Abdominal pain in

Children
Ho Lii Chyuan
Age Surgical Non Surgical
Neonatal Volvulus/ Malrotation Colic
Incarcerated hernia Milk allergy
Pyloric Stenosis Gastroenteritis
Intestinal anomalies Gastrooesophageal reflux disease
Hirsprung disease
Intestinal perforation
Trama

Infancy ( less than 2 years ) Intussusception Gastroenteritis

Incarcerated hernia Viral syndrome
Trauma Constipation
Meckel’s diverticulum Urinary tract infection
Appendicitis Sepsis
Tumour

Childhood ( 2 to 10 years Appendicitis Gastroenteritis

Trauma Constipation
Meckel’s diverticulum Functional pain
Intussusception UTI
Tumour Pneumonia

Adolescence Appendiciits Gastroenteritis

Trauma Viral syndrome
Ectopic Pregnancy Pneumonia
Testicular Torsion Functional pain
Tumour
 • Viral illness
• Streptococcal pharyngitis
• Henoch-Schonlein Purpura
Extra • Sepsis
abdominal • Acute rheumatic fever
causes of • Collagen vascular disease
abdominal •
•
Diabetic Ketoacidosis
Leukemia
pain • Sickle cell crisis
• Heavy metal poisoning
• Ingestion of alcohol, aspirin, and insecticide
History
• Onset – sudden onset is more likely associated with perforation, intussuception,
torsion and ectopic pregnancy. Slow or insidious in appendicitis, pancreatitis,
cholecystitis, colicky pain, hollow viscus irritation or obstruction
• Associated symptom- vomiting preceding or coincidental with the onset of pain
suggest intussusception, AGE, ureteric colic
• Vomitting following well after onset of pain suggestive of peritoneal irritation as
in appendicitis, bowel obstruction, cholecystitis
• Billious vomiting is mechanical obstruction
• Diarrhoea suggest AGE
• Fever and vomiting are non specific in children, occurs in both intra abdominal
and extra abdominal causes as well as viral infection
Physical examination

• Inspection to look for activity level, interaction with parents, apparent degree of
discomfort:
• A writhing, rocking or moaning child has a colicky pain
• An ill appearing and lethargic child suggest sepsis or dehydration
• A motionless child lying with knees drawn up suggest peritoneal irritation
• Inspection: scaphoid? Distended? Surgical scar
• Auscultation
• Percussion: peritoneal irritation
• Palpation

DO Not forget examine genital area

 • FBC, RP, Amylase, LFT
• Urinalysis
• UPT
• DXT - first step in the evaluation of any ill-
Investigations appearing child or in cases of persistent
vomiting or poor oral intake
• Plain abdominal X ray – air fluid level,
sentinel loops, mass, fecolith
• Abdominal ultrasonography
Necrotizing Enterocolitis

• Neonatal disease thought to be caused by immune overreaction to an

insult to the intestine followed by inflammation, bacterial translocation
and coagulation necrosis of the intestine.
• Mortality is 15% to 30% with many survivors left with short bowel
syndrome and growth retardation.
• Largely disease of prematurity, 10% occur in term infants.
• Predisposition conditions include congenital heart disease, sepsis,
neonatal asphyxia, polycythemia and hypotension.
• Poor feeding, lethargy, abdominal distension, bilious vomiting,
temperature instability, apnea and abdominal tenderness are the
common signs and symptoms.
• Evaluation must include a search for
underlying causes, especially sepsis.
• Managements includes Nil by mouth,
gastric tube decompression, aggressive
IV hydration, broad spectrum antibiotics
and surgical consultation.
• Ampicilin to cover gram positive
organism, gentamicin or cefotaxime to
cover gram negative organism,
metronidazole or clindamycin to cover
anaerobes.
Hypertrophic Pyloric Stenosis

• HPS causes functional gastric outlet obstruction as a result of the

hypertrophy and hyperplasia of the muscular layer of the pylorus
• In infant, HPS is the most common gastric outlet obstruction and the
most common cause of vomiting (non projectile)
• Typical presentation is non billous, no bloody vomiting at 4 to 8 weeks of
age,occasionally slight hematemesis or bright red flecks or a coffee
ground appearance
• It can be infrequent, but eventually becomes more predictable, at
nearly every feeding.
• Usually not ill-looking nor febrile. In early stage of disease, child may
remain hungry and suck vigorously after episodes of vomiting.
• Child may develop hypochloraemic alkalosis and hypokalemia due to
recurrent vomiting
• Diagnosis: ultrasound (first choice), barium, endoscopy.
• ED management: fluid resuscitation correction of electrolytes and
urgent referral to paediatric surgical team
Intussusception

• Invagination of one segment of bowel into an adjacent lower segment

causing bowel obstruction .
• Typically affects children between 6 months and 4 years.
• It may affect small or large bowel, most cases are ileocolic.
• Usually no underlying cause, although there are some evidence saying
that viral infection can lead to enlargement of Peyer patches
 • Vomitting: bilious or non bilious, reflexive
• Abdominal pain: colicky, severe, intermittent
• Passage of blood and mucus: occasionally
describe as red current jelly stool, which is a
mixture of mucus, slough mucosa, shed
Clinical blood
features • Diarrhoea
• Lethergy
• Palpable abdominal mass
• Dehydration , pyrexia
• Shock
Diagnosis
 Volvulus
• Maybe due to congenital malformation, Meckel’s diverticulum or adhesion
• Clinical features: abdominal pain, vomiting,abdominal distension
• AXR will show coffee bean sign, Frimann Dahl sign, absent of rectal gas
Hirsrpung disease

• Absence of ganglion cells in a section of large bowel

• Usually confined to rectosigmoid, may extend involving the whole colon
• This result a section of a bowel is atonic
• Examination will find tympanitic abdominal distension and symptoms of
intestinal obstruction
• It is usually diagnosed by age 2 years
• Older infant/children will present as chronic constipation
• Abdominal examination will find distended abdomen and palpable
dilated loops of colon
Toxic Megacolon

• It is a life threatening presentation of Hirschprung disease

• History of constipation , with additional history of failure to pass
meconium in the first 24 hours of life, should raise the suspicion of
Hirschprung disease.
• Child might present with poor feeding, vomiting, irritability, abdominal
distension, hematochezia and shock
• Initial management will be stabilization of ABC, fluid resuscitation, and
administration of broad spectrum of antibiotics
• Abdominal radiograph may reveal enlarged/dilated section of colon
 • HSP is a vasculitis of children between2 and
11 years. Group A Streptococcus may trigger
the condition. Immunoglobulin A deposits
Henoch- are seen in the glomeruli and vessels walls
Schonlein • Typical presentations are triad of palpable
purpuric rash, acute abdominal pain and
Purpura arthritis. The rash may initially be urticarial
(HSP) oe macular-popular. The lesion typically
appear first on the extensor surfaces of the
lower extremities and buttocks, they may
involve the arms and ears
• GI symptoms including abdominal pain and GI bleeding occur in 50% to 75% of
cases. The pain usually diffuse, colicky in nature and may be associated with
vomiting.
• Abdominal pain usually presents after the rash. Intussusception occur in 3.5%.
• Arthralgia or arthritis occurs in 80% of casesand is the presenting sign in 25%.
Joint symptoms are migratory and usually involve the knees and ankles with
periarticular swelling and tenderness.
• Renal involvement including hematuria edema and proteinuria is the most
significant long term consequences.
• Treatment is mainly supportive. IV hydration of dehydration. NSAID is used in
arthritis or joint pain if renal function normal. Oral corticosteroids reduce
symptoms of severe abdominal and joint pain.
• Abnormal renal function, proteinuria, hypertension and nephritic syndrome
should be discussed with paediatrics nephrologist
Thank you