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Paediatric

Acute abdominal emergencies in childhood

Simon e Kenny

Abstract

abdominal pain is a ubiquitous experience during childhood and a com- mon presenting complaint to secondary health care facilities. amongst the large caseload are a number of serious and / or life-threatening conditions. in this article an approach to history and examination, initial management, diagnostic categories, modes of investigation, and treat- ment are discussed. common and serious causes of abdominal pain in children are discussed. the clinical skills required to differentiate between them should not be underestimated.

Keywords acute abdominal pain; appendicitis; children; paediatric surgery

History and examination

Evaluating a child with abdominal pain is a challenge and a good relationship with the child and parents is essential. Successful evaluation requires patience and often deviates from the normal pattern of history-taking and examination.

General principles

Addressing the child whenever possible and allowing him time

to answer questions is important; questions should give the

child several options without biasing his choice of answer, for example:

‘Is the pain getting better, worse or staying the same?’

• ‘Is the pain bad all the time or does it come and go?’

Showing interest in the child often helps his confidence. His- tory-taking should be age-related; a tactful gynaecological and sexual history should be taken where appropriate (this may be best achieved with the parents absent and a nurse present). Care should be taken to characterize the colour of any vomitus. Dark-green, bilious vomiting is a surgical problem until proven otherwise. Bloody mucus in the stool suggests a surgical cause (although it can also be found in bacterial gastroenteritis).

Abdominal examination

No information can be obtained by attempting to examine the abdomen of a crying child who is pinned to the examination

Simon E Kenny is a Consultant Paediatric Surgeon and Urologist at Alder Hey Children’s Hospital, Liverpool, UK. Conflicts of interest: none declared.

couch. Often the child picks up parental anxieties and attempts should be made to calm their fears. The abdominal examination is often best performed in an un- orthodox manner. Examination of the child on a parent’s lap or when he is standing up often feels safer for the child and allows clinical signs to be detected. A useful strategy with an uncoop- erative child is to defer examination: the fretful, tearful child in the emergency room is often more cooperative on a calm ward in a comfortable bed. Play specialists can be invaluable when assessing children and if any invasive procedures are needed.

Other examinations

Respiratory and ENT examinations should be performed because these are common sites of referred pain. Rebound tenderness should not be sought in the presence of localized tenderness and guarding. It is mandatory to examine the inguinal region and scrotum in boys to avoid missing strangulated herniae and tes- ticular torsion respectively. Digital rectal examination is a con- tentious issue; the balance between clinical information gained versus trust lost is such that many do not practise this procedure in the evaluation of children with abdominal pain. Rectal exami- nation may have a role in conditions such as constipation and some cases of complex appendicitis, anorectal anomalies and Hirschsprung’s disease.

Initial management

Initial evaluation involves assessment of airway, breathing, cir- culation (ABC) protocol. In the shocked or listless child, 100% oxygen via a rebreathing circuit should be given with continuous pulse oximetry. Intravenous or intraosseous access should be obtained if there is shock or dehydration: initial crystalloid infu- sions should be given as a bolus of 10 ml/kg. It is not uncommon for children to require >40 ml/kg of intravenous fluids: estab- lishing an adequate capillary refill time (<2 seconds) should be used as an endpoint. Analgesics should be given via oral, rectal or intravenous routes as appropriate: intramuscular morphine should be avoided (especially in the presence of shock). Physical signs of peritonitis are not masked by the administration of opiate analgesia and analgesia should not be withheld pending surgical assessment. One must know what analgesia has been given when assessing a child (or assessing progress).

Investigation

Serum biochemistry should be obtained if there has been sig- nificant vomiting. Liver function tests and serum amylase should be obtained if there are clinical indications of hepatobiliary dis- orders or pancreatitis. Capillary or arterial blood gases are use- ful in the assessment of associated acid–base disorders and their response to treatment. Metabolic acidosis is common in hypo- volaemic shock, but failure of the acidosis to respond to fluid resuscitation and supportive measures may suggest ischaemic or infarcted bowel (especially in the presence of raised levels of lactate in serum). C-reactive protein levels and white cell count with differential can be of use as discriminatory factors in cases where the diagnosis is uncertain. Intravenous antibiotics (e.g. cefotaxime, metronidazole) should be given preoperatively to children with obvious peritonitis.

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Paediatric

Common causes of abdominal pain (Table 1)

Appendicitis

Appendicitis can be difficult to diagnose in the very young and

neurologically impaired. Young children invariably present late with appendicitis; virtually all children aged <5 years have per- forated their appendix at presentation. Abdominal signs can be subtle and true peritonism may be absent. Abdominal distension is common. A similar situation may occur in the neurologically impaired. Ultrasound and/or CT may provide useful diagnostic informa- tion in equivocal cases and prevent unnecessary surgery. Careful assessment of dehydration or shock is essential, and vigorous fluid resuscitation and antibiotics should be given intravenously (if necessary). The choice between an open or a laparoscopic approach to appendicectomy in children is controversial, although a recent systematic review concluded that laparoscopic appendicectomy was ‘likely to be beneficial’ when performed by an experienced laparoscopist. In children aged >5 years, persistent guarding in the right iliac fossa on repeated clinical examination is the key to diagnosis. Complex appendicitis can cause pyuria or diarrhoea which can mislead the inexperienced surgeon.

Non-specific abdominal pain

About 60% of all children admitted to hospital in the UK with

abdominal pain will be diagnosed as having non-specific abdomi- nal pain. This category encompasses all children in whom no cause is diagnosed and who recover with no specific treatment. Anorexia is common (although less so than with appendicitis); most other symptoms are less prominent. Tenderness of the right iliac fossa may be present, although guarding and rebound are rare.

Mesenteric adenitis

Vague central or generalized abdominal pain often accompa- nies viral infections of the upper respiratory tract. The pain is

Common causes of abdominal pain in childhood appendicitis Gastroenteritis

infection of the urinary tract constipation

Mesenteric adenitis

Ovulatory/perimenstrual pain

Non-specific abdominal pain

Serious causes of abdominal emergencies in childhood appendicitis intussusception Malrotation/volvulus

Bleeding Meckel’s diverticulum Bacterial enterocolitis Ovarian/testicular torsion Pancreatitis

Obstruction/strangulated hernia

Table 1

thought to result from a concomitant mesenteric lymphadenopa- thy. A history of vomiting is rare and children may complain of headache or sore throat. Examination may reveal a high pyrexia (>38.5°C), cervical lymphadenopathy and diffuse abdominal tenderness. Management is symptomatic; if the diagnosis is in doubt, surgical exploration is indicated.

Gastroenteritis

Gastroenteritis typically presents with non-bilious vomiting and colicky central abdominal pain, often accompanied by diarrhoea. There may be dehydration and pyrexia. Abdominal tenderness is rare, although distension can occur. The presentation of bacterial enterocolitis can be dramatic, with high fever, listlessness, signs of hypovolaemia, abdominal distension and bloodstained diar- rhoea. Occasionally, it can be difficult to differentiate between bacterial enterocolitis and a surgical cause; observation usually answers the question.

Infections of the urinary tract

Infections of the urinary tract are common in children, affecting 1.5% of boys and 5% of girls by the age of sixteen years in the UK. Usual symptoms are of lower abdominal or loin pain, dysuria, pyrexia and vomiting. Children with acute pyelonephritis may have renal angle tenderness. Infections of the urinary tract are typ- ically secondary to ureterovesical reflux (although acute obstruc- tion of the urinary tract or stones should also be considered). Diagnosis is best made on finding bacteria on microscopic examination of a fresh specimen of urine followed by culture. Urine dipsticks can screen for potential infection. Trimethoprim is suitable as a first-line antibiotic. Ureterovesical reflux can lead to recurrent infections, hyper- tension and end stage renal failure. Children with recurrent infec- tions, atypical symptoms / signs or family history of renal disease plus the very young will require further investigation with a renal tract ultrasound and a 99m technetium dimercaptosuccinic acid scan. (Ref: NICE guideline)

Constipation

Childhood constipation (the infrequent painful passage of stools, with or without soiling) is extremely common. It may be accom- panied by colicky abdominal pain and soiling due to overflow incontinence. Abdominal examination shows minimal tenderness and usually a firm faecal mass in the rectosigmoid or descend- ing colon. Most cases are idiopathic, but constipation may be a presenting feature of a pelvic mass, anorectal pathology or a neurological deficit. Therapy for idiopathic constipation should focus on clear explanation of the problem, with advice on diet, toileting, and the use of laxatives.

Ovulatory/perimenstrual pain

A menstrual history should be taken in all adolescent girls. The timing of the pains is important (especially the mittelschmertz associated with mid-cycle ovulation). Examination may show pel- vic tenderness. A sexual history should be taken because pelvic inflammatory disease and pregnancy may need to be excluded. Abdominal ultrasound can be useful in assessing ovarian pathology. If a large ovarian cyst is encountered at laparotomy, it should be drained and the ovary conserved (unless there is concern that

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Paediatric

there may be a tumour). Laparoscopy is a useful investigative and therapeutic tool in the case of ovarian pathology.

Intussusception

In an intussusception, a segment of bowel (usually ileum) tele- scopes into distal bowel (usually colon), causing obstruction and compromising blood flow to the intussuscepted bowel (Figure 1). Intussusception is most common between 2 and 24 months and most cases are idiopathic. In older children, a pathological lead- point, such as a Meckel’s diverticulum (see below) or lymphoma of the small bowel may be found. Typically, infants experience colicky abdominal pain and vomiting. They draw their legs up and look pale. Rectal bleeding with mucus (‘redcurrant jelly’) is a late sign. Most disease and death from intussusception arises from delays in diagnosis. Between bouts of colic, infants are quiet, but irritable, with evidence of hypovolaemia. A mobile abdominal mass may be palpable. Some children present atypi- cally with lethargy but no colic; mild abdominal tenderness and mucoid rectal blood may be the clue to the cause. Vigorous fluid resuscitation and supplemental oxygen is often required. The diagnosis can be confirmed by ultrasound scanning. Treatment is commonly by air reduction through a rectal Foley catheter under controlled pressure conditions managed by an experienced radiologist. Children must be adequately resus- citated and monitored by staff trained in paediatric life support during these procedures. Possible complications include intesti- nal perforation and tension pneumoperitoneum. Enema reduction is contraindicated in refractive shock or in children with signs of peritonitis. In a minority of patients, reduc- tion is unsuccessful and open surgical reduction or resection is needed.

Mid-gut malrotation

Malrotation is where the intestine is not fixed normally in the abdomen. The common form is midgut malrotation in which there are two components: the third part of the duodenum lies to the right of the vertebral column (instead of crossing to the left) and the caecum lies in the upper abdomen (adjacent to the duodenum). The mesentery of the midgut is not attached

Paediatric there may be a tumour). Laparoscopy is a useful investigative and therapeutic tool in the

Figure 1 Operative findings of intussusception where the a ileum is telescoped into large bowel. the caecum and appendix are visible following partial pneumatic reduction. also seen are the b caecum, c appendix and d dilated proximal intestine.

in the usual manner across the posterior abdominal wall, but is freely suspended on a narrow pedicle from the base of the superior mesenteric artery. It can twist at any time. A volvulus of >270° may lead to midgut infarction. In the infant, acute midgut volvulus presents with dark-green bilious vomiting, abdominal distension and tenderness and rectal bleeding. With progressive midgut ischaemia, the infant rapidly deteriorates with hypovolaemia and metabolic acidosis. A plain radiograph of the abdomen shows duodenal obstruction with sparse or absent distal bowel gas. Urgent laparotomy is required after rapid resuscitation and the volvulus is derotated to permit restoration of blood flow. The bowel is placed in the non-rotated arrangement and the mesentry broadened (Ladd’s procedure). The risk of acute volvulus is highest during the neonatal period, but malrotation may remain asymptomatic for years.

a Operative findings of a Meckel’s diverticulum (red arrow). the ileum is represented by the white

a Operative findings of a Meckel’s diverticulum (red arrow). the ileum is represented by the white arrows. b Positive 99m technetium scan (lateral view) demonstrating a Meckel’s diverticulum (red arrow). the white arrow represents the gastric mucosa.

Figure 2

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Paediatric

Recurrent volvulus may present at any age and must be sus- pected when there is a history of chronic intermittent abdominal pain with or without vomiting. A radiological upper gastrointes- tinal contrast study is usually diagnostic.

Meckel’s diverticulum

A Meckel’s diverticulum (Figure 2) is an embryological remnant caused by failure of regression of the vitellointestinal duct that normally occurs between the fifth and seventh week of gestation.

Usually, a Meckel’s diverticulum is asymptomatic and found inci- dentally at laparotomy/autopsy. However, it can present with bleeding, intussusception, obstruction and a clinical picture sim- ilar to appendicitis. Gastric or pancreatic mucosa is present in >50% of symptomatic Meckel’s diverticula and is often respon- sible for the associated bleeding. 99m Technetium scans label het- erotopic gastric mucosa and are 85% sensitive, 95% specific and 90% accurate in the diagnosis of a bleeding Meckel’s diverticu- lum. A symptomatic Meckel’s diverticulum should be excised.

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