ABDOMINAL PAIN in the PEDIATRIC PATIENTTim Weiner, M.D.Dept. of SurgeryUniversity of North Carolinaat Chapel Hill

In GeneralCommon problems occur commonlyintussusception in the infantappendicitis in the childThe differential diagnosis is age-specificIn pediatrics most belly pain is non-surgicalMost things get better by themselves. Most things, in fact, are better by morning.Bilous emesis in the infant is malrotation until proven otherwiseA high rate of negative tests is OK

The HistoryPain (location, pattern, severity, timing)pain as the first sx suggests a surgical problemVomiting (bile, blood, projectile, timing)Bowel habits (diarrhea, constipation, blood, flatus)Genitourinary complaintsMenstrual historyTravel, diet, contact history

Diagnosis by Locationgastroenteritisearly appendicitisPUDpancreatitisnon-specificcolicearly appendicitis

constipationUTIpelvic appendicitisbiliaryhepatitis

appendicitisenteritis/IBDovarianspleen/EBV

constipationnon-specificovary

The Physical ExaminationWarm hands and exam roomTry to distract the child (talk about pets)A quiet, unhurried, thorough examPlan to do serial examsDo a rectal exam

The Abdominal Examinationbreath soundsMurphys signsausage

Dances signreboundtender at McBurneys pointcecal squishherniastorsionbreath soundsspleen edge

constipationRovsings sign

Relevant Physical FindingsTachycardiaAlert and active/still and silentAbdominal rigidity/softnessBowel soundsPeritoneal signs (tap, jump)Signs of other infection (otitis, pharyngitis, pneumonia)Check for hernias

Blood in the StoolNewborningested maternal blood, formula intolerance, NEC, volvulus, HirschsprungsToddleranal fissures, infectious colitis, Meckels, milk allergy, juvenile polyps, HUS, IBD2 to 6 yearsinfectious colitis, juvenile polyps, anal fissures, intussusception, Meckels, IBD, HSP6 years and olderIBD, colitis, polyps, hemorrhoids

Blood in the VomitusNewborningested maternal blood, drug induced, gastritisToddlerulcers, gastritis, esophagitis, HPS2 to 6 yearsulcers, gastritis, esophagitis, varices, FB6 years and olderulcers, gastritis, esophagitis, varices

Further Work-upCBC and differentialUrinalysisX-rays (KUB, CXR)USAbdominal CTStool culturesLiver, pancreatic function tests(Rehydrate, ?antibiotics, ?analgesiscs)

Relevant X-ray FindingsSigns of obstructionair/fluid levelsdilated loopsair in the rectum?FecalithPaucity of air in the right sideConstipation

Operate NOWVascular compromisemalrotation and volvulusincarcerated hernianonreduced intussusceptionischemic bowel obstructiontorsed gonadsPerforated viscusUncontrolled intra-abdominal bleeding

Operate SOONIntestinal obstructionNon-perforated appendicitisRefractory IBDTumors

AppendicitisCommon in children; rare in infantsSymptoms tend to get worsePerforation rarely occurs in the first 24 hoursThe physical exam is the mainstay of diagnosisClassify as simple (acute, supparative) or complex (gangrenous, perforated)

Incidental AppendectomyCan be done by inversion techniqueAbsolute indicationLadds procedureRelative indicationsHirschsprungs pullthroughOvarian cystectomyIntussusceptionAtresia repairWilms tumor excisionCDH

IntussusceptionTypically in the 8-24 month age groupDiagnosis is historicalintermittent severe colic episodesunexplained lethargy in a previously healthy infantContrast enema is diagnostic and often therapeuticPost-op small bowel intussusception

The Medical BellyachePneumoniaMesenteric adenitisHenoch-Schonlein PurpuraGastroenteritis/colitisHepatitisSwallowed FBPorphyriaFunctional ileusUTIConstipationIBD flarerectus hematoma

LaparoscopyDiagnosisnon-specific abdominal painchronic abdominal painfemale patientsundescended testestraumaTreatmentappendicitisMeckels diverticulumcholecystitisovarian detorsion/excisionlysis of adhesions

The Neurologically Impaired PatientThe physical exam is important for non-verbal patientsThe history is important for the spinal cord dysfunction patientClose observation and complementary imaging studies are necessary

The Immunologically Impaired PatientA high index of suspicion for surgical conditions and signs of peritonitis may necessitate operationperforationuncontrolled bleedingclinical deteriorationBlood product replacement is essentialTyphlitis should be considered; diagnosis is best established by CT

The Teenage FemaleMenstrual historyregularity, last period, character, dysmenorrheaPelvic/bimanual exam with culturesPregnancy test/urinalysisUSLaparoscopyDifferential diagnosismittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis

In SummaryMy dear surgeon, beware- haste not,Pleads the child silently,Listen to my mother, and then-Examine and again examine me:This will improve my lotAnd assure you accuracy.