS, Sickle cell.
- Urine examination for UTI, porphyria
Additional investigations
- Serum Amylase/lipase – for pancreatitis
- Blood cultures
- Beta HCG
- CT scan for abdomen
- Stool examination for worm infestation
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Typical presenting clinical characteristics of common abdominal disorders in infants and children
| Diagnosis |
Age/Sex |
History |
Physical
Examination |
Lab Analysis |
Radiology
(Abdomen) |
Treatment |
| Appendicitis |
Peak:10-12 years M:F=3:2 |
Periumbilical pain (early) followed by vomiting and localized right lower quadrant pain. |
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Fever >100.5 degree F.
- Localized right lower quadrant peritonitis |
Increased WBC (> 10000/cumm) |
X-Ray
- Concave curvature of spine to the right.
- Presence of faecolith in 5–10 %
USG
- Pericolic /appendicea fluid and/or edema.
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- IV Fluids,
- Antibiotics,
- Antispasmodics
- Appendectomy |
| Intussuception |
5 – 9 months
M:F= 3:2 |
- Paroxymal crampy abdominal pain followed by periods of calm
- Nonbilious vomiting (early), later bilious vomiting
- Currant jelly stools. |
- Fever
- Distension (late sign)
- Right Sided mass (85%) |
- Dehydration
- Pallor
- Later increased WBC. |
X-Ray – Obstructive pattern
USG – "Pseudo kidney" and "target" sign Contrast enema – Intussuception and failure of gas/contrast to reflux in the small bowel |
- Ba enema / Gastrograffin enema,
- In severe cases: Operative reduction, Resection and end-to-end anastomosis. |
| Malrotation / midgut volvulus |
< 1 month
M:F=3:2 |
Unexpected bilious vomiting in an otherwise healthy infant |
- Is normal in early stages
- There may be tenderness.
- Distension and peritonitis may be late features |
- Dehydration
- Anemia
- Increased WBC (late sign). |
X-Ray – Distended stomach, gasless abdomen (high obstruction).
Upper GL contrast
Study – Abnormal duodenal sweep
Lower GI contrast study – Caecum in the left abdomen or RUQ |
- Surgical reduction,
- Adhesionolysis. |
| Incarcerated inguinal hernia |
<1 year
F>M |
- Irritability,
- Crampy, abdominal pain.
- Early – nonbilious vomiting, later bilious vomiting.
- Previously noted groin mass. |
- Firm, tender groin or scrotal mass.
- Abdominal distension is seen in late stages |
- Dehydration - Later- Increased WBC |
X-Ray – Obstructive pattern |
Surgery and hernitomy. |
| Cholelithiasis |
All |
- Associated illness
>- Hemolytic anemia
- Nausea, vomiting,
- Vague right upper quadrant pain |
Minimal physical findings |
Normal |
USG – Gall bladder stones/sludge |
Cholecystectomy |
| Cholecystitis |
All |
- Fever
- Right upper quadrant pain
- Nausea, vomiting |
- Fever,
- Right upper quadrant tenderness
- Mass |
- Increased LFT,
- Increased WBC |
USG – Gall bladder distension, thickening, stones/sludge
- Pericholecystic fluid
HIDA scan – Non functioning gall bladder |
IV Fluids, IV antibiotics,Antispasmodics, Cholecystectomy |
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Management of acute abdomen |
Along with treatment of the specific conditions, patients may require
intravenous fluids, antibiotics and antispasmodics. The commonly used
antibiotics are ampicillin (100 mg/kg/d), gentamicin (5 mg/kg/d), clindamycin
(40 mg/kg/d) or metronidazole (30 mg/kg/d). Other antibiotics such as
third generation cephalosporins are also useful. Surgical treatment would
depend on the presenting cause.
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Last created on 23-02-2001
Last updated on 01-07-2006 |
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