abdominal pain in children
DESCRIPTION
Abdominal Pain in ChildrenPediatr Clin N Am 53(2006) 107-137TRANSCRIPT
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Abdominal Pain in ChildrenPediatr Clin N Am 53(2006) 107-137
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Gastroenteritis
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Epidemiology
• Most common GI inflammatory process• Usually viral, rotavirus being most commo
n• Rotavirus: peak incidence between 4~23
mths• Norwalk virus more common in older childr
en; 40%• Camphylobacter leading cause of bateria
diarrhea
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Presentation
• Vomiting usu precedes the diarrhea by 12~24hrs
• Decreased urine output late sign of dehydration
• Risk for dehydration:– Younger than 12 mths old– Frequent vomiting (>2X/day)– Frequent stool (>8X/day)– Severely undernourished
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Lab Data and Imaging
• Blood glucose (R/O diabetic ketoacidosis)
• AAP: electrolytes not recommended in all
• Urinalysis to R/O infection
• Stool cultures generally not necessary
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Management
• Rehydration: oral vs intravenous
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Appendicitis
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Epidemiology
• Abd pain most commonly treated surgically; 4 out of 1000
• 2.3% of all children with abd pain
• Perforation rates are higher than in the general adult population(30%~60%)
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Presentation
• Classic presentation is seen less often
• History of abd pain preceded by vomiting can be helpful
• Position of appendix can vary greatly and tenderness can be found in many locations
• Very young children often have diarrhea as the presenting Sx
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Lab data and Imaging
• WBC can be used as an adjunct
• Appendicoliths are present in 10%
• Ultrasonography: imaging test of choice– Inflammed appendix > 6mm– Sensitivities 85%-90%– Specificities 95%-100%
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Calcified Appendicolith
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Appendicitis with Appendicolith
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Management
• Surgical intervention
• To return to ER within 8 hrs for re-evaluation for those MBD
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Intussusception
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Epidemiology
• Mostly between 3m/o and 5y/o
• 60% occuring in the 1st yr
• Peak incidence at 6 to 11 mths
• Usually idiopathic in the younger age
• Children > 5y/o often have a pathologic “lead point”
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Presentation
• Classic triad: intermittent colcky pain, vomiting and bloody mucous stool
• Classic triad: 20%-40%
• Palpable abd mass uncommon finding
• Currant jelly stool: late and unreliable sign
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Pseudokidney Sign
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Management
• Emergent reduction of the obstructed bowel
• Gold standard: barium enema
• Newer modality: air enema
• Contraindications to enema– Prolonged symptoms >24hrs– Evidence of obstruction
• Recurrence .5%~15% within 24hrs
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Small Bowel Obstruction
• Most common causes: adhesions
• Decreased oral intake and bilious vomiting
• Plan film: Paucity of air in the Abd and distended loops of bowels
• Immediate surgical consultation
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Incarcerated Hernia
• Inguinal hernia: 1%~4% of population
• More common in males 6:1
• More often on the Rt side 2:1
• 60% of incarcerated hernia occur in 1st yr of life
• Reduction if no signs of incarceration
• Surgical intervention
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Meckel’s Diverticulum
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Epidemiology
• Most common congenital abnormality of the small intestine
• Commonly described by “the rule of 2s”• Present in 2% of the population• 2% of affected patients become symptomatic• 45% of symptomatic p’ts are <2y/o• Most common location is 2 feet(40-100cm) from
the ileocecal valve• Diverticulum typically 2 inches long
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Presentation
• Classic: painless or minimally painful rectal bleeding
• Abdominal pain, distension and vomiting
• Presenting as bowel perforation
• Act as a lead point and result in intussusception
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Lab data and Imaging
• IV injection of technetium-pertechnetate
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Management
• Fluid resuscitation if active bleeding
• Surgical intervention
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Hypertrophic Pyloric Stenosis
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Epidemiology
• Occurs in 1 of every 250 births
• Male to female ratio 4:1
• More common in Whites
• Rare in Asians
• A child of an affected parent has an increased chance
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Presentation
• Presents during the 3rd and 5th wk of life
• Emesis is nonbilious
• Projectile vomiting
• A palpable olive mass in RUQ
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Lab data and Imaging
• Hypokalemic, hypochloremic, metabolic alkalosis
• Ultrasonography measures the thickness of the pyloric wall (normally <2mm, HPS > 4mm), and the length of the pyloric canal (normally <10mm, HPS > 14-16mm)
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Upper GI series “string sign”
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Management
• Hydration and correction of electrolytes abnormalities
• Surgery; Ramstedt procedure
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Malrotation with midgut volvulus
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Epidemiology
• Incidence of volvulus peaks during the 1st mth of life
• Male to female ratio 2:1
• Congenital adhesions; Ladd’s bands
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Presentation
• Sudden onset of bilious vomiting and abd pain in a neonate
• History of feeding problems with bilious vomiting; appears like bowel obstruction
• Failure to thrive with feeding intolerance
• Hematochezia: late sign and indicates bowel necrosis
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Lab data and Imaging
• Double bubble sign in plain film
• Gold standard: Upper GI contrast study
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Double bubble sign
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Cork-screwing appearance
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Management
• Bilious vomiting is considered a surgical emergency until proven otherwise
• Aggressive resuscitation
• Broad spectrum antibiotics
• Emergent surgical intervention
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Necrotizing enterocolitis
• Premature infants is 1st few weeks of life
• Anoxic episodes at birth
• Acute ill looking, lethargy, distended abd and bloody stools
• Fluid resuscitation and broad spectrum antibiotics
• Early surgical consultation
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Pneumatosis Intestinalis