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8/8/2019 Galea - Abdominal Pain in Childhood
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Abdominal Pain inAbdominal Pain inChildhoodChildhood
-- an overviewan overviewMs. JulieMs. Julie GaleaGalea MDMD MRCSEdMRCSEd
Paediatric Surgical UnitPaediatric Surgical Unit
Mater Dei HospitalMater Dei Hospital
MaltaMalta
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BackgroundBackground Abdominal pain in childhood is common
Most can be treated in the community
Even those treated in a hospital settingmostly recover without a diagnosis
Disconcerting experience for mostclinicians
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BackgroundBackground Signs are often subtle and non
specific
Children do not possess an adultsability to explain what is wrong withthem
Much has been written on thesubject much controversy
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HistoryHistory Obtained from parents / guardians they
know their child best!!
Ask how the childs behaviour compares to
normal Where possible involve the child
Be sympathetic
Take time to build rapport and interact
with them history and examination mustbe informal and playful use concepts thechild understands
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HistoryHistory Birth / Perinatal history:
- Important to assess repercussions oftrauma/illnesses/congenital
abnormalities eg preterm /NEC / early UTIs
- Problems in pregnancy andperinatally incl admission to NPICU
- Gestational age at delivery- Mode of delivery
- Birth weight
- Location of birth (hereditary illnesses)
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History (cont)History (cont) History of presenting complaint:
Pain onset, duration, location, nature, radiation,relieving and exacerbating factors (eg. Non specific abdopain is usually vague, central and colicky ; Appendicitisis unilateral and well localised)
Nausea and vomiting. Is vomiting bilious? alwaysominous in children
Good appetite / Feeding well Irritability / Crying Passage of blood and mucus rectally/ with stool Bowel habit Dysuria / Urinary frequency
Recent URTIs, GI upsets Wetting nappies / passing adequate/large amount ofurine
Menstrual / sexual history in older girls Polydypsia
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Alarm symptomsAlarm symptoms Unintentional weight loss
Failure to thrive
Unexplained fever Severe diarrhoea and vomiting
GIT bleeding
Family history of IBD Chronic RIF or RUQ pain
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ExaminationExamination Observe child while you are chatting
and taking history behaviour,
dynamics with carers Abdominal examination must be
done methodically, calmly withoutupsetting the child
Be gentle / use toys to distract /examine on parents lap if necessary
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ExaminationExamination
Ask child to show you with one finger the area ofmaximal pain
Ask child to protrude and then suck in theirabdomen and to cough and jump on the spot unable to do if peritoneal irritation existent. NOASSESSMENT OF REBOUND
Palpate all quadrants Hernial orifices External genitalia ENT examination Rectal examination rarely needed Signs of hydration mucous membranes /
sunken eyes / decreased skin turgor / capillaryrefill time>2sec / decreased temperature /sunken fontanelle
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Differential diagnosisDifferential diagnosisEMERGENCY/LIFE THREATENING OTHERS DKA - NSAP IBD/Crohns - Porphyria Ladds bands/Malrotation/volvulus - UTIs and calculi Appendicitis - Constipation
Intestinal obstruction - Mesenteric adenitis(adenoviral infection) Meckels diverticulum - Pneumonia Intussusception - Peptic ulcer disease Incarcerated inguinal hernia - Sickle cell crisis/anaemia Testicular torsion - Gallstones Trauma - Pancreatitis (choledochal cysts) Food/drug poisoning - Pica Ectopic pregnancy / ovarian torsion - Tonsillitis
- Otitis media- Gynae pathology- Infective enteritis- Child abuse- Attention seeking behaviour
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Differential diagnosisDifferential diagnosis
Gynae pathologyNSAP
ConstipationSickle cell crises
DMHSPHirschprungs
PneumoniaDMVolvulus
TraumaPneumoniaDMPsychogenicTraumaPneumonia
Testicular torsionPsychogenicTrauma
Pregnancy / ectopicpregnancy
Onset of menstruationIncarcerated inguinalhernia
UTIUTIUTI
Ovarian cyst torsionConstipationInfantile colic
Menstruation /Mittelschmerz
Acute appendicitisIntussusception
Acute appendicitisMesenteric adenitisConstipation
Mesenteric adenitisGastroenteritisGastroenteritis
12-16 yrs2-12 yrs
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InvestigationsInvestigations Laboratory studies:
- Complete blood count:- peritonitis- suspected perforated appendicitis- toxic appearance
- U&Es, Creat:
- >10%dehydration- significant history of vomiting and diarrhoea
- Amylase +/- LFTs:- RUQ/epigastric pain- suspected gallstones
- Blood cultures:- Toxic child
- Temperature >103- TFTs- Drug levels- ESR, CRP- H. pylori antibodies- RAST, Tissue transglutaminases etc
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Investigations:Investigations: Urinalysis:- all patients- look for red/white cells, ketones,
glucose, metabolites
- stone analysis
Urine culture:- UTI if >100000 organisms/mm3
Stool culture / O,C,P:- if diarrhoea present
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Investigations:Investigations: Radiological studies:
- AXR: use sparingly- suspected pneumoperitoneum- diffuse peritonitis- suspected intestinal obstruction- palpable mass
- past history of cholelithiasis/urolithiasis- Ultrasound
- Pelvic pain (girls)- abdominal/pelvic mass eg intussusception- past history of cholelithiasis/urolithiasis- testicular problems
- CT: use sparingly
- trauma- large BMIs- Equivocal / complicated cases
Others: Laparoscopy
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InvestigationsInvestigations THE MOST USEFUL TOOL IS
REGULAR ACTIVE OBSERVATION INTHE WARD
If sent home to the care of thefamily physician or under the care of
the A&E doctor pts need re-evaluation after 8-12hrs if symptomspersist
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AppendicitisAppendicitis 4 in 1000 children aged 5-14yrs yearly
70,000 paediatric cases per year in the
USA Extremely rare in neonates
Incidence of 1-2 cases per 10,000 childrenper year between birth and 4 years
Increases to 25 cases per 10,000 childrenper year between 10 and 17 years of age
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AppendicitisAppendicitis Rate of perforation is 80-100% for
children younger than 3 years vs
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Evaluation algorithmsEvaluation algorithms Kharbanda et al:
- based on 6-part scoring system: nausea (2pts), history offocal RLQ pain (2 pts), migration of pain (1pt), difficulty walking(1pt), rebound/percussion tenderness (2 pts), absolute neutrophilcount of >6.75x103/l (6 pts)
- score of 7 sensitivity of 73% and specificity of 80%- limited to risk stratification of suspected appendicitis inchildren
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AppendicitisAppendicitis
Vague central abdominal pain preceded by anorexia andvomiting. Pain shifts and settles in right lower quadrant.
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WCC in AppendicitisWCC in Appendicitis WCC neither sensitive nor specific forappendicitis
Elevated in 70-90% of pts with acuteappendicitis also elevated in other abdoconditions
Predictive value limited 10% of pts havenormal WCC
WCC >15,000cells/mm3 suggestive of
perforation but Cardall et al (2004)found no significant difference betweensimple and perforated appendicitis asregards WCC
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Ultrasound in AppendicitisUltrasound in Appendicitis Overall sensitivity of 85% and
specificity of 94% in experiencedhands for paediatric pts
Noncompressible dilated appendix
Periappendiceal abscess
Fluid in appendiceal lumen
Transverse diameter of 6mm or more
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Functional abdominal pain orFunctional abdominal pain or
nonspecificnonspecific abdominal painabdominal pain 15% of school age children
Most common symptom in childhood
worldwide Considerable morbidity / missed
school days / high use of healthresources
Characterized by diagnosticuncertainty and parental anxiety
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DefinitionsDefinitions Apley a nd N aish 1 9 5 8 :- waxes and wanes- occurs with 3 episodes within 3 monthperiod
- severe enough to affect childs activities
Subcom m ittee on chronic abdom inal pain,2 0 0 5 :
- Chronic abdominal pain
- Longstanding intermittent or constantabdominal pain
- functional in most children
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DefinitionsDefinitions Rome I I I cr it e r ia , 20 06 : Each of the following subtypes:
- without evidence of inflammatory,anatomical, metabolic or neoplasticprocesses to explain the pain
- all criteria fulfilled for at least 1 a wk per 2mths before diagnosis
Functional dyspepsia:- persistent or recurrent pain centred upperabdomen (above umbilicus)
- not relieved by defaecation or associated withchange in form or frequency of bowel action
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DefinitionsDefinitions I rr itable bow el syndrome:- Abdominal discomfort or pain associatedfor 25% of the time or more with 2 or moreof:
- improvement with defaecation- change in frequency of stool- change in form or appearance of stool
Functional abdom inal pain:
- Episodic or continuous abdominal pain- Insufficient criteria for other functional GIdisorders
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DefinitionsDefinitions
Functional abdom inal pain syndrom e:- Functional abdominal pain with one or moreof:
- some loss of daily functioning- additional somatic symptoms
(headache, limb pain, sleep difficulty) Abdominal m igraine:
- Paroxysmal episodes of intense periumbilicalpain lasting 1 or more hours (2 or moretimes in the preceding 12mths)
- Healthy in between for weeks or months- Pain interferes with normal activities- Pain associated with 2 or more of:
nausea, anorexia, vomiting, headache,photophobia, pallor
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CauseCause Multifactorial
?Enhanced sensitivity of the enteric
nervous system, diet and stress playa role in causation
Paucity of organic cause
Biopsychosocial model proposed
Girls>Boys
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ManagementManagement Reassurance, supportive therapy,
education of patient and carer to preventabdo pain taking over lives
Prognosis good and remits spontaneously
Parental factors rather than psychologicalcharacteristics of the child are moreimportant when predicting persistence of
abdominal pain parents acceptingsituation strongly associated with recovery
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THANKYOU
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