ABDOMINAL PAIN IN CHILDREN

Aswitha BoediarsoChild Health Department Faculty of Medicine University of Indonesia, Jakarta

Abdominal pain :Common symptomLesion: - intra abdomen - extra abdomenFor early diagnosis: - careful anamnesis - physical examination - further investigationSurgical case or not?

Source of abdominal pain :Viscera abdomenOthers organ outside of abdomenLesion of Medulla SpinalisMetabolic disturbancePsychosomatic

PathogenesisVascular disorders(emboli / thrombosis, rupture, occlusion caused by torsion or tension)InflammationPain if the inflammation process are in peritoneum parietalis somatic inervationLocal pain or general pain.Type of pain : stabile, increase with movement of inflammatory peritoneum

Passage disorders/obstruction of luminal organ in peritoneal or retroperitoneal cavityPartial obstruction or total obstruction intra lumen pressure painTraction, inflammation and stretching of peritoneum visceralis

Fore gut pain in upper abdomenMid gut pain in middle abdomenHind gut pain in lower abdomenMuscle spasm colic which difficult to investigate the localization, not influenced with cough or abdominal pressurePeritoneal irritation pain in the field of irritation, stable, influenced by cough and abdominal pressureType of pain and source of pain

Referred pain

Disorders of extra abdominal organ (i.e. thorax) sensory inervation (N. Vagus) abdominal pain

Infant commonly caused by obstructionColicConstipationVolvulusIntussusceptions/invaginationStrangulated hernia Pyloric stenosisPerforation of gastrointestinal tractAppendicitisAcute hydrops of gallbladder

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

GastroenteritisAppendicitisMesenteric lymphadenitisMeckels diverticulumIleitis regionalColitis ulserativaDiabetic acidosisPneumoniaTorsion of ovarian cordConstipation Older child commonly caused by infection

PyelonephritisColic UreterLead intoxicationTorsion of spermatic cordAbdominal epilepsySickle cell crisisMononucleosisPorphiriaCholecystitis and cholelytiasisPancreatitis

Cause of acute abdominal pain by age groups, that requirring surgical intervention(Walker-Smith et al, 1983)Infant / age < 2 years oldAbdomen :Perforation of gastric ulcersBowel obstruction : - intusussception - volvulus and malrotationAppendicitis and enterocolitis necroticansExtra abdomen :Inguinal hernia with strangulation and incarceration

Age > 2 years oldAbdomen:Obstruction Bowel obstruction caused by fibrosis, volvulus, malrotationPerforation caused by bowel obstructionInflammation (appendicitis, primary peritonitis, peritonitis caused by Meckels diverticle perforation, perforation of duodenal ulcer, perforation caused by typhoid fever, Meckels diverticulitis, cholecystitis with or without gall stone, toxic mega colon with perforation) Trauma (rupture of spleen, urinary bladder, another visceral organs, hematoma sub serosa) Bleeding (bleeding intra ovarian cyst)In tropic area (perforation associated with ascariasis, strongiloidiasis, jejunitis necrotican in New Guinea, perforation of abscess amoeba)

Extra abdomen:Torsion of testis Inguinal hernia with strangulation and incarceration

Infant / age < 2 years oldAbdomen :- Intestinal infection

Extra abdomen :- Pneumonia- Urinary tract infection Cause of non surgical abdominal pain (Walker and Smith, 1983)

Infant / age > 2 years oldAbdomen :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

b. Liver and billiary tree - Hepatitis - Cholelytiasis c. Pancreas - Pancreatitisd. Kidney - Urinary tract infection - Stone - Nephritis

e. Metabolic - Phorphiria - Hiperlipidemia - Diabetic keto acidosis - Familial Mediterranean feverf. Gynecologic - Salphyngitis

Cause of abdominal pain in Indonesia Neonatal - 3 months - Cows milk allergy - Pyloric hypertrophy - Torsion of testis - Obstipation/with anal fissure - Bowel malrotation

3 months 2 years

- Obstipation - Gastroenteritis - Bowel duplication - Maldigestion - Gastric mucosal membrane - Meckels diverticulum

> 5 years

- Appendicitis - Gastritis - Ovarian torsion - Menstrual cycle - Cholecystitis - Functional abdominal pain - Urinary tract stone - Varicocele testis

2 years 5 years

- Obstipation - Volvulus - Hepatitis - Urinary tract infection - Ascariasis - Appendicitis - Pancreatitis

0 - 3 months : vomiting 3 months 2 years : vomiting, pitching/crying, trauma(-)2 5 years : can tell the pain, localization not true> 5 years : can tell the type and localization of the pain

Clinical manifestation by age group ( Halimun 1980 )

Diagnostic approach

AnamnesisPhysical examination Laboratories and further investigation

AnamnesisAgePain (localization, type, time, frequency, other symptom) Defecation patternUrination pattern Menstrual cycle Skeletal muscle disordersGrowth and development disorders Psychosocial aspectTraumaHistory of family disease

Physical examination

Comprehensive In abdomen and extra abdomen

Physical examination

Especially in abdomen- Inspection: Asymmetry, meteorismus, bowel contour - Palpation: Stretching, pain, tumor - Percussion: Fluid? - Auscultation: Bowel sound - Rectal touchier Extra abdomen examination- Pneumonia/Acute respiratory infection - Hernia

Laboratory and further investigation

Routine ( urine, blood, feces)Culture3 positions of abdominal plan photoThorax photo (severe disease)Barium meal/follow through Barium enemaIntravenous pyelographyUltrasoundEndoscopies

Therapy

Require surgical intervention?Depend on etiology

Surgical abdominal pain

Abdominal pain that require surgical intervention Symptoms- Severe pain, stable, onset 3-4 hours - Vomiting : green or fecal- Increase temperature

Surgical abdominal pain

Obstruction- Invagination, bolus ascariasis, volvulus/rotation of gaster

Inflammation- Acute appendicitis, acute cholecystitis, peritonitis

Blood flow disturbance- Invagination, malrotation, volvulus, ovarian cyst torsion

Physical examination

Localized or generalized peritoneal sign Sign of obstruction- Abdominal distention - Bowel contraction and peristaltic Tumor massAnorectal bleeding

Abdominal emergency

Rigidity of abdominal wallTenderness Rebound tenderness Defense muscular

Further investigation

Abdominal plain photoBarium meal/follow throughBarium enemaIntravenous pyelography if suspected urinary tract disordersUltrasoundEndoscopy

Therapy

Exploration/operation laparotomy

Definition (Apley, 1975)Recurrent abdominal pain is intermittent abdominal pain at least 3 times which persists for longer than 3 months and affects normal activity Recurrent abdominal pain

Prevalence

Age 3 14 years old mostly 5 10 years old5% of pediatric outpatientOrganic cause 5-10%

Etiology

Organic 5-15,6% casesFunctional 80%

Cipto Mangunkusumo Hospital (1988)

17 cases47% spasmophylia11.8% gastritis5.9% colitis29.4% worms infection11,8% psychological/psychiatric disorders

Recurrent abdominal pain concept

Classical (2 groups)OrganicFunctionalBarr OrganicDisfunctional Psychogenic Levine & Rappaport

Life style Environment andInducers BehaviorResponse pattern Somatic predispositionDisfunctionOrganic disorders Levine and Rappaport1984

Etiology of abdominal painGastrointestinal

Chronic diarrheaPeptic ulcersBezoarDuplicationIntermittent volvulusMeckels diverticulumAppendicitisMesenterical adenitisAbdominal TBcMilk protein intolerancelactose intoleranceConstipatianAscariasisDrugs

Anti convulsionAntibioticBrochodilator

Urinary tract

HidronephrosisPyelonephritisStoneRenal neoplasmOvarian cystDismenorrheaEndometriosisiTestis torsionTestis neoplasmLiver, spleen and pancreas

CholecyctitisCholelithiasisPancreatitisMassive spleenomegali

Metabolic

HypoglycemiaPhorphiriaLead intoxicationHyperlipidemiaAngioneurotic edema

Symptoms suggested organic disorders Persistent feverGrowth and development disturbanceWeight lossAnemiaHematemesisMelenaHematocheziaPain away from midlinePerianal disease

Diagnostic approach

Careful anamnesis, Physical examination, and further investigation High cost examination and commonly was not positiveEndoscopy greater probability to find the etiology

AnamnesisAgePain (localization, type, time, frequency, other symptom) Defecation patternUrination pattern Menstrual cycle Skeletal muscle disordersGrowth and development disorders Psychosocial aspectTraumaHistory of family disease

Laboratory and further investigationRoutine ( urine, blood, feces)Ureum, creatinine Culture3 positions of abdominal plan photoThorax photo (severe disease)Barium meal/follow through Barium enemaIntravenous pyelographyUltrasoundEndoscopy

Therapy

Depend on etiologySedative and analgesic