Abdominal pain in children - dr. Hermanto Sp.BA.pptx

Abdominal pain in children - dr. Hermanto Sp.BA.pptx

1. Abdominal Pain In Children S urgery or N ot Dr. Hermanto . SpB, SpBA Dokter Spesialis Bedah Konsultan Bedah Anak Rumah Sakit Umum Daerah Dr . Soedarso Pontianak, Kalimantan Barat Singkawang, 3 Maret 2018

2. Abdominal pain is extremely common in children and may reflect a variety of conditions

3. The cause cannot be determined with certainty, Caused by pathology unrelated to the abdomen. Pain which lasts for more than 4–6 h, becoming worse persistent vomiting prolonged diarrhoea , Should be taken seriously S urgical cause excluded.

4. Unknown cause The symptoms resolve spontaneously over several hours . At the other end of the spectrum, abdominal pain may reflect signficant pathology and necessitate precise Clinical assessment before the appropriate therapeutic measures can be undertaken

5. In young children , infection outside the abdomen ( e.g. lung , hip) may be interpreted as abdominal pain . This pain must be distinguished from pain arising within the abdomen.

6. Influence of Age on the Incidence of Acute A bdominal D isease

7. The Location of Pain Inflammation or distension of the bowel or its coverings causes pain which is transmitted through two separate pathways. Distension of the bowel and inflammation of the visceral peritoneum stimulate sympathetic pathways, and the perceived location is dependent on the level of bowel involved Pain arising in the foregut projects to the epigastrium , in the midgut to the umbilicus and in the hindgut to the infra-umbilical or hypogastric region.

8. Type of pain Visceral pain S timulation of visceral organs, due to injury or inflammation The visceral peritonium enveloping the abdominal organs is innervated by the autonomic nervous system Not sensitive to touch or incision Sensitive to pull, strain and excessive contractions cause ischemia such as colic and inflammation, pain may arise

9. Type of pain Somatic pain: S timulation of the peripheral innervated nerves Stimulation on the parietal peritoneum and injury to the abdominal wall Pain as stabbed or cut The location of the pain can be pointed appropriately Stimulation pain in the form of touch, pressure, chemical, and inflammation

10. Colicky pain Visceral pain due to spasm of hollow innocent muscle due to barrier obstacles, bowel obstruction, ureteral stones, gallstones etc . Pain is caused by hypoxia of the affected organ . Because peristal t i c pause, so the pain felt lost arise

11. Ischemic pain Severe pain, persisting and not reduced It is a sign of tissue threatened by necrosis T achycardia and shock due to a bsorption of necrotic tissue toxins

12. Inflammatory pain P ain due to stimulation of peritoneum parietale will be felt continuously peritonitis, local tenderness Muscle rigidity : reflex c ontraction of the abdominal wall to protect the inflamed part from local pressure

13. A bdominal pain intensity

14. Colicky pain intensity

15. Characteristics of the pain History

16. Extra-abdominal illnesses causing abdominal pain

17. Differential diagnosis for acute abdominal pain

18. P hysical examination S ignificant abdominal pain are anxious and scared. U ncooperative . Patience and skill are needed to assess the abdomen accurately to avoid the disaster of not recognizing significant intra-abdominal pathology.

19. T he vast majority of children with abdominal pain of unknown cause, The symptoms resolve spontaneously over several hours. At the other end of the spectrum, abdominal pain may reflect significant pathology and necessitate precise clinical assessment before the appropriate

20. The ‘appendix shuffle ’. Movement of adjacent inflamed peritoneal surfaces makes the pain worse. The pain can be minimized by adopting this posture whilst walking

21. Associated Features Vomiting commonly companies abdominal pain in children because autonomic reflexes stimulate vomiting in response to any inflammation or severe pain. The relationship of its onset to the development of pain It’s frequency The nature of the vomitus

22. In appendicitis, vomiting generally commences several hours after the onset of pain. In acute colic of the ureter, the onset of vomiting coincides with that of pain, both being sudden and dramatic. In obstruction of the intestinal tract, the onset of vomiting is dependent

23. Relationship between type of vomitus and its underlying cause

24. Relationship between abnormal stools and their underlying cause

25. Non-specific Signs of Peritonitis Facial expression will show the child in pain , pale . The cheeks are red in association with perioral pallor. Vomiting , Pyrexia , fetor and furred tongue A tachycardia In long-standing peritonitis, septicaemic shock Loops of intestine become distended and paretic, causing abdominal distension. The abdomen is silent on auscultation. Vomiting of small bowel contents develops, and the respiratory rate becomes rapid.

26. The inexperienced clinician may be misled by the apparent paucity of signs. Where the appendix occupies a position in the pelvis, The area of maximal tenderness is vague and lower than McBurney’s point. There is no guarding of the peritoneum of the lower abdomen. Clues to the presence of pelvic appendicitis include: (1) complaints of pain in the abdomen during micturition (this is not urethral dysuria but is pain caused by movement of the peritoneum over the bladder) as the bladder empties , ( 2) Passage of loose bowel actions owing to irritation of the rectum

27. Digital Rectal Examnination ?

28. Does There Have to Be Evidence of Localized Peritonitis Before a Diagnosis of Appendicitis Is Made ? It is in the patient’s interest that a diagnosis is made on clinical grounds before peritonitis develops . Peritonitis is a sign of advanced disease, and in most cases, a history consistent with appendicitis , combined with marked localized tenderness in the right iliac fossa, provides sufficient grounds for a diagnosis of appendicitis to be made.

29. When Does Diarrhea Occur with Appendicitis ? If the inflamed appendix lies against the rectum,the irritation it causes produces mild diarrhoea . Retro- ileal and retrocaecal appendicitis may also produce loose bowel actions . If the appendix perforates, the infected material released collects R etrovesical pouch in the male R etrouterine recess in the female Pelvic abscess develops. As the abscess increases in size, it causes irritation of the rectum and can be palpated as a hot, tender bulge of the anterior rectal wall .

30. Does Appendicitis Produce a Fever ? In most children with appendicitis, the temperature is slightly elevated (37.5–38 °C). A normal or slightly subnormal temperature does not preclude the diagnosis of appendicitis – nor does a grossly elevated temperature (39–40 °C ), although this is unlikely unless peritonitis is present . Unfortunately, most of the other conditions from which appendicitis must be distinguished are inflammatory or infective in nature and produce elevation of the temperature.

31. A Mass in the Right Iliac Fossa I t can be felt as a tender, Immobile I nflammatory phlegmon of an infected appendix, stuck by infl a mmatory exudate O edematous loops of small bowel , and greater omentum . In girls, a large ovarian cyst may be palpable as a smooth surfaced mass in the right iliac fossa. T he mass is non-tender and mobile, unless there is torsion of its pedicle .

32. In the child under 2 years of age, the mass may be an intussusception. The sudden onset of a colicky pain Vomiting , pallor, lethargy and short duration of symptoms with or without rectal bleeding with generalized anorexia, malaise and marked abdominal tenderness would make one more suspicious of appendicitis.

33. Other Patologies 1 Viral Enteritis (‘Mesenteric Adenitis ’) In addition to the localized collection of lymphoid tissue seen in the terminal ileum ( Peyer’spatches ) There are numerous lymph nodes at the mesenteric edge of the bowel and within the mesentery of both small and large intestine. Tenderness is often maximal in the right iliac fossa and is simply a reflection of the location of the enlarged nodesrepeated in a few hours.

34. 2. Gastroenteritis This common condition is characterized by vomiting and diarrhoea . The diarrhoea usually commences as the first symptom or shortly after the onset of vomiting. There may be associated abdominal pain which tends to be cramping and diffuse . In the majority of children, symptoms are improving within 24–72 h. Persistence of either vomiting or diarrhoea should make one suspicious of alternative diagnoses , of which appendicitis is one.

35. 3. Constipation Poor diet, a constitutional predisposition Poor bowel training Anal fissure there is a long history of infrequent passage of hard bowel actions over a long period. The pain is often colicky and may be relieved by a bowel action . Examination of the abdomen reveals faecal Material , There is no peritonitis. Digital examination of the rectum will reveal a capacious rectum full of faecal material.

36. 4 . Urinary Tract Infection or Obstruction These conditions may produce abdominal pain and be difficult to separate from appendicitis . A high index of suspicion and urinary examination will exclude this important cause. The child has a higher fever and fewer localizing Occasionally , abdominal pain may be the first manifestation of one of the rare conditions

37. Rare causes of abdominal pain

38. Abdominal Pain In Children : Surgery or Not ?

39. The end