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Abdominal pain :

Common symptom

Lesion: - intra abdomen

- extra abdomen

For early diagnosis: - careful anamnesis

- physical examination

- further investigation

Surgical case or not?


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Source of abdominal pain :

Viscera abdomen

Others organ outside of abdomen

Lesion of Medulla Spinalis

Metabolic disturbance

Psychosomatic


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Pathogenesis

1. Vascular disorders

(emboli / thrombosis, rupture, occlusion causedby torsion or tension)

2. Inflammation Pain if the inflammation process are in

peritoneum parietalis somatic inervation

Local pain or general pain.

Type of pain : stabile, increase with movement ofinflammatory peritoneum


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3. Passage disorders/obstruction of luminalorgan in peritoneal or retroperitoneal cavity

Partial obstruction or total obstruction intra

lumen pressure pain

4. Traction, inflammation and stretching of

peritoneum visceralis


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Infant commonly caused by obstruction

a. Colic

b. Constipation

c. Volvulusd. Intussusceptions/invagination

e. Strangulated hernia

f. Pyloric stenosis

g. Perforation of gastrointestinal tract

h. Appendicitis

i. Acute hydrops of gallbladder

Cause of abdominal pain by age groups


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a. Gastroenteritis

b. Appendicitis

c. Mesenteric lymphadenitis

d. Meckels diverticulume. Ileitis regional

f. Colitis ulserativa

g. Diabetic acidosis

h. Pneumonia

i. Torsion of ovarian cord

j. Constipation

Older child commonly caused by infection

k. Pyelonephritis

l. Colic Ureter

m. Lead intoxication

n. Torsion of spermatic cordo. Abdominal epilepsy

p. Sickle cell crisis

q. Mononucleosis

r. Porphiria

s. Cholecystitis andcholelytiasis

t.

Pancreatitis


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Cause of acute abdominal pain by age groups,that requirring surgical intervention

Infant / age < 2 years old

Abdomen :

Perforation of gastric ulcers

Bowel obstruction : - intusussception

- volvulus and malrotation

Appendicitis and enterocolitis necroticans

Extra abdomen :Inguinal hernia with strangulation and incarceration


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Age > 2 years old

Abdomen:a. Obstruction

Bowel obstruction caused by fibrosis, volvulus, malrotation

Perforation caused by bowel obstruction

b. Inflammation (appendicitis, primary peritonitis, peritonitiscaused by Meckels diverticle perforation, perforation ofduodenal ulcer, perforation caused by typhoid fever, Meckelsdiverticulitis, cholecystitis with or without gall stone, toxicmega colon with perforation)

c. Trauma (rupture of spleen, urinary bladder, another visceralorgans, hematoma sub serosa)

d. Bleeding (bleeding intra ovarian cyst)

e. In tropic area (perforation associated with ascariasis,strongiloidiasis, jejunitis necrotican in New Guinea, perforation

of abscess amoeba)


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Extra abdomen:a. Torsion of testis

b. Inguinal hernia with strangulation and incarceration


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Infant / age < 2 years old

Abdomen :

- Intestinal infection

Extra abdomen :

- Pneumonia

- Urinary tract infection

Cause of non surgical abdominal pain(Walker and Smith, 1983)


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b. Liver and billiary tree- Hepatitis- Cholelytiasis

c. Pancreas- Pancreatitis

d. Kidney- Urinary tract infection- Stone- Nephritis

e. Metabolic- Phorphiria- Hiperlipidemia- Diabetic keto acidosis

- Familial Mediterraneanfever

f. Gynecologic- Salphyngitis


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Cause of abdominal pain in Indonesia

Neonatal - 3 months

- Cows milk allergy- Pyloric hypertrophy

- Torsion of testis- Obstipation/with

anal fissure- Bowel malrotation

3 months2 years

- Obstipation- Gastroenteritis

- Bowel duplication- Maldigestion- Gastric mucosal

membrane

- Meckels diverticulum


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> 5 years

- Appendicitis- Gastritis

- Ovarian torsion- Menstrual cycle- Cholecystitis- Functional

abdominal pain- Urinary tract stone- Varicocele testis

2 years5 years

- Obstipation- Volvulus

- Hepatitis- Urinary tract

infection- Ascariasis

- Appendicitis- Pancreatitis


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0 - 3 months : vomiting

3 months2 years : vomiting, pitching/crying,

trauma(-) 25 years : can tell the pain, localization not

true

> 5 years : can tell the type and localization ofthe pain

Clinical manifestation by age group


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Diagnostic approach

1. Anamnesis

2. Physical examination

3. Laboratories and further investigation


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Laboratory and further investigation

Routine ( urine, blood, feces)

Culture

3 positions of abdominal plan photo Thorax photo (severe disease)

Barium meal/follow through

Barium enema Intravenous pyelography

Ultrasound

Endoscopies


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Therapy

Require surgical intervention?

Depend on etiology


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Surgical abdominal pain

Abdominal pain that require surgicalintervention

Symptoms

- Severe pain, stable, onset 3-4 hours

- Vomiting : green or fecal- Increase temperature


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Surgical abdominal pain

Obstruction

- Invagination, bolus ascariasis,

volvulus/rotation of gaster

Inflammation

- Acute appendicitis, acute cholecystitis, peritonitis

Blood flow disturbance

- Invagination, malrotation, volvulus,

ovarian cyst torsion


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Physical examination

Localized or generalized peritoneal sign

Sign of obstruction

- Abdominal distention

- Bowel contraction and peristaltic

Tumor mass

Anorectal bleeding


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Therapy

Exploration/operation laparotomy


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Definition (Apley, 1975)

Recurrent abdominal pain is intermittent

abdominal pain at least 3 times whichpersists for longer than 3 months andaffects normal activity

Recurrent abdominal pain


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Prevalence

Age 314 years old

mostly 510 years old

5% of pediatric outpatient

Organic cause 5-10%


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Etiology

Organic 5-15,6% cases

Functional 80%


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Di RSCM

17 cases

47% spasmophylia

11.8% gastritis

5.9% colitis

29.4% worms infection

11,8% psychological/psychiatric disorders


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Symptoms suggested organic disorders

Persistent fever

Growth and development disturbance

Weight loss

Anemia

Hematemesis

Melena

Hematochezia Pain away from midline

Perianal disease


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Diagnostic approach

1. Careful anamnesis, Physical examination,and further investigation

2. High cost examination and commonly wasnot positive

3. Endoscopygreater probability to find theetiology


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Anamnesis

Age

Pain (localization , type, time, frequency, other symptom)

Defecation pattern

Urination pattern Menstrual cycle

Skeletal muscle disorders

Growth and development disorders

Psychosocial aspect

Trauma

History of family disease


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Laboratory and further investigation

Routine ( urine, blood, feces) Ureum, creatinine

Culture

3 positions of abdominal plan photo Thorax photo (severe disease)

Barium meal/follow through

Barium enema Intravenous pyelography

Ultrasound

Endoscopy


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Therapy

Depend on etiology

Sedative and analgesic

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