ABDOMINAL

PAIN : IS IT
APPENDICITIS?
dr. Selly Adyta Kemara
Stase Bedah Anak
Tahap II

Department of Surgery
Medical Faculty, of Diponegoro University
Abdominal Pain

• Common in children
• Examination of abdomen : directed at loaclizing the origin of pain &
detecting the presence of peritonitis
• If peritonitis  surgical emergency and should be operated within
hours of diagnosis
• In young children, infection outside the abdomen (lung/hip) may
be interpreted as abdominal pain  must be distinguished
• Age of patient  helpful in diagnosing acute abdominal disease
• Knowledge of the age of patient, detailed history of the onset,
duration, location, characteristic of pain and related symptoms
 provide substansial diagnosed before physical examination

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Abdominal Pain

Common in Children with diferensial diagnosis

Very common Acute appendicitis
Non-specific viral infection
Gastroenteritis
Constipation
Urinary Tract Infection
Less Common Intussusception
Lower lobe pneumonia
Intestinal obstruction (Congenital & Adhesion)
Urinary tract obstruction
Strangulated inguinal hernia
Rare Henoch-schonlein purpura
Primary peritonitis
Diabetic ketoacidosis
Lead poisoning
Acute porphyria
Herpes zoster
Sickle-cell anemia 3
Haemophilia
GENERAL
CONSIDERATION
Physical characteristics of the Abdomen in Children

• Shape of abdomen in infants differ from older child :

1. More protuberant
2. Wider . Infants : abdomen tends to bulge between the costal margin &
iliac crest  reason of horizontal line incision in children
3. The pelvis is shallow. Infants : bladder is abdominal organ, rectal
digiital examination gains
more information

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Physical characteristics of the Abdomen in Children

• Posterior abdominal wall : not flat, has prominent midline

ridge due to vertebral bodies  aorta and transverse colon
easy to feel compared w/ adrenal glands (at the side of
vertebral column)
• Infant : direction of ribs is relatively horizontal  normal liver
edge being palpable below the right costal margin
• Inguinal skin crease : attachment of scarpa’s fascia to the
fascia lata of thigh, located between inguinal ligament, may
be a trap in the localization of the herniae in infants between
6-18 months.

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Physical characteristics of the Abdomen in Children

• Processus vaginalis : often patent, any fluid in the peritoneal

cavity (e.g. blood, pus, meconium) may track down &
produce discoloured scrotum.
• Muscles of ventral abdominal wall contract while crying 
hard to examine
• Palpate when the child’s relaxed or between episodes of
crying, most easy  lateral rectus muscle (abdominal
musculature is thinnest)
• Do Manoeuvre (child leaning forwards in sitting position) 
on tight abdominal muscle and suspected peritonitis

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Location of Pain

• Distension of the bowel & inflammation of visceral

peritoneum  stimulate sympathetic pathways
• The perceived location depends on the level of bowel
involved
Foregut epigastrium
Midgut  umbilicus
Hindgut  infraumbilical/hypogastric
• Localization of pain is not precise
(in autonomic pathway)

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Location of Pain

• Localized distension w/ peristaltic against obstruction 

cause colic
• Inflammatory lesions  constant pain
• Visceral pain  cause vomiting (e.g appendicitis)

• Irritation of parietal peritoneum  segmental somatic nerves

 localized, sharp, continues. Worse by movement

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Location of Pain

Referred pain  not commonly recognized in children

• Irritation of underside of diaphragm by pus/blood cause pain
in shoulder tip
 diaphragm is supplied by nerve phrenic which is made
up of fibres from the fourth cervical nerve root
• Biliary colic (rare)  pain in the back below the inferior angle
of right scapula
• Uterine and rectal pain  lumbosacral region of the back
• Loin pain from kidney  radiate to ipsilateral testis
• Ovarian disease pain radiating to the inner aspect of thigh

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Masses Palpable in Normal Abdomen

• Faeces  may be palpable in colon and indentable (different

form mass)
• Lower pole of right kidney  palpable with deep inspiration
• Liver  often palpable 2-3 finger breadths below the right
costal margin

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HISTORY TAKING
The History

• Characteristic of the pain

Time of onset Duration

Location At onset
At examination
‘reffered pain”
Severity Mild to severe
Progression
Alleviating factors
Exacerbating factors
Type Colicky
Constant
Associated symptoms

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Duration of Pain

• Knowledge of duration of pain and rate of progression  key

to assesment of physical sign
• In malrotation with volvulus, infarct of midgut  within
several hours
• Appendicitis  inflammatory process may proceed to
gangrene and localized perforation  uncommon within 18h

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Shifting of pain

• Movement of pain away from a vague central location to

another side  indicative of development of parietal
peritoneal sign
• Pain extension from lateral position to involve whole
abdomen  the pathology extends to other parts of
peritoneal cavity

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Type of pain

• Obstruction of hollow viscus

causes sharp spasm of colic
between which patient suffers dull
ache
• Not all abdominal pains are
caused by intraabdominal disease

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Exacerbating and relieving factor

• Exacerbating factor : anything that

cause movement between
adjacent surfaces of inflamed
peritoneum.
 cough, sneeze, vomit, take
deep breath, walk.
Micturation & defecation (if
pelvis involved; pelvic app)
• Relieving factor : prevent
movement of peritoneal surface

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Associated Features

Vomiting
• Caused by stimulation of autonomic reflex in response to
inflammation
• The relation of its onset to development of pain
Appendicitis  several hours after pain
Acute colic/ureter  coincides with pain (both sudden)
Obstruction; high  early
low  day/ longer

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Associated Features

Vomiting
• Its frequency : Correlates with severity of pathology
Severe vomiting in Acute appendicitis  obstructed
appendix & likely to perforate
Proximal obstruction  frequent & forceful vomiting
• Bile-stained vomitus  volvulus (obstruction at the second
part of duodenum e.c twisting midgut)
• Distal small bowel obs : vomitus’s initially gastric content
followed by bile-stained material, yellow/brown feculent fluid

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Associated Features
Vomiting
Vomitus
Bile stained
Gastric contents, then bile
Gastric contents then bile,
then faecal fluid
Not bile-stained
Blood
Cause Reason
Malrotation w/ volvulus Duodenum obstructed just
beyond the ampulla
Gastroenteritis Inflamed stomach or
secondary to pain
Intestinal Obstruction Fluid collection above
distal block
Pyloric stenosis Blocked above ampulla
Oesophageal varices Portal hypertension
Gastritis Infection/crrosion/aspirin
Gastro-oesophageal reflux Oesophagitis
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Associated Features

Abnormal stools

Stools Cause Reason

High volume & watery Gastroenteritis Primary effect on
absorption
Small volume and mucousy Appendix abscess Secondary irritation of
the rectum
Intial evacuation then Intussusception Mass induces reflex
blood ± mucus emptying and vascular
compression leading to
venous congestion

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PHYSICAL
EXAMINATION
Preparation for Examination

• Warm room
• Remove the clothes to expose abdomen, chest & external
genitalia
• Child lie comfortably in supine position with pillow behind the
head and arms at the side

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Is there peritonitis?

• History : pain that worsen by movement

• Child use chest wall muscles in breathing to a greater
degree  make the abdomen still
• Ask child to puff out the abdomen  unable
• Do maonuovre : by press each side of the chest wall
and pelvis firmly and shake side to side  shaking
cause abdominal pain
• Elicit percussion tenderness

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Is there peritonitis?

• Mucular Guarding : the involuntary feflex contraction or spasm of anterior

abdominal wall muscles when anterior parietal peritoneum is inflamed,
persist even when the child’s asleep
• Most sensitive area : area lateral to rectus abdominisis muscle
• Children < 3y: assesment can be done by diverting attention /re-examine
when asleep/ allowing the mother to cuddle the child facing her face and
we gantly palpated the abdomen.

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Is there peritonitis?

• Auscultation the presence of bowel sounds doesn’t rule out peritonitis

• Second Major sign  tenderness
most marked in the region of primary pathology – can be widespread
progression and extension of tenderness  suggestive peritonitis
• Non specific sign
Early  facial expression (pain), pale/flushed face, red cheeks (w/
perioral pallor). Pirexya, fetor, furred tongue, tachycardia.
Late  septichaemic shock, abdominal distension, bowel sounds (-)

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APPENDICITIS
Appendicitis

• Commences with dull continuous central abdominal pain

which moves after 6-24h to right iliac fossa where it
perceived ad being more severe.
 appendix (form midgut) so the inflammation
involves splanchnic fibres  umbilical discomfort
 inflammation progresses to adjacent parietal
peritoneum  pain is sharply localized and severe.
• Pain is accompanied by anorexia,nausea, and vomiting

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Appendicitis
• Presentation of appendicitis
1. Anterior Right Iliac fossa
Obvious right iliac fossa
tenderness
Guarding
Rebounf tenderness
 Easy and early diagnosis
Anterior peritoneum
inflemed early
2, Posterior right iliac fossa
Vague deep tenderness
± Guarding
May develop mass behind
colon / perforation before
diagnosis
± Limp
 Hard dealyed diagnosis
Posterior peritoneum or
psoas inflamed ( limp),
but few anterior
abdoominal wall signs
3. Pelvis
Vague suprapubic
tenderness
No guarding
± Urinary symptoms
± diarrhoea
Commonly perforated
before diagnosis
 Hardest, late diagnosis
Pelvic peritoneum inflamed
(bladder and rectal
irritation), but few anterior
abdominal wall signs
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Rectal Examination

• Indication : suspect pelvic appendicitis or other

diagnoses
• <3y  use lubricated little finger. Older  index
finger
• Introducing the finger firmly and keep it for several
seconds until the child comfortable before palpating
each direction for abnormal masses or localized
tenderness.

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Appendicitis

• Rare in child under 5 years, difficult to diagnose

• The child can be asked to point with one finger which part hurts the
most  most : Mc burney’s point (1/3 betwwen SIAS and umbilicus)
• History consistent w/ appendicitis + marked localized tenderness in
right iliac fossa  base of diagnosing appendicitis
• Generalized peritonitis : advanced disease. If caused by appendicitis 
the guarding most pronounced in right iliac fossa

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Appendicitis

• Persistent small volume diarrhoea and the passage of mucus

• If appendix perforates  infected material collects in peritoneal cavity
(retrovesical pouch/retrouterine recess)  developing pelvic abcess.
As the size increase  irritation of rectum (palpated hot, tender buldge
of anterior rectal wall)  cause small and frequent loose stools
containing mucous.
• Elevated temperature (37,5-38,5℃)
• May produce a mass in right illiac fossa ( tender, immobile mass deep
to muscles of ventral abdominal wall)
 it is an inflammatory phlegmon of an infected appendix, stuck by
inflammatory exudate to adjacent oedematous loops of small
bowel and greater omentum.
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Other Patologies in suspected Appendicitis

Viral enteritis
• Etio : Infection by enteric organism (yersinia/campylobacter)
in the lymph nodes  enlargement and suppuration 
diffuse tenderness (maximal in the right iliac fossa)
• Inflamed ileum  distended with fluid and gas  succusion
splash (on deep palpation)
• Other sign of viral infection : conjunctivitis, headache,
rhinorrhoea, moderate nelargement of cervical, axillary, and
inguinal lymph nodes
• Temp : 40℃, usually return normal within 48h
• Self limiting  resolve 3 or 4 days

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Other Patologies in suspected Appendicitis

Gastroenteritis
• Vomiting and diarrhoea (diarrhoea usually commences at the first place,
or shortly after vomiting
• Abdominal pain : cramping and diffuse
• Symptoms are improved within 24-72 h

UTI
• Higher fever
• Abdominal pain
• Urinary examination

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Other Patologies in suspected Appendicitis

Constipation
• Risk factor : poor diet, constitutional predisposition, poor bowel training
• There is a long history of infrequent passage of hard bowel over long
period
• Pain : colicky and relieved by bowel action
• Examination : reveals fecal material on left & right sides of colon.
digital exam : capacious rectum full of faecal material.

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Golden Rule

1. Symptoms intraabdominal pathology : pain persist more than 4h,

increase in intensity, persistent vomiting, even in absence of pain
2. Beware peritonitis
3. Beware uncooperative child
4. Commonest lump in acute abdomen is faececs (palpable colon)
5. Visceral pain : epigastrium, umbilical, hypogastrium  based on
involvement of foregut, midgut, hindgut
6. Irritation of anterior parietal peritoneum produces pain via segmental
somatic nerves & causes guarding muscle
7. Inflammation of posterior parietal peritoneum doesn’t cause guarding

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Golden Rule

9. Infant’s abdomen is more protuberant, wider, shallower plevis

10. Narcotic analgesia : given to child with abdominal pain only once a
definite clinical diagnosis / decision to operate has been made
11. Abdominal pain may be caused by extra abdominal organ pathology
12. Abdominal sign of peritonitis : painon movement abdomen, reluctance
to indraw or protrude abdomen, involuntary guarding.
13. Late signs of peritonitis include rigid, distended abdomen & sign of
septicaemia
14. Beware diarrhoea persisting for more than 48h

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THANK YOU