+ Abdominal Pain in Children Updated 5/2/2015 Arjun Rao
+Outline
Clinical evaluation – tips and tricks Appendicitis Ovarian Torsion Intussusception “Constipation” Medical Causes Extra-abdominal causes
+Epidemiology of Abdominal Pain ~ 5% of all presentations to PED Surgery only required in 1-7% No specific diagnosis in up to 15%
+History – the basics 1
Maintain empathy at all times, no matter how tired you are
Parents are anxious and worried – don’t let this frustrate you
Open ended questions to start – let the parents speak, don’t interrupt early
Acknowledge that they might be exhausted, especially if they have been transferred from another hospital and have had a long day
Age appropriate engagement of child
+History – the basics 2
History of pain – if child is old enough can ask them
Temporal history important
Associated symptoms
Red flagsBile stained vomitingFlank or back painWaking at nightNot walking
+History – tips
Ask about journey to hospital – when the car went over bumps
When asking about nature and severity let the child know that the questions are hard and not to worry too much if they can’t answer
If the history is long try to establish if they had any days when they were well
Ask about stool frequency (beware assuming “constipation”)
Ask about family history of appendicits
+Examination – the basics
Distraction, be non-threatening, keep parents close
Positioning
Observation – RR (measure yourself), work of breathing, movement, level of distress “well v unwell”, Sa02 if monitored
Vital signs – measure HR, CR
All systems including ENT
Inspection, Palpation, Percussion, Auscultation
+Examination - tips
Don’t stand over child, kneel or sit next to bed
Keep arm horizontal, palpate with palm not tips of fingers
Look at their face
Distraction Ask about age, siblings, school, movies, parents, pets
If you think the abdomen is distended measure
Don’t forget hernia, testes
Mobility, don’t be afraid to try to walk them but don’t push
+Examination – the abdomen
Superficial palpation away from site of reported pain – look at face
Deep palpation
Liver, spleen, kidneys
Masses
Percussion
+Appendicitis in Children
Most common non-traumatic surgical emergency
Peak 12-18 yrs Classic appendicitis easy “Atypical” appendicitis common in
children Beware false localising signs – diarrhoea,
dysuria
+Appendicitis - Investigations
No single diagnostic test
Aim: high sensitivity/specificity minimise missed appendicitis minimise normal appendicectomy rate minimise delay to OT
+Appendicitis - Investigations
• Urinalysis– Pyuria in ~ 30%
• FBC– Neither sensitive nor specific
• U/S– Sensitivity 87%, Specificity 89%– Not visualised 10%
• CT– Sensitivity 91%, Specificity 94%– RIM risk (single CT in 5yo -> 20-25:100000)
•Klein, M. D. (2007). "Clinical approach to a child with abdominal pain who might have appendicitis." Pediatric Radiology 37(1): 11-14•Doria, A. (2009). "Optimizing the role of imaging in appendicitis." Pediatric Radiology 39(Suppliment 2): S144-148.
+ Appendicitis scores – Alvarado Score
Clinical Feature Score
M Migration of pain to RIF 1
A Anorexia 1
N Nausea 1
T Tenderness in RLQ 2
R Rebound pain 1
E Elevated temperature 1
L Leukocytosis 2
S Shift to left of WBC 1
10
<5: Rule out>7: Rule in
Probably - good at ruling out, not great at ruling in, overestimates appendicitis in children with intermediate scores
+Intussusception
Telescopic invagination of one section of the bowel into another
Usually ileo-colic
Can be a great “mimic”
Image Definition
http://yoursurgery.com
+Intussusception
• Mostly idiopathic but consider lead point • Vomit / pain / blood [classic triad < 30%]• Most common 5-10mths – “any age”• M:F 3:1, 1-4:1000• X-ray may show signs• US (sensitivity ~ 100%)• Air enema
• Consider pathological lead point in very young or older children
Del-Pozzo et al (1996). “Intussusception: US findings with pathologic correlation – the cresent in doughnut sign. Radiology 199: 688-792
+ Intussusception
Liver edge not well defined“Cresent” in right upper quadrantPaucity of gas on right side of abdomenDistended loop of transverse colon
+Meckel’s Diverticulum
• Omphalomesenteric duct vestige (vitelline duct)• Contain gastric mucosa• Can mimic appendicitis
http://www.health.act.gov.au
+Meckel’s Diverticulum
“Rule of 2s” 2% population 2% symptomatic (actually ~ 4%) 2 inches long 2 ft prox to terminal ileum 2 times more common in boys 2 types of ectopic tissue (gastric and pancreatic)
Pain, bleed, perforation, obstruction Classic presentation -> painless bleeding Can be lead point for intussusception Meckel’s scan
~ 80% sensitivity, 95% specific Surgical excision
+Ovarian Torsion
• Rare in children• Usually seen with ovarian pathology• Usually colicky lower pain• Acute onset• Right > Left• May be associated nausea, vomiting,
raised WCC• Ultrasound has high specificity /
sensitivity
+Formulating a provisional and differential diagnosis
Be systematic
Most likely to least likely
Anatomical
Most serious
Surgical v Non-surgical
Abdominal v extra-abdominal
PnemonicV Vascular
I Inflammatory/infectious
N NeoplasticD Drugs
I Iatrogenic
C Congenital
A Autoimmune
T TraumaticE Endocrine / Environmental
M Metabolic
+Formulating a provisional and differential diagnosis
Constipation is not a diagnosis
Rare but serious Discitis ALL Intra-abdominal abcess Tumour
Anatomical approach
Systems approach
+Differential
AppendicitisUTI/PyelonephritisTesticular torsionCholecystitisPneumoniaPancreatitisIntussusceptionBowel obstructionMeckel’s DiverticulumPoor diet -> constipation
http://www.lifescript.com
+Management in ED - Analgesia
Assessment of pain• Can be difficult – pain vs anxiety• Age dependent • Pain scales, Visual analogue scale
+Management in ED - Analgesia
• Simple analgesia as appropriate• Are opioids contra-indicated?• No RCT• Practice is to not withhold analgesia• Intranasal Fentanyl (1-2mcg/kg)• Intravenous Morphine (0.1-0.2mg/kg)
Sharwood, L. N. and F. E. Babl (2009). "The efficacy and effect of opioid analgesia in undifferentiated abdominal pain in children: a review of four studies." Paediatric Anaesthesia 19(5): 445-451.
+Disposition
Admission v Discharge
Solid plan for discharge and follow up
“Obs admit” – try to avoid prolonged observation admission
Admission for observation and serial examination is a good option in equivocal cases
+Essentials
1. Only a small percentage have surgical cause
2. Age influences diagnostic possibilities3. Abdominal examination critical4. Don’t withhold analgesia5. Aetiology may be intra or extra abdominal6. Serial examination useful7. Definitive diagnosis not always possible8. Clear follow up important