Stuart A Bradin, DO, FAAP, FACEPAssociate Professor of Pediatrics and Emergency Medicine

Introduce common causes for abdominal pain in the pediatric population

Recognition of typical presentation for these illnesses Identify surgical abdominal emergencies Discuss diagnostic and management strategies

Frequent, nonspecific symptom typically associated with self-limited minor conditions Represents 5% ER visits yearly Less then 10% of those visits require surgery

Abdominal pain is common complaint in ED Most common discharge diagnoses:

Abdominal pain Gastroenteritis Viral syndrome Constipation Strep pharyngitis

Adapted from: Scholer SJ, Pituch K, Orr DP, et al. Clinical outcomes ofchildren with acute abdominal pain. Pediatrics 1996;98(4):680-685.

To identify uncommon diagnoses that require further intervention

Appendicitis SBO Intussusception Incarcerated hernia Pancreatitis Malrotation with volvulus Foreign body ingestion

Way, L. Doherty, G. Current Surgical Diagnosis and Treatment, 11th ed.

Mediated by ONLY afferent C fibers Visceral pain slow in onset, dull, poorly localized Signaled by distention, inflammation or ischemia, or indirect stimulation of sensory nerves Visceral pain is usually midline because sensation is provided to both sides of spinal cord

What the ED physician wants to know Is this a surgical emergency?

▪ Peritonitis▪ Obstruction

Is this an urgent medical problem?

What the surgeon wants to know Does this patient need an operation now? Will this patient need an operation later?

(i.e. what testing and follow up do I need to figure that out?)

Onset Pain precedes other symptoms Sudden: perforation or ischemia Gradual: inflammatory

Location Point with one finger? Diffuse hard to localize: obstruction Well localized: peritonitis

Anorexia the rule for urgent/emergent abdominal pathology

Vomiting before pain or after pain, bilious, bloody, feculent

Diarrhea bloody*, black or tarry, currant jelly, mucusy, watery

Constipation hard stools, no stools

Abdominal Distention Suggests obstruction

Fever, Chills Suggests infection

Jaundice Biliary/Liver dysfunction

Urinary changes Renal pathology

EPIGASTRIUM

Stomach, Duodenum, Pancreas, Liver, Biliary tree

PERIUMBILICAL

Small intestine; ureters, colon, bladder uterus, testes, ovaries, early appendicitis.

SUPRAPUBIC

Bladder, ureter, uterus, ovaries, retrosigmoid colon

LUQ

Pancreas, spleen, transverse colon, splenic flexure, diaphragm

LLQ

Pelvic and retrosigmoidcolon, descending colon, Left adnexa, psoas abscess

RUQ

Liver,

Gallbladder, biliary tree, hepatic flexure

Pancreas, diaphragm

RLQ

Appendix, terminal ileum, ceacum, right adnexa, Meckelsdiverticulum

FLANK: U

reters and kidney

FLANK: U

reters and kidney

Acute (hours) and Subacute (days) Often presentation of serious medical illness

Recurrent and Chronic Often presentation of functional abdominal pain

Involuntary weight loss Decreased linear growth velocity GI bleeding RUQ or RLQ pain Significant vomiting Persistent diarrhea Unexplained fevers Family history of Inflammatory Bowel Disease

Mild, moderate, severe (FACES or 1-10) Crampy (colic) Dull/aching (visceral) Sharp/stabbing (somatic) Associated symptoms-

anorexiavomitingbloody stoolpallor

Alleviating/ aggravating Worse with movement, cough, sneezing: peritonitis Better with changes in position: obstruction

Radiation To right shoulder = cholecystitis To back = pancreatitis Flank to groin = Ureter

Treatment Anything help? Anything hurt?

Observation Vital signs Abdomen Inspect, auscultate then palpate Light percussion; Light palp; Deep palp Note guarding and rebound

Rectal: only if diagnosis unclear, h/o bleeding, h/o Intussusception GU: eval for hernias

Many diverse causes

Could this be trauma? How old is the patient?

▪ Infant -2 y/o▪ 2y/o – 5 y/o▪ School-aged (5y/o -12 y/o) ▪ Adolescent (menstruating or > 12 y/o)

A common cause of fatal injuries in childhood Constellation of injuries: severe and indolent Splenic injury (most common) Liver injury Kidney injury Duodenal and pancreatic injury (handle bars) Bowel and mesenteric injury (lap belts) Non accidental trauma

Common Colic (age

A 3-day-old infant presents to the ED for bilious vomiting and abdominal distention. He has been feeding poorly and has been difficult to console.

Incidence: 1: 500 births 75% present within the 1st year

Etiology: Twisting of bowel along it’s own axis resulting in vasulcular compromise

Presentation: Bilious emesis, dehydration, Abd. Distention, Abd Pain; Shock

Diagnosis: abdominal Xray: no air, dilated loops Upper GI with SBF: malpositon of c loop of duodenum

Treatment: Fluid support, NG tube, Surgical correction with Ladds procedure.

Occurs in 1 in 500 live births Male predominance by at least 2 75% present in the 1st month of life Presentation – acute onset bilious emesis

abdominal distentionill appearing

Diagnostic procedure of choice – Upper GIabnormal position of duodenojejunal flexure"corkscrew" appearance of distal duodenum and proximal jejunum

Place of ultrasound is still being determined

Volvulus

Non rotation

Malrotation

An 18-month-old male infant presents to the emergency department with a 2-hour history of intermittent abdominal pain and vomiting. His mother reports that he is difficult to arouse between these episodes.

Incidence: Most common intestinal obstruction in infant 3-6 m/o 80% present before 2 y/o

Etiology Loop of bowel invaginates caudally Most common ileocecal 10% have lead point (Meckels, Lymphoid tissue, HSP, Tumor)

Presentation Paroxysmal colicky abdominal pain with pain free periods Emesis bilious Increasing lethargy eventually shock Bloody stools (12 hr -2 days later) Palpable mass in RLQ/epigastrum

Most common cause of intestinal obstruction in children younger then 2 Estimated incidence 1 per 2000 children younger then 15 years of age Male predominance Presentation – abdominal pain, vomiting, and bloody stools

Lower GI contrast study Obstruction to flow of barium with coiled spring appearance

X-ray Multiple air fluid levels Soft tissue shadow Paucity of large bowel gas

US Target sign Free/interloop fluid

Sensitivity 88.2 % Specificity 100% Positive predictive value 100% Negative predictive value 94.5%

1st time parents of a 1 m/o bring him in to the ED for inconsolable crying for the past 4 ½ hours…it has been 5 hours since his last diaper change

Incidence: 10-20% of pediatric hernias become incarcerated 50% in infants younger than 6 months

Etiology: Indirect Hernia (most common) bowel enters inguinal canal Bowel becomes trapped (incarcerated) leading to obstruction If not reduced:

blood supply cut off (strangulated) bowel death, necrosis, shock

Extra abdominal cause of abdominal pain Most common cause of intestinal obstruction between 1-16 weeks of

life Presentation :

abdominal painscrotal edemanauseavomitinglow-grade fever

Presentation Incarcerated: Nausea, vomiting, abdominal distention, painful enlargement of hernia that cannot be reduced Strangulated: Fever and toxic appearance or pain persist after reduction

Diagnosis Will be noted on PE X-rays: may help visualize SBO Ultrasound and CT can be used as needed

Treatment Attempt manual reduction Surgical correction for failed reduction or suspected strangulation

5 week old, benign birth hx, “pukes all the time” birth wt 4 kg Meeting milestonesSeems like the “excorcist”- projectile , non bilious. Seems hungry after vomiting. Afebrile. Triage wt 4.8 kg

Most common cause of infantile GI obstruction after 1st month of life Occurs 1 in every 250 life births Boys >>>> Girls Whites > African Americans > Asian Americans Presentation – gradually progressive emesis that becomes projectile and remains nonbilious Hungry after feeds- ultimately poor wt gain Hyponatremic, hypokalemic, hypochloremic metabolic alkalosis Must correct dehydration, electrolyte anomalies before OR

Exam with palpation of olive then no further workup required Ultrasound diagnostic modality of choice Both US and upper GI have accuracies >95%

positive UGI = narrowed pyloric channel the “string sign.” positive US =

pyloric muscle thickness > 4 mm length pyloric canal > 14 mm.

Common Acute Gastro UTI Trauma Appendicitis Pneumonia HbSS “Viral syndromes” Constipation

Uncommon Meckel's diverticulum Henoch-Schönlein purpura Toxin Intussusception

Rare Incarcerated hernia Neoplasm HUS Hepatitis IBD Diabetes mellitus

A 3-year-old girl presents with irritability and abdominal pain following several days of bloody diarrhea. Patient is hypertensive and pale with petechiae and purpura.

Incidence 0.3-10/100,000 children Age: 7 months to 6 years. Increase in summer and early fall; outbreaks

Etiology Bacteria (e.g. E Coli 0157:H7) releases toxins absorbed by gut Toxins cause endothelial damage: primarily in kidney Endothelium swells, triggers fibrin deposition, and microthrombi Consumes platelets and sheers RBCs

Presentation Diarrhea (80% bloody), vomiting and crampy abdominal pain 3-12 days later:

Irritability, restlessness, oliguria, edema, hypertension, pallor, petechiae, hematuria

Diagnosis CBC: Leukocytosis with Left shift

ThrombocytopeniaAnemia (shistocytes and helmet cells on smear)

Elevated BUN/Cr, Uric acid and K increased, Bicarb decreased Stool cx or serum antibodies for E Coli 0157:H7

Treatment Supportive care:

▪ ARF: Careful fluid and electrolyte management, Dialysis as needed▪ Anemia: Keep Hbg > 7 with PRBC transfusion▪ Thrombocytopenia: Plts only if bleeding

A 4 year-old boy complains of migratory pain and swelling of his joints. He is noted to have a purple, papular rash on his buttocks and lower extremities and was experiencing severe abdominal pain and swelling of his left elbow

Incidence 14-15:100,000 children Peaks: age 5 y/o Increase in cases Nov – Jan

Etiology IgA related vasculitis usually following a URI

Presentation: HSP Tetrad

RASH: (100%)▪ Symmetric Mac-pap rash on lower extremities▪ Rash becomes purpuric and spreads to legs, perineum and arms▪ May coalesce and look like bruises

ARTHRITIS (~ 80%) ▪ Arthralgias effect knees & ankles>>wrists & fingers

ABDOMINAL PAIN (~ 60%) ▪ Colicky abdominal pain & bloody/guiac + stools

RENAL INVOLVEMENT (~40%)▪ Proteinuria and hematuria w/ RBC casts▪ Renal involvement rarely leads to renal failure

Diagnosis CBC: Leukocytosis with Eosinophila

Thrombocytosis UA: proteinuria and hematuria Stool Guiac + (50%) IgA increased in 50% of pts

Treatment Supportive care ~90% resolve spontaneously Steroids?: severe abdominal pain

GI bleedingrenal involvementscrotal edema

Common Acute gastroenteritis Trauma Appendicitis UTI Functional abdominal pain HbSS Constipation “Viral syndromes”

Uncommon Pneumonia, asthma IBD Peptic ulcer disease Cholecystitis Pancreatic disease Diabetes mellitus Collagen vascular disease

Rare Toxin Renal calculi Testicular Torsion Ovarian torsion CF Intussusception

10 y/o male awoke from sleep writhing in pain and later began to vomit. He is taken to the ED laying in backseat of the car and remembers every bump. He cannot walk back to Room 3 because it hurts so much . He denies scrotal pain. Temp 38.7 at triage

Most common surgical problem in pediatrics Most common non-traumatic surgical emergency in children Peak incidence between 9-12 yrs of age Up to 8% of abdominal pain visits to pediatric ED Initial diagnosis missed in up to 57% Lifetime risk ~7% Uncommon in children less then 5 years of age- hard to diagnose Presentation – abdominal pain

nausea/vomitingfeveranorexia

Negative operative exploration rates: 10-15%

Incidence 4/1000 children 2x more common in males

Etiology Obstruction of appendix; usually by fecolith Mucosal edema, bacterial overgrowth Inflammation, ischemia, gangrene Children develop peritonitis Adolescents develop abcess.

Presentation Initial: intermittent periumbilical pain (visceral) Later: pain migrates to RLQ (somatic) Pain with percussion, hopping or coughing Inability to walk/ limping Nausea, anorexia Afebrile or low grade fever “Classic” Presentation (Appendicitis with perforation until proven otherwise!

Diagnosis Labs:

▪ CBC: WBC elevated (> 8850 but less than 18,000)ANC elevated (> 6750)CRP

▪ UA: r/o renal disease mild pyuria/ hematuria with pelvic appendicitis▪ HcG

Imaging▪ Plain films: low yield, may see paucity of gas RLQ, Fecolith (5%)▪ US: operator dependent (sens: 85%; spec: 94%) ▪ CT: ideally Rectal contrast and IV contrast ▪ Focused MR ( > 7 yrs age)

Treatment Surgery Observation and Antibiotics

Of the following, which is the most sensitive PE finding in appendicitis?

1. Obturator sign 2. Psoas sign3. Rovsing sign 4. Pain with hopping

Guarding: voluntary contraction of abdominal musclesRigidity: involuntary reflex spasm of muscles of abdominal wall Rebound Tenderness: press over point of pain and leave hand there for 30-60 seconds, then remove

You are evaluating an 8 y.o. female with suspected appendicitis. After informing the parents, they inquire about serum lab work for diagnosis. Your response regarding laboratory diagnosis of appendicitis is:

1. Elevated C-reactive protein (CRP) is very sensitive for acute appendicitis 2. High white blood cell count (WBC) is highly sensitive3. Elevated C-reactive protein (CRP) is very specific4. Diagnostic radiology is a better option than lab tests

Operator dependentSensitivity 80-90% Specificity 85-98%

LimitationsAtypical position of appendix Abdominal wall rigidity Obesity

Sensitivity 89-98% Specificity 90-99% IV = IV contrast + po contrast +/- rectal contrast

LimitationsPaucity of fat in RLQ Radiation Cost

RCT of children 5-16 year old Suspected acute surgical abdomen by attending PEM physician

Morphine group: Reduction in pain No delay in diagnosis or procedure No increase in perforated appendicitis

Green K et al, Pediatrics, 2005

Children with missed appendicitis (Rothrock, 1991)28% previously evaluated by physician Young children and adolescent females No abdominal pain at initial evaluation in 50% !

Most common misdiagnosis: gastroenteritis (42%) 2nd most common PEM malpractice claim IF Discharge :

NEVER say you are 100 % sure Provide specific instructions to when to return

9 Y/O male complains of abdominal pain. Abdomen has been increasing in size for the past few days. +anorexia, feels nauseated but has not vomited, tactile temp for 24 hours. Has hx constipation, uses miralax daily

Abdomen is very distended with quiet bowel sounds and tender throughout

Constipation Obstruction Abdominal Mass Appendicitis

Enterocolitis causing toxic megacolon Fever Bilious vomiting Abdominal distention Diarrhea Shock

Hirschsprungs Disease

50‐90% of patients present in neonatal period Classic Presentation:

Failure to pass meconium within the first 8‐24 hours of lifeBilious emesisAbdominal distensionFTT

Rectal exam - no stool in rectal vault— “gloved finger”can cause patient to have explosive diarrhea

If stool passes ribbon‐like Chronic constipation diagnosed later in life Gold standard= rectal biopsy

Uncommon Ectopic pregnancy Testicular torsion Ovarian torsion Renal calculi Peptic ulcer disease Hepatitis Cholecystitis Pancreatic disease CF Collagen vascular disease IBD Toxin

Rare Rheumatic fever Tumor Abdominal abscess

Common Acute gastroenteritis Gastritis GERD Trauma Constipation Appendicitis PID UTI Pneumonia, asthma “Viral syndromes” Dysmenorrhea Epididymitis Lactose intolerance Sickling syndromes

Rare in children younger then 10 Incidence of 1 in 50,000 children Presentation – epigastric pain that radiates to the back,

nausea, and vomiting Complications – abscess, pseudocyst, and fistulae

Gastritis/Peptic Ulcer disease: Loss of mucosal protection from HCL caused by NSAIDs, alcohol, stress, H. pylori Vague, dull periumbilical or epigastric

vomitingGuiac + stoolHematemesis

Pancreatitis Inflammation /auto digestion of pancreas Severe epigastric pain radiating to back with nausea and vomiting

Hepatitis Inflammation of Liver Causes diverse: Infectious, toxins, autoimmune Tenderness in RUQ, hepatomegaly, scleral icterus, dark urine, nausea, anorexia, +/- fever

Cholecystitis/ Cholelithiasis Inflammation of gallbladder Caused by Bile stasis, gallstones, congenital anomalies, hemoglobinopathies Tenderness in RUQ with pain radiating to back jaundice Nausea/ vomiting following meals +/- fevers

UTI 2nd most common infection in children Caused by Ascending infection; E coli Abdominal or flank tenderness dysuria +/- fever vomiting and diarrhea

Urolithiasis Commonly Calcium stones Rising rate w/ rising obesity Abdominal or flank colicky pain with radiation to groin gross or microscopic hematuria

UPJ obstruction

Most common cause of Hydronephrosis Epidemiology 1: 500 Live births Boys> girls Left > right 10-20% bilateral

Pathophysiology: Usually a partial obstruction Intrinsic: anatomic or functional Extrinsic: Compression by artery

Clinical presentation: Commonly diagnosed on asymptomatic prenatal US. Infants: Palpable mass

UTIFailure to ThriveRenal failure

Older children: Intermittent flank/abdominal painPain worse with diuresisPain lasts from minutes to hourshematuria following minimal traumahypertension

Ovulatory pain PID Spontaneous abortion / Ectopic pregnancy Torsion of the ovary In all ages, mostly adolescents Sudden onset sharp pain on one side of the abdomen that radiates to back and down to

thigh. +/-Vomiting, >50% tender mass Pelvic US with Doppler if suspected

Sort Acute from Chronic Exclude trauma Think about your age-based differential Focus the evaluation to exclude peritonitis and obstructive causes Take a thorough History and Physical When in doubt, evaluate and reevaluate

Abdominal complaints are common in children Maintain healthy skepticism of “constipation” diagnosis The cardinal presenting symptom in Hirschsprung’s disease is delayed passage of meconium. Surgically correctable causes of abdominal pain in children are relatively uncommon (about 1% of cases of abdominal pain presenting to the ED). Of surgically correctable causes of abdominal pain in children, appendicitis is by far the most common. Lethargy is a common presentation of intussusception- can present as altered mentation A small minority have the “classic” presentation of intermittent abdominal pain, vomiting, and bloody stool with or without a palpable right upper-quadrant mass. A neonate with bilious vomiting has malrotation with midgut volvulus until proven otherwise. This is a surgical emergency. Appendicitis may present with white cells in the urine. Suspect ectopic pregnancy in any post-menarchal girl with abdominal pain. Utilize observation time in the ED to help sort out ambiguous abdomens. Consider pneumonia as a cause of abdominal pain, particularly if cough or tachypnea is present. Drop the diaper to search for testicular torsion and incarcerated inguinal hernias. Don’t use the diagnoses “gastroenteritis” or “constipation” when the diagnosis is unclear Consider non-accidental trauma in cases where the history is confusing, changes over time, or doesn’t make sense

Which of the following is true of Hirschsprung’s disease?

A. Incidence of the disease is 1 in every 5,000 live births.B. The disease is four times more prevalent in boys.C. Child may present with poor feeding.D. Plain x-rays may show massive distention of the colon with gas and feces present.E. All of the above

Which of the following is NOT true regarding hypertrophic pyloricstenosis?

A. Pathognomonic feature is gastric outlet obstructionB. Incidence higher in first born maleC. Infants between ages 3-12 weeks of life make up 95% of casesD. Current mortality rate is about 30%

The likely component(s) of the clinical presentation of midgut volvulusis/are:

A. Poor feedingB. IrritabilityC. Bloody stoolD. Bilious vomitingE. All of the above

The findings of “cockscrew sign” on upper GI series is indicative of:

A. Incarcerated herniaB. Midgut volvulusC. Pyloric stenosisD. Aganglionic colon

The estimated perforation rate in infant with acute appendicitis is:

A. 10%–20%B. 25%–40%C. 45%–50%D. 60%–70%

What is the most common misdiagnosis of appendicitis?a. Mesenteric adenitisb. Pneumoniac. Diabetic ketoacidosisd. Gastroenteritis

An important consideration in the differentialdiagnosis of a menstruating female patient is:

a. Pelvic inflammatory diseaseb. Ovarian torsionc. Early pregnancyd. All of the above

What are the interventions that should be donein a patient with a diagnosis of appendicitis?

a. Pain controlb. IV fluid hydration with NPO statusc. Surgical consultationd. All of the above

All are true about intussusception except:

a. The leading cause of intestinal obstruction in children 5 months to 3 years of ageb. One of the most common causes of acute abdominal emergency in young childrenc. Is common over the age of 5 yrsd. Can be associated with recent viral illnessd. None of the above