Abdominal pain in children

Prof. (Dr. Ms.)Sushmita Bhatnagar

B.J.Wadia Hospital for childrenBombay hospital

Joint Secretary - Association of Medical Consultants

Abdominal pain

ACUTECHRONIC

Abdominal pain is one of the most common reason for which parents take the child to a doctor.

Surgical causes of abdominal pain

• Intestinal obstruction

• Perforation of bowel

• Infections - Gall bladder, appendix, meckel's diverticulum,

• Constipation - due to Hirschsprung's disease

• Volvulus

• Intussusception

• Kidney stones

• Chronic Pancreatitis

• Tumors/cysts

• Hernia

• Trauma

What is significant pain?

ANY PAIN WHICH INTERRUPTS ACTIVITY OF CHILD AND DISTURBS SLEEP

RED FLAGS1. Weight loss2. Failure to thrive3. Fever with pain4. Severe diarrhoea/vomiting or both5. Family history6. Severe right lower abdominal pain

Abdominal pain: evidence-based data

Abdominal pain: appendicitis or not?

Abdominal pain: evidence-based data

• Appendicitis– Incidence

• 11/10,000 population per year• Highest in males 10-14 years (27/10,000)• Highest in females 15-19 years (20/10,000)• Male:female ratio: 1.4:1• Life time risk:

– Males: 8.6%; Females: 6.7%

• Perforation: 18% ; highest in < 5 and >65 y.o.

Appendicitis: evidence-based data

• Signs and symptoms– Neonates:

• Abdominal distension• Vomiting• Fever• Hypothermia• Respiratory distress

Appendicitis: evidence-based data

• Signs and symptoms– 3 years and under

• Diffuse abdominal pain• Fever• Vomiting• Diarrhea• Abdominal distension• Diffuse abdominal tenderness

Appendicitis: evidence-based data

• Signs and symptoms– Older children

• Abdominal pain• Vomiting• Fever• Anorexia• Pain with movement or cough• Localized RLQ tenderness• Diffuse/rebound tenderness

Abdominal pain: evidence-based data

• Radiologic studies– Ultrasound

• Appendiceal diameter or >6 mm• Target sign with 5 concentric layers• Distension or obstruction of the lumen• High echogenicity around the appendix• Pericecal or perivesical fluid• Appendix wall > 2 mm• Absence of appendiceal peristalsis

– Can confirm but not exclude appendicitis

Abdominal Pain: Evidence-based Data

• Radiologic studies– CT scan

• Enlarged appendiceal diameter (> 6 mm)• Appendiceal wall thickening (> 1 mm)• Periappendiceal inflammatory changes

including fat streaks, phlegmon, fluid collection, and/or extraluminal gas

• Other findings: appendicalith, abscess, arrowhead sign, or cecal bar

– Sensitivity 87 – 100 %, Specificity 89 – 98%

Treatment of appendicitis

• Conservative management– Antibiotics – IV hydration

• Surgery– Laparoscopic– Open

Treatment of appendicitis• Conservative management

– IV and oral antibiotics• Cefotaxime + (ofloxacin +tinidazole)• Ciprofloxacin and metronidazole + (ciprofloxacin +

tinidazole)

– Advantages• Less pain• Shorter recovery time• Avoid complications of surgery and anesthesia

Functional abdominal Pain (FAP)Real pain; not faking or malingeringWhy does it occur

abnormal bowel reactivity to physiologic stimuli (meal, gut distention, hormonal), noxious stressful stimuli (inflammatory procees), psychological stressful stimuli (parental seperation, anxiety) Leading to the development of visceral hyperalgesia

Symptoms of chronic or recurrent abdominal pain in children where there is no identifiable structural, inflammatory, infectious, neoplastic or metabolic cause.

FAP is a POSITIVE diagnosis and not a failure to the true cause of the pain

Chronic Abdominal Pain in children

One of the most common complaints in children and adolescents13% of Middle School aged; 17% of High School aged children experience weekly abdominal pain (Hyams JS et al J Pediatr. 1996)Functional Abdominal Pain was found in 15% of school aged children (Youssef NN. Clinical Pediatrics 2007)10-15% of school age children seek help

10-15% more have symptoms but never seek medical attention10% have an organic causeFemales>malesHigher in > 10 years oldPrevalence increases during school, not vacations

Drug Action Indication Risk

PeppermintOil

? Smooth MuscleRelaxation

IBS None

FiberStoolBulking

ConstipationPredominant

Bowel obstruction

Lactose FreeDiet / Lactaid

EliminatesLactose

Lactase Deficiency None

Probiotics Replacement of “Toxic Bacteria”

S/P Antibiotics / Enteritis

Systemic Translocation

Drug Action Indication Risk

PEG Stool Softner Constipation Dehydration / Bowel Obstruction

H2 Blocker Histamine Antagonist Dyspepsia Tachyphalaxis after

2 weeks

PPI Inhibits Acid Production

Dyspepsia / PUD

?Osteopenia/Bacterial

Overgrowth/ Gastronoma

Serotonin 2A Antagonist

Serotonin Blockade

Abdominal Migraine /

Anxiety

Drowsiness, Dizziness

Anti - Tricyclics Anti - Depressant Depression Dependancy / Suicide / Arrythmias

Drug Action Indication

Mylicon Anti - Flatulance Excessive/Discomfort/ Gas Pains

Bentyl Anti - Spasmodic (AS) Spasms / Cramping

Levsin AS, Sedation Spasms / Cramping

DonnatolAS, Sedation Spasms / Cramping

Drotaverine AS Spasms/ Cramping

Thank you!