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Nancy Brown, APRN, CPNPApril 18, 2018

OBJECTIVES1. Understand the principle causes of acute abdominal

pain in children.2. Make symptom based diagnoses of functional

abdominal pain in children.3. Recognize warning signs that differentiate disease

from functional abdominal pain in children.

LOCATION & NATURE OF THE PAIN VISCERAL PAIN RECEPTORS SOMATOPARIETAL PAIN RECEPTORS REFERRAL PAIN

LOCATION OF VISCERAL PAIN RECEPTORS

Muscle and mucosa of hollow organs Mesentary – tissue that attaches abdominal organs to

wall of abdomen Serosal surfaces- membrane that covers the wall of the

organs

VISCERAL PAIN RECEPTORS

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VISCERAL PAIN RECEPTORS Respond to Stretch Not always well localized 3 areas of association

SOMATOPARIETAL PAIN RECEPTORS

SOMATOPARIETAL PAIN RECEPTORS Respond to stretching, tearing or inflammation Better Localized One sided More intense

REFERRAL PAIN Visceral fibers affect somatic nerve fibers in the CNS Occurs when visceral nerve fibers affect nerve fibers in

spinal cord or CNS Pain is localized but distant from affected site

HISTORY AND SYMPTOMS Onset of symptoms

In what order & Progression

Pain Improving or getting worse? Does eating make it better or worse? Does defecation make it better or worse? Does exercise make it better or worse? What makes it better or worse? Have you tried any treatment?

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DIFFERENTIAL DX BY COLOR OF VOMITUS

EMESIS SUGGESTED DIAGNOSIS

Bile-colored

Coffee-ground colored

Bright red blood, small

Bright red blood large Food or gastric Content Fecal Appearance

Obstruction Midgut volvulus Esophagitis Gastritis Gastric ulcer Trauma from forceful vomiting Esophagitis Gastritis Esophageal tear, gastric ulcer Duodenal ulcer, Esophageal varices Infectious gastroenteritis, obstruction Obstruction

DIFFERENCIAL BY APPEARANCE OF THE STOOL

DIFFERENTIAL BY APPEARANCE OF STOOLSTOOL SUGGGESTED DIAGNOSIS

Watery diarrhea

Hard or Large Stool Decrease in stool frequency Mucus-containing

Infection: Bacterial, viral, parasitic

Appendicitis with perirectal abscess

Constipation Constipation or Obstruction Colitis

APPEARANCE OF STOOL CONT’DStool Suggested Diagnosis Bright red blood, small amount

Bright red blood, large amount

“Currant jelly stool” Melena Pale, acholic stools

Constipation Fissure Hemorrhoid, suggesting

constipation Colitis Henoch-Schonlein purpura Polyp Colitis , Polyp Intussusception Intussusception Gastric or Duodenal Ulcer Biliary or Hepatic disease

GUIDELINES (TIPS) TO DETERMINE SEVERITY OF THE ILLNESS

Can be difficult due to individual’s response to pain from the stoic to hysterical

Does the patient look ill? Acute appears ill, tachypnea, fixed facial grimace Chronic often look sad, but not acute ill

Symptoms improving or worsening Examination for acute abdomen

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EXAM FOR ACUTE ABDOMEN Examination for acute abdomen

Psoas Sign Rovsing’s Sign Obturator Sign Heel Tap Sign

https://youtu.be/6LrL4ysi_AE

MCBURNEY’S POINT https://youtu.be/kjo5KBql_fo

Murphy’s Sign https://youtu.be/9L7N89sOSuc

LABORATORY DIAGNOSIS “In perplexing cases, laboratory studies frequently are

requested, and with notable exceptions, are remarkably unhelpful.” Ross, PIR 2010

Studies may include: CBC Erythrocyte sedimentation rate Urinalysis Teen female - pregnancy

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RED FLAGS – WHEN TO WORRY RED FLAGS Pain localized to the right upper or right lower

quadrants + Acute Abdomen exam Blood in the stools Weight loss Fever Persistent vomiting

ACUTE ABDOMINAL PAIN REQUIRING SURGICAL

INTERVENTION

APPENDICITIS Inflammation of the appendix results in distention leading

to ischemia. Necrosis, perforation and peritonitis or abscess may ensue.

Inflammation starts, the visceral nerves send a message of general unease, which may manifest as pain referred to umbilical region, then anorexia, nausea.

Vomiting, fever, guarding, and abdominal pain with any movement (esp walking)

Inflammation increases and the parietal peritoneum becomes irritated, the somatic nerves begin to signal that something is wrong. - pain McBurney Point

APPENDICITIS CONT’S If Appendix ruptures, may have clinical improvement, then over

the next 12-24 hours the child worsens due to peritonitis. Sometimes localized abscess forms instead, RLQ pain continues

and a tender mass becomes palpable

Diagnostic Tests CBC RLQ ultrasound CT scan BECAUSE THERE IS NO PERFECT TEST FOR APPENCICITIS

OTHER THAN THE PATHOLOGY REPORT, THE BEST DIAGNOSTIC INSTRUMENT IS THE EXAMINER. (Baker PIR)

SIGNS OF APPENDICITIS Tenderness at McBurney point

Involuntary guarding

Pain on movement

Rovsing sign

Percussion or palpation in the RLQ results in pain in an area approximately 2/3 of the distance from the umbilicus to the anterior superior iliac spine

Abdominal wall muscle spasm to protect inflamed abdominal organs from motion

Significant increase in pain with walking, hopping off of the table, or jumping up and down

Pressure in the LLQ results in pain in the RLQ

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SIGNS OF APPENDICITIS CONT’D Rebound tenderness

Psoas sign

Obturator sign

Anorexia, nausea, vomiting, fever Bent knees

Sudden release of deep palpation of the abdomen results in a large increase in pain DO THIS LAST

With the pt on h/her left side, extend the right thigh while applying stabilizing resistance to the right hip. Should cause an increase in pain due to the location of the appendix over the iliopsoas muscle

Increased pain wit passive flexion and internal rotation of the right thigh

The child is most comfortable while laying with knees bent

PYLORIC STENOSIS

INTUSSUSCEPTION SMALL BOWEL VOLVULUS

REPRODUCTIVE SURGICAL EMERGENCIES

Ovarian Torsion Testicular Torsion Ectopic Pregnancy MEDICAL CAUSES OF ACUTE

ABDOMINAL PAIN

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COMMON MEDICAL CAUSES OF ACUTE ABDOMINAL PAIN TREATMENT CONSTIPATION

Diet changes Miralax 8mg/Kg

5Kg 11 lb 2 oz ¼ cap10Kg 22 lb 4 oz ½ cap15Kg 33lb 6 oz ¾ cap20Kg 44lb 8 oz 1 cap

Regular toilet time – stool for feet Try oral clean out at home – may need hospitalization

OTHER ACUTE MEDICAL CAUSES OF ABDOMINAL PAIN

Gastritis NSAID- Induced Dyspepsia Henoch-Schonlein Purpura Ulcer Disease Abdominal Migraine Esophagitis Hepatitis Pancreatitis Biliary Tract Disease

GYN CAUSES OF ACUTE ABDOMINAL PAIN

Pelvic Inflammatory Disease

Mittelschmerz Ovarian Cyst

CHRONIC AND RECURRENT ABDOMINAL PAIN

FUNCTIONAL ABDOMINAL PAIN DISORDERS

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EPIDEMIOLOGY Definition – pain must occur at least 4 times each

month for at least 2 months One in 10 children visits a clinician because of chronic

or recurrent abdominal pain

NORWEGIAN STUDY 87% of pts with abdominal pain met criteria for

functional gastrointestinal disorder (FGIDs) on first visit

Only 1-2% of those had diagnoses change over time to an organic disease

CHANCES ARE SLIM THAT THE NEXT CHILD WHO COMES TO THE OFFICE WITH A BELLYACHE HAS A DISEASE

PATHOPHYSIOLOGY OF CHRONIC AND RECURRENT ABDOMINAL

PAIN Disability associated with FGID’s maybe related to the

child’s catastrophization: the child believes the symptoms are severe and hopeless. The patient may exaggerate symptoms and believe that they cannot cope

Improving the child’s self-efficacy, belief they can help themselves get better, may be an important factor in symptom resolution

RISK FACTORS FOR FAP

HOW CAN CLINICIAN SCREEN QUICKLY FOR DISEASE?

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DURATION OF EACH EPISODE If pain lasts less than 5

minutes, even many times per day is unlikely to be worrisome

Pain lasting few minutes may be abdominal wall muscle cramps or colon contractions

LOCATION OF THE PAINGENERALLY THE CLOSER THE COMPLAINT OF AIN IS TO THE UMBILICUS, THE LESS LIKELY IT IS DUE TO DISEASE

TIME OF DAY Usually upon awakening

or going to sleep At this time the child

assesses their body for discomfort

Less aware of body sensations during the active day

DESCRIPTION OF THE PAIN Is the Pain Constant or intermittent

Constant Unrelated to events as eating or defecation likely reflects CNS

pain

Comes and Goes How often does it occur, how long does it last Does eating make it better, worse, no different? Does defecation make the pain better, worse, or no different? Does exercise make your pain better, or worse, or no different?

PHYSICAL APPEARANCE Patient may appear to be

in no distress, but may rate their pain as an 8-9

May look sad, but rarely ill

“No one believes that I am in pain because I look normnal”

INDIVIDUALS RESPONSE TO PAIN HEALTHY COPING

SKILLS Poor coping skills Anxiety Depression Academic or social stress Coexisting mental health

disorder

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OTHER FACTORS AFFECTING GI SYMPTOMS

Food, infection, inflammation, intestinal permeability, and the microbiome

Early childhood acute pain events

OTHER FACTORS AFFECTING SYMPTOMS

FUNCTIONAL GASTROINTESTINAL DISORDERS

Definition comes from Rome Criteria International GI meeting Rome I 1994 Rome IV 2016

Rome Foundation classification of FGID’s is based on symptoms rather than physiological criteria

FUNCTIONAL DYSPEPSIA (FD) Must include 1 or more of the following at least 4x mo

for at least 2 mo Postprandial fullness Early satiation Epigastric pain or burning not associated with

defecation After appropriate evaluation, the symptoms cannot be

fully explained by another medical condition

IRRITABLE BOWEL SYNDROME (IBS) Abdominal pain at least 4 days per month associated

with 1 or more of the following Related to defecation A change in frequency of stool A change in form (appearance) of stool

In children with constipation, the pain does not resolve with resolution of the constipation (if the pain resolves the child has functional constipation, not IBS)

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition

ABDOMINAL MIGRAINE Must include all of the following occurring at least

twice Paroxysmal episodes of intense, acute periumbilical,

midline or diffuse abdominal pain lasting 1 hour or more (should be the most severe and distressing symptom)

Episodes are separated by weeks to months The pain is incapacitating and interferes with normal

activities

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ABDOMINAL MIGRAINES CONT’D The pain is associated with 2 or more of the following

Anorexia Nausea Vomiting Headache Photophobia Pallor

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition

FUNCTIONAL CONSTIPATION Must include 2 or more of the following occurring at

least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of IBS Two or fewer defecations in the toilet per week in a child

of a developmental age of at least 4 years At least one episode of fecal incontinence per week History of retentive posturing or excessive volitional

stool retention History of painful or hard bowel movements

FUNCTIONAL CONSTIPATION CONT’D

Presence of a large fecal mass in the rectum History of large-diameter stools that can obstruct the

toilet After appropriate evaluation, the symptoms cannot be

fully explained by another medical condition

More information is available at http://theromefoundation.org

FUNCTIONAL ABDOMINAL PAIN –NOT OTHER WISE SPECIFIED

Must be fulfilled at least 4 times per month and include ALL of the following Episodic or continuous abdominal pain that does not

occur solely during physiologic events (eg eating, menses)

Insufficient criteria for IBS, FD, or abdominal migraine After appropriate evaluation, the abdominal pain cannot

be fully explained by another medical condition

DIFFERENTIAL DIAGNOSIS School phobia and Separation Anxiety General Anxiety – Psychosomatic Abdominal wall Pain Celiac Disease Lactose Intolerance

TESTING????

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THE MORE TESTS YOU DO

THE MORE THE PARENT/CHILD

THINKS THERE IS SOMETHING YOU HAVEN’T FOUND

TREATMENT Therapeutic alliance

with the Parent Reassurance and

Empathy that the pain is real

Abdominal pain without disease more common that abdominal pain with disease

TREATMENT – PAIN IS REAL Cognitive behavioral

therapy Dietary therapy Supplements medications

TIME TO WORRY

ALARM SIGNS AND SYMPTOMS PROMPTING TESTING FOR DISEASE Pain localized to the RUQ or RLQ Weight loss or Poor weight Gain Persistent vomiting Blood in Stool Slow or delayed puberty Painful swallowing Dysphagia Family Hx of IBS or celiac disease Fevers Arthritis Perianal disease: skin tags, fissures, fistulae

WHEN TO SEE A SPECIALIST Treatment failure Prolonged School Absence Presence of Alarm Features Abnormal laboratory test results

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PARENT RESOURCES Chromic and Recurrent Abdominal Pain https://www.healthychildren.org/English/health-

issues/conditions/abdominal/pages/abdominal-pain-in-Children.aspx

Spanish: https//www.healthychildren.org/spanish/health-issues/conditions/abdominal/paginas/abdominal-pain-in-children.aspx

https://www.healthychildren.org/English/health-issues/conditions/abdominal/pages/abdominal-pains-in-infants.asps (English only)

REFERENCES Chogle, Ashish et al. Pediatric IBS: Overview on

Pathophysiology, Diagnosis and Treatment. Pediatric Annals. 2014;43(4) 76-82.

Fishman, Mary B. et al. Chronic Abdominal Pain in Children and Adolescents: Approach to the evaluation. www.uptodate.com 2018

Hyams, Jeffrey S. et al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2016;150:1456-1468.

Hyman, Paul E. Chronic and Recurrent Abdominal Pain. Pediatrics in Review. 2016;37(9) 377-390.

REFERENCES Ross, Albert, LeLeiko, Neal S. Acute Abdominal Pain.

Pediatrics in Review. 2010;31(4) 135-144 Schmulson, Max J., Drossman, Douglas, A. What is

New in Rome IV. J Neurogastroentrol. 2017;23(2) 151-163