Galea - Abdominal Pain in Childhood

8/8/2019 Galea - Abdominal Pain in Childhood

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Abdominal Pain inAbdominal Pain inChildhoodChildhood

-- an overviewan overviewMs. JulieMs. Julie GaleaGalea MDMD MRCSEdMRCSEd

Paediatric Surgical UnitPaediatric Surgical Unit

Mater Dei HospitalMater Dei Hospital

MaltaMalta


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BackgroundBackground Abdominal pain in childhood is common

Most can be treated in the community

Even those treated in a hospital settingmostly recover without a diagnosis

Disconcerting experience for mostclinicians


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BackgroundBackground Signs are often subtle and non

specific

Children do not possess an adultsability to explain what is wrong withthem

Much has been written on thesubject much controversy


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HistoryHistory Obtained from parents / guardians they

know their child best!!

Ask how the childs behaviour compares to

normal Where possible involve the child

Be sympathetic

Take time to build rapport and interact

with them history and examination mustbe informal and playful use concepts thechild understands


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HistoryHistory Birth / Perinatal history:

- Important to assess repercussions oftrauma/illnesses/congenital

abnormalities eg preterm /NEC / early UTIs

- Problems in pregnancy andperinatally incl admission to NPICU

- Gestational age at delivery- Mode of delivery

- Birth weight

- Location of birth (hereditary illnesses)


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History (cont)History (cont) History of presenting complaint:

Pain onset, duration, location, nature, radiation,relieving and exacerbating factors (eg. Non specific abdopain is usually vague, central and colicky ; Appendicitisis unilateral and well localised)

Nausea and vomiting. Is vomiting bilious? alwaysominous in children

Good appetite / Feeding well Irritability / Crying Passage of blood and mucus rectally/ with stool Bowel habit Dysuria / Urinary frequency

Recent URTIs, GI upsets Wetting nappies / passing adequate/large amount ofurine

Menstrual / sexual history in older girls Polydypsia


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Alarm symptomsAlarm symptoms Unintentional weight loss

Failure to thrive

Unexplained fever Severe diarrhoea and vomiting

GIT bleeding

Family history of IBD Chronic RIF or RUQ pain


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ExaminationExamination Observe child while you are chatting

and taking history behaviour,

dynamics with carers Abdominal examination must be

done methodically, calmly withoutupsetting the child

Be gentle / use toys to distract /examine on parents lap if necessary


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ExaminationExamination

Ask child to show you with one finger the area ofmaximal pain

Ask child to protrude and then suck in theirabdomen and to cough and jump on the spot unable to do if peritoneal irritation existent. NOASSESSMENT OF REBOUND

Palpate all quadrants Hernial orifices External genitalia ENT examination Rectal examination rarely needed Signs of hydration mucous membranes /

sunken eyes / decreased skin turgor / capillaryrefill time>2sec / decreased temperature /sunken fontanelle


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Differential diagnosisDifferential diagnosisEMERGENCY/LIFE THREATENING OTHERS DKA - NSAP IBD/Crohns - Porphyria Ladds bands/Malrotation/volvulus - UTIs and calculi Appendicitis - Constipation

Intestinal obstruction - Mesenteric adenitis(adenoviral infection) Meckels diverticulum - Pneumonia Intussusception - Peptic ulcer disease Incarcerated inguinal hernia - Sickle cell crisis/anaemia Testicular torsion - Gallstones Trauma - Pancreatitis (choledochal cysts) Food/drug poisoning - Pica Ectopic pregnancy / ovarian torsion - Tonsillitis

- Otitis media- Gynae pathology- Infective enteritis- Child abuse- Attention seeking behaviour


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Differential diagnosisDifferential diagnosis

Gynae pathologyNSAP

ConstipationSickle cell crises

DMHSPHirschprungs

PneumoniaDMVolvulus

TraumaPneumoniaDMPsychogenicTraumaPneumonia

Testicular torsionPsychogenicTrauma

Pregnancy / ectopicpregnancy

Onset of menstruationIncarcerated inguinalhernia

UTIUTIUTI

Ovarian cyst torsionConstipationInfantile colic

Menstruation /Mittelschmerz

Acute appendicitisIntussusception

Acute appendicitisMesenteric adenitisConstipation

Mesenteric adenitisGastroenteritisGastroenteritis

12-16 yrs2-12 yrs


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InvestigationsInvestigations Laboratory studies:

- Complete blood count:- peritonitis- suspected perforated appendicitis- toxic appearance

- U&Es, Creat:

- >10%dehydration- significant history of vomiting and diarrhoea

- Amylase +/- LFTs:- RUQ/epigastric pain- suspected gallstones

- Blood cultures:- Toxic child

- Temperature >103- TFTs- Drug levels- ESR, CRP- H. pylori antibodies- RAST, Tissue transglutaminases etc


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Investigations:Investigations: Urinalysis:- all patients- look for red/white cells, ketones,

glucose, metabolites

- stone analysis

Urine culture:- UTI if >100000 organisms/mm3

Stool culture / O,C,P:- if diarrhoea present


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Investigations:Investigations: Radiological studies:

- AXR: use sparingly- suspected pneumoperitoneum- diffuse peritonitis- suspected intestinal obstruction- palpable mass

- past history of cholelithiasis/urolithiasis- Ultrasound

- Pelvic pain (girls)- abdominal/pelvic mass eg intussusception- past history of cholelithiasis/urolithiasis- testicular problems

- CT: use sparingly

- trauma- large BMIs- Equivocal / complicated cases

Others: Laparoscopy


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InvestigationsInvestigations THE MOST USEFUL TOOL IS

REGULAR ACTIVE OBSERVATION INTHE WARD

If sent home to the care of thefamily physician or under the care of

the A&E doctor pts need re-evaluation after 8-12hrs if symptomspersist


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AppendicitisAppendicitis 4 in 1000 children aged 5-14yrs yearly

70,000 paediatric cases per year in the

USA Extremely rare in neonates

Incidence of 1-2 cases per 10,000 childrenper year between birth and 4 years

Increases to 25 cases per 10,000 childrenper year between 10 and 17 years of age


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AppendicitisAppendicitis Rate of perforation is 80-100% for

children younger than 3 years vs


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Evaluation algorithmsEvaluation algorithms Kharbanda et al:

- based on 6-part scoring system: nausea (2pts), history offocal RLQ pain (2 pts), migration of pain (1pt), difficulty walking(1pt), rebound/percussion tenderness (2 pts), absolute neutrophilcount of >6.75x103/l (6 pts)

- score of 7 sensitivity of 73% and specificity of 80%- limited to risk stratification of suspected appendicitis inchildren


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AppendicitisAppendicitis

Vague central abdominal pain preceded by anorexia andvomiting. Pain shifts and settles in right lower quadrant.


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WCC in AppendicitisWCC in Appendicitis WCC neither sensitive nor specific forappendicitis

Elevated in 70-90% of pts with acuteappendicitis also elevated in other abdoconditions

Predictive value limited 10% of pts havenormal WCC

WCC >15,000cells/mm3 suggestive of

perforation but Cardall et al (2004)found no significant difference betweensimple and perforated appendicitis asregards WCC


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Ultrasound in AppendicitisUltrasound in Appendicitis Overall sensitivity of 85% and

specificity of 94% in experiencedhands for paediatric pts

Noncompressible dilated appendix

Periappendiceal abscess

Fluid in appendiceal lumen

Transverse diameter of 6mm or more


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Functional abdominal pain orFunctional abdominal pain or

nonspecificnonspecific abdominal painabdominal pain 15% of school age children

Most common symptom in childhood

worldwide Considerable morbidity / missed

school days / high use of healthresources

Characterized by diagnosticuncertainty and parental anxiety


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DefinitionsDefinitions Apley a nd N aish 1 9 5 8 :- waxes and wanes- occurs with 3 episodes within 3 monthperiod

- severe enough to affect childs activities

Subcom m ittee on chronic abdom inal pain,2 0 0 5 :

- Chronic abdominal pain

- Longstanding intermittent or constantabdominal pain

- functional in most children


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DefinitionsDefinitions Rome I I I cr it e r ia , 20 06 : Each of the following subtypes:

- without evidence of inflammatory,anatomical, metabolic or neoplasticprocesses to explain the pain

- all criteria fulfilled for at least 1 a wk per 2mths before diagnosis

Functional dyspepsia:- persistent or recurrent pain centred upperabdomen (above umbilicus)

- not relieved by defaecation or associated withchange in form or frequency of bowel action


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DefinitionsDefinitions I rr itable bow el syndrome:- Abdominal discomfort or pain associatedfor 25% of the time or more with 2 or moreof:

- improvement with defaecation- change in frequency of stool- change in form or appearance of stool

Functional abdom inal pain:

- Episodic or continuous abdominal pain- Insufficient criteria for other functional GIdisorders


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DefinitionsDefinitions

Functional abdom inal pain syndrom e:- Functional abdominal pain with one or moreof:

- some loss of daily functioning- additional somatic symptoms

(headache, limb pain, sleep difficulty) Abdominal m igraine:

- Paroxysmal episodes of intense periumbilicalpain lasting 1 or more hours (2 or moretimes in the preceding 12mths)

- Healthy in between for weeks or months- Pain interferes with normal activities- Pain associated with 2 or more of:

nausea, anorexia, vomiting, headache,photophobia, pallor


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CauseCause Multifactorial

?Enhanced sensitivity of the enteric

nervous system, diet and stress playa role in causation

Paucity of organic cause

Biopsychosocial model proposed

Girls>Boys


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ManagementManagement Reassurance, supportive therapy,

education of patient and carer to preventabdo pain taking over lives

Prognosis good and remits spontaneously

Parental factors rather than psychologicalcharacteristics of the child are moreimportant when predicting persistence of

abdominal pain parents acceptingsituation strongly associated with recovery


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THANKYOU


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Galea - Abdominal Pain in Childhood