Acute
abdominal pain
in children
Ext.Jetsadaporn Phansomrong
Surin hospital
Extern Ro.C
Midgut volvulus
Midgut volvulus
EPIDEMIOLOGY
Ø one month of age: 30 percent
Ø before one year of age: 58 percent
Ø before five years of age: 75 percent
Clinical presentation
Ø Crampy abdominal pain
ü Sudden onset in previously healthy or growing infant
Ø Vomiting : sudden onset
ü Typically bilious (neonate) but can be nonbilious (old children)
Ø Hematochezia
ü Bowel ischemia and possible necrosis due to volvulus
Physical examination
Ø Hemodynamic instability
ü hypovolemia and/or septic shock
Ø Abdominal distension
ü not always present in young infants
Ø Abdominal tenderness
ü can be difficult to elicit
Ø Peritonitis
ü volvulus with perforation
Diagnosis
Ø Clinical presentation + Physical examination + presence of metabolic
acidosis
Ø Confirm diagnosis by
Ø Doppler ultrasound
Ø Upper GI contrast radiography => Gold standard
Ø CT
Ø Laparotomy or Laparoscope diagnosis (vascular compromise)
Double bubble of acute duodenal obstruction
Pre-operation
Ø NPO
Ø Isotonic solution for resuscitation
Ø 20 cc/kg IV bolus up to and over 60 cc/kg until perfusion improves
Ø If not improves -> inotrope
Ø NG tube
Ø Foley catheter
Ø IV antibiotic cover bowel flora
Ø Lab : CBC, Electrolyte
Ø Gold period 6-8 hr if vascular compromise
Ø Set OR for Ladd procedure
Definite : Ladd procedure Open or
Laparoscope
Meckel’s
diverticulitis
Meckel's diverticulum
Ø Most common congenital anomaly of the
gastrointestinal tract
Ø Incomplete obliteration of the vitelline
duct leading to the formation of a true
diverticulum of the small intestine
Ø “Omphalomesenteric duct remnant”
Ø Meckel's diverticulum is a true
diverticulum, containing all layers of the
small bowel wall
The “rule of 2” of Meckel diverticulum
Ø 2% of the population
Ø 2:1 male-to-female ratio
Ø 2 years of age usually discovered
Ø 2 feet (60 cm) from the ileocecal valve
Ø 2 cm in diameter
Ø 2 inches (5 cm) long
Ø 2 types of heterotopic mucosa
Clinical presentation
Ø Clinically silent
Ø 25%-50% of patients with symptoms present under 10 years of age
Ø Painless LGIB (30-56%)
Ø ulceration of the small bowel due to acid secretion by ectopic gastric mucosa
Ø chronic and insidious or acute and massive
Ø Bowel obstruction (14-42%)
Ø Intussusception and volvulus are most common
Clinical presentation
Ø Diverticular inflammation (6-14%)
Ø Meckel's diverticulitis with or without perforation
Ø Likely Appendicitis
Ø Littre hernia = Meckel diverticulum found incarcerated hernia
Ø Neoplasm elderly
Physical examination
Ø volume depletion
Ø anemia
Ø abdominal examination
Ø PR
Children, particularly those less than 10 years of age, who
present with painless lower gastrointestinal bleeding
without symptoms or signs of gastroenteritis (diarrhea) or
inflammatory bowel disease (abdominal pain, diarrhea)
Diagnosis
Ø one of three ways depending upon the initial clinical presentation
Ø Meckel's scan
Ø mesenteric arteriography
Ø abdominal exploration
Meckel's scan
Ø The technetium-99m pertechnetate radionuclide study commonly used
today
Ø Administration
q Pentagastrin
ü which increases gastric mucosal uptake and is a potent
stimulator of gastric acid secretion and increased gastric motility
q H2 blockers
ü which inhibit the excretion of the isotope into the bowel lumen
and increase the cellular concentration
q Glucagon
ü slows bowel transit and allows the isotope to persist longer in the
diverticulum
Meckel's scan
Ø False negatives
Ø high bleeding rate, poor blood supply to the diverticulum, or an
inadequate isotopes
Ø False-positives
Ø intestinal duplications with heterotopic gastric mucosa. Other causes
include obstructed loops of bowel, intussusception, inflammatory
lesions, arteriovenous malformations, ulcers, and some bowel
neoplasms
Pre-operation treatment
Ø NPO for bowel rest
Ø NG tube for decompression/ exclude UGIB
Ø Foley catheter
Ø Rehydration with IV fluid
Ø Lab CBC, Electrolyte
Ø Correct electrolyte Imbalance
Ø Antibiotic IV
Ø Blood transfusion in case bleeding with significant anemia
Definite : OR for Resection
open/laparoscopic
Intussusception
Intussusception
Ø Acquired invagination of the proximal bowel (intussusceptum) into the
distal bowel (intussuscipiens)
Ø most frequent cause of bowel obstruction in infants and toddlers.
PRIMARY INTUSSUSCEPTION
Ø Especially in infants
Ø Idiopathic intussusceptions
Ø Cause is generally attributed to hypertrophied Peyer patches within the
bowel wall
SECONDARY INTUSSUSCEPTION
Ø lead point
Ø drawing the proximal bowel into the distal bowel by peristaltic activity
Ø most common lead point is a Meckel diverticulum followed by polyps and
duplications
Ø Other benign lead points include the appendix, hemangiomas, carcinoid
tumors, foreign bodies, ectopic pancreas or gastric mucosa, hamartomas
from Peutz-Jeghers syndrome and lipomas
Ø Systemic diseases ; Henoch–Schönlein purpura and cystic fibrosis
Ø Other diseases ; celiac disease and Clostridium difficile colitis
Incidence
Ø Approximately 1 to 4 in 2000 infants and children
Ø Males > females = 2:1 or 3:2 ratio
Ø 75% of cases occur within the first 2 years
Ø 90% in children within 3 years of age
Ø More than 40% are seen between 3 and 9 months of age
Ø uncommon below 3 months and after 3 years of age
Clinical presentation
Ø Abdominal pain
Ø sudden onset of intermittent, severe, crampy, progressive
Ø episode q 15-39 min
Ø Stiffen and pull the leg up to abdomen
Ø Associated hyperextension, writhing, breath holding,
Ø Vomiting
Ø If Bilious emesis
Ø Bowel obstruction progression
Ø Currant jelly stool up to 50%
Ø Impending ischemia
Ø Late sign
Ø Lethargy (often episodic)
Physical examination
Ø V/S usually normal
Ø Ischemia +- bacteremia and perforate = fever, tachycardia, hypotension
Ø Lethargy or altered consciousness (often episodic)
Ø Anemia
Ø No abdominal tenderness, or only focal tenderness
Ø especially in the right mid or upper abdomen
Ø Abdomen not distended
Ø If distention => obstruction
Ø Rectal examination = rectal prolapse
Physical examination
Specific for intussusception, but are present in a minority of patients
Ø Right lower quadrant that is scaphoid (empty; Dance's sign)
Ø Palpable "sausage-shaped" mass in the right mid or upper abdomen
Diagnosis
Ø Abdominal radiography
Ø Abdominal ultrasonography (method of choice)
Ø CT scan and MRI
Abdominal radiography
Ø Characteristic signs of intussusception
Ø meniscus sign or crescent sign
Ø target sign
Abdominal radiography
Ø Nonspecific radiographic findings
Ø right-sided soft tissue mass
combined with an absence of
cecal gas are easier to detect
Abdominal ultrasonography
“Target” or “doughnut” sign “Pseudokidney”sign
CT scan and MRI
confirm this diagnosis and/or pathologic causes for intussusception, such as a
malignancy (i.e., lymphoma)
The characteristic CT finding is a target or doughnut sign
Pre-operative treatment
Ø NPO
Ø NG tube for decompression
Ø Foley catheter
Ø IV fluid for resuscitation
Ø CBC, electrolyte
Ø Correct electrolyte imbalance
Ø Broad spectrum IV ATB
Ø G/M PRC
Definite : Reduction emergency
Done within 24 hr -> less bowel gangrene
Ø Nonoperative reduction (treatment of choice for clinically stable)
Ø Air or Pneumatic enema
Ø Liquid or hydrostatic edema
Ø Contraindication for nonoperative
Ø Intestinal perforation
Ø Peritonitis
Ø Persistent hypotension
Ø Operative reduction
Nonoperative reduction emergency
Nonoperative reduction
