ABDOMINAL PAIN IN CHILDREN

Aswitha Boediarso

Child Health Department Faculty of Medicine University of Indonesia, Jakarta

Abdominal pain :

Common symptom Lesion: - intra abdomen - extra abdomen

For early diagnosis: - careful anamnesis

- physical examination

- further investigation

Surgical case or not?

Source of abdominal pain :

Viscera abdomen Others organ outside of abdomen Lesion of Medulla Spinalis Metabolic disturbance Psychosomatic

Pathogenesis
1.

Vascular disorders

(emboli / thrombosis, rupture, occlusion caused by torsion or tension)

2.

Inflammation

Pain if the inflammation process are in peritoneum parietalis somatic inervation Local pain or general pain. Type of pain : stabile, increase with movement of inflammatory peritoneum

3.

Passage disorders/obstruction of luminal organ in peritoneal or retroperitoneal cavity

Partial obstruction or total obstruction intra lumen pressure pain

4.

Traction, inflammation and stretching of peritoneum visceralis

Type of pain and source of pain

Fore gut pain in upper abdomen Mid gut pain in middle abdomen Hind gut pain in lower abdomen Muscle spasm colic which difficult to investigate the localization, not influenced with cough or abdominal pressure Peritoneal irritation pain in the field of irritation, stable, influenced by cough and abdominal pressure

Referred pain
Disorders of extra abdominal organ (i.e. thorax) sensory inervation (N. Vagus) abdominal pain

Cause of abdominal pain by age groups (Chamberlain and Recee, 1978)

Infant commonly caused by obstruction a. Colic b. Constipation c. Volvulus d. Intussusceptions/invagination e. Strangulated hernia f. Pyloric stenosis g. Perforation of gastrointestinal tract h. Appendicitis i. Acute hydrops of gallbladder

Older child commonly caused by infection

a. b. c. d.

e.
f. g. h. i. j.

Gastroenteritis Appendicitis Mesenteric lymphadenitis Meckels diverticulum Ileitis regional Colitis ulserativa Diabetic acidosis Pneumonia Torsion of ovarian cord Constipation

k. l. m. n.

o.
p. q. r. s.

t.

Pyelonephritis Colic Ureter Lead intoxication Torsion of spermatic cord Abdominal epilepsy Sickle cell crisis Mononucleosis Porphiria Cholecystitis and cholelytiasis Pancreatitis

Cause of acute abdominal pain by age groups, that requirring surgical intervention (Walker-Smith et al, 1983)

Infant / age < 2 years old Abdomen : Perforation of gastric ulcers Bowel obstruction : - intusussception - volvulus and malrotation Appendicitis and enterocolitis necroticans Extra abdomen : Inguinal hernia with strangulation and incarceration

Age > 2 years old Abdomen:

a.

b.

c.

d. e.

Obstruction Bowel obstruction caused by fibrosis, volvulus, malrotation Perforation caused by bowel obstruction Inflammation (appendicitis, primary peritonitis, peritonitis caused by Meckels diverticle perforation, perforation of duodenal ulcer, perforation caused by typhoid fever, Meckels diverticulitis, cholecystitis with or without gall stone, toxic mega colon with perforation) Trauma (rupture of spleen, urinary bladder, another visceral organs, hematoma sub serosa) Bleeding (bleeding intra ovarian cyst) In tropic area (perforation associated with ascariasis, strongiloidiasis, jejunitis necrotican in New Guinea, perforation of abscess amoeba)

Extra abdomen: a. Torsion of testis b. Inguinal hernia with strangulation and incarceration

Cause of non surgical abdominal pain (Walker and Smith, 1983) Infant / age < 2 years old Abdomen : - Intestinal infection

Extra abdomen : - Pneumonia - Urinary tract infection

Infant / age > 2 years old Abdomen : a. Intestinal - Infection (Salmonella, Shigella, Campylobacter, Yersinia enterocolitica) - Food intoxication (Toxin of Staphylococcus, etc) - Purpura Henoch Schonlein (purpura anaphylactoid) - Crohns disease - Colitis ulcerative - Colitis amoeba - Fecal impaction - Sickle cell anemia - Ileus meconeum - Adenitis mesenterica

b. Liver and billiary tree - Hepatitis - Cholelytiasis c. Pancreas - Pancreatitis d. Kidney - Urinary tract infection - Stone - Nephritis

e. Metabolic - Phorphiria - Hiperlipidemia - Diabetic keto acidosis - Familial Mediterranean fever f. Gynecologic - Salphyngitis

Cause of abdominal pain in Indonesia

Neonatal - 3 months Cows milk allergy Pyloric hypertrophy Torsion of testis Obstipation/with anal fissure - Bowel malrotation 3 months 2 years Obstipation Gastroenteritis Bowel duplication Maldigestion Gastric mucosal membrane - Meckels diverticulum

2 years 5 years Obstipation Volvulus Hepatitis Urinary tract infection - Ascariasis - Appendicitis - Pancreatitis -

> 5 years

Appendicitis Gastritis Ovarian torsion Menstrual cycle Cholecystitis Functional abdominal pain - Urinary tract stone - Varicocele testis

Clinical manifestation by age group ( Halimun 1980 )

0 - 3 months : vomiting 3 months 2 years : vomiting, pitching/crying, trauma(-) 2 5 years : can tell the pain, localization not true > 5 years : can tell the type and localization of the pain

Diagnostic approach
1. 2. 3.

Anamnesis Physical examination Laboratories and further investigation

Anamnesis

Age Pain (localization , type, time, frequency, other symptom) Defecation pattern Urination pattern Menstrual cycle Skeletal muscle disorders Growth and development disorders Psychosocial aspect Trauma History of family disease

Physical examination
1. 2.

Comprehensive In abdomen and extra abdomen

Physical examination

Especially in abdomen - Inspection: Asymmetry, meteorismus, bowel contour - Palpation: Stretching, pain, tumor - Percussion: Fluid? - Auscultation: Bowel sound - Rectal touchier Extra abdomen examination - Pneumonia/Acute respiratory infection - Hernia

Laboratory and further investigation

Routine ( urine, blood, feces) Culture 3 positions of abdominal plan photo Thorax photo (severe disease) Barium meal/follow through Barium enema Intravenous pyelography Ultrasound Endoscopies

Therapy

Require surgical intervention? Depend on etiology

Surgical abdominal pain

Abdominal pain that require surgical intervention Symptoms - Severe pain, stable, onset 3-4 hours - Vomiting : green or fecal - Increase temperature

Surgical abdominal pain

Obstruction
- Invagination, bolus ascariasis, volvulus/rotation of gaster

Inflammation
- Acute appendicitis, acute cholecystitis, peritonitis

Blood flow disturbance

- Invagination, malrotation, volvulus, ovarian cyst torsion

Physical examination

Localized or generalized peritoneal sign Sign of obstruction

- Abdominal distention

- Bowel contraction and peristaltic

Tumor mass Anorectal bleeding

Abdominal emergency

Rigidity of abdominal wall Tenderness Rebound tenderness Defense muscular

Further investigation

Abdominal plain photo Barium meal/follow through Barium enema Intravenous pyelography if suspected urinary tract disorders Ultrasound Endoscopy

Therapy

Exploration/operation laparotomy

Recurrent abdominal pain

Definition (Apley, 1975) Recurrent abdominal pain is intermittent abdominal pain at least 3 times which persists for longer than 3 months and affects normal activity

Prevalence

Age 3 14 years old mostly 5 10 years old 5% of pediatric outpatient Organic cause 5-10%

Etiology

Organic 5-15,6% cases Functional 80%

Cipto Mangunkusumo Hospital (1988)

17 cases 47% spasmophylia 11.8% gastritis 5.9% colitis 29.4% worms infection 11,8% psychological/psychiatric disorders

Recurrent abdominal pain concept

1.

Classical (2 groups)
Organic Functional

2.

Barr
Organic Disfunctional

Psychogenic
3.

Levine & Rappaport

Life style

Somatic predisposition Disfunction Organic disorders

Behavior Response pattern

Environment and Inducers

Levine and Rappaport 1984

Etiology of abdominal pain

Gastrointestinal
Chronic diarrhea Peptic ulcers Bezoar Duplication Intermittent volvulus Meckels diverticulum Appendicitis Mesenterical adenitis Abdominal TBc Milk protein intolerance lactose intolerance Constipatian Ascariasis

Drugs
Anti convulsion Antibiotic Brochodilator

Liver, spleen and pancreas

Cholecyctitis Cholelithiasis Pancreatitis Massive spleenomegali

Urinary tract
Hidronephrosis Pyelonephritis Stone Renal neoplasm Ovarian cyst Dismenorrhea Endometriosisi Testis torsion Testis neoplasm

Metabolic
Hypoglycemia Phorphiria Lead intoxication Hyperlipidemia Angioneurotic edema

Symptoms suggested organic disorders Persistent fever Growth and development disturbance Weight loss Anemia Hematemesis Melena Hematochezia Pain away from midline Perianal disease

Diagnostic approach
1.

2.

3.

Careful anamnesis, Physical examination, and further investigation High cost examination and commonly was not positive Endoscopy greater probability to find the etiology

Anamnesis

Age Pain (localization , type, time, frequency, other symptom) Defecation pattern Urination pattern Menstrual cycle Skeletal muscle disorders Growth and development disorders Psychosocial aspect Trauma History of family disease

Laboratory and further investigation Routine ( urine, blood, feces) Ureum, creatinine Culture 3 positions of abdominal plan photo Thorax photo (severe disease) Barium meal/follow through Barium enema Intravenous pyelography Ultrasound Endoscopy

Therapy

Depend on etiology Sedative and analgesic