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ABDOMINAL PAIN in the PEDIATRIC PATIENT Tim Weiner, M.D. Dept. of Surgery University of North Carolina at Chapel Hill.

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Presentation on theme: "ABDOMINAL PAIN in the PEDIATRIC PATIENT Tim Weiner, M.D. Dept. of Surgery University of North Carolina at Chapel Hill."— Presentation transcript:

1 ABDOMINAL PAIN in the PEDIATRIC PATIENT Tim Weiner, M.D. Dept. of Surgery University of North Carolina at Chapel Hill

2 In General u Common problems occur commonly –intussusception in the infant –appendicitis in the child u The differential diagnosis is age-specific u In pediatrics most belly pain is non-surgical –“ Most things get better by themselves. Most things, in fact, are better by morning.” u Bilous emesis in the infant is malrotation until proven otherwise u A high rate of negative tests is OK

3 The History u Pain (location, pattern, severity, timing) –pain as the first sx suggests a surgical problem u Vomiting (bile, blood, projectile, timing) u Bowel habits (diarrhea, constipation, blood, flatus) u Genitourinary complaints u Menstrual history u Travel, diet, contact history

4 Diagnosis by Location gastroenteritis early appendicitis PUD pancreatitis non-specific colic early appendicitis constipation UTI pelvic appendicitis biliary hepatitis appendicitis enteritis/IBD ovarian spleen/EBV constipation non-specific ovary

5 The Physical Examination u Warm hands and exam room u Try to distract the child (talk about pets) u A quiet, unhurried, thorough exam u Plan to do serial exams u Do a rectal exam

6 The Abdominal Examination breath sounds Murphy’s sign “sausage” Dance’s sign rebound tender at McBurney’s point cecal “squish” hernias torsion breath sounds spleen edge constipation Rovsing’s sign

7 Relevant Physical Findings u Tachycardia u Alert and active/still and silent u Abdominal rigidity/softness u Bowel sounds u Peritoneal signs (tap, jump) u Signs of other infection (otitis, pharyngitis, pneumonia) u Check for hernias

8 Blood in the Stool u Newborn –ingested maternal blood, formula intolerance, NEC, volvulus, Hirschsprung’s u Toddler –anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile polyps, HUS, IBD u 2 to 6 years –infectious colitis, juvenile polyps, anal fissures, intussusception, Meckel’s, IBD, HSP u 6 years and older –IBD, colitis, polyps, hemorrhoids

9 Blood in the Vomitus u Newborn –ingested maternal blood, drug induced, gastritis u Toddler –ulcers, gastritis, esophagitis, HPS u 2 to 6 years –ulcers, gastritis, esophagitis, varices, FB u 6 years and older –ulcers, gastritis, esophagitis, varices

10 Further Work-up u CBC and differential u Urinalysis u X-rays (KUB, CXR) u US u Abdominal CT u Stool cultures u Liver, pancreatic function tests u (Rehydrate, ?antibiotics, ?analgesiscs)

11 Relevant X-ray Findings u Signs of obstruction –air/fluid levels –dilated loops –air in the rectum? u Fecalith u Paucity of air in the right side u Constipation

12 Operate NOW u Vascular compromise –malrotation and volvulus –incarcerated hernia –nonreduced intussusception –ischemic bowel obstruction –torsed gonads u Perforated viscus u Uncontrolled intra-abdominal bleeding

13 Operate SOON u Intestinal obstruction u Non-perforated appendicitis u Refractory IBD u Tumors

14 Appendicitis u Common in children; rare in infants u Symptoms tend to get worse u Perforation rarely occurs in the first 24 hours u The physical exam is the mainstay of diagnosis u Classify as simple (acute, supparative) or complex (gangrenous, perforated)

15 Incidental Appendectomy u Can be done by inversion technique u Absolute indication –Ladd’s procedure u Relative indications –Hirschsprung’s pullthrough –Ovarian cystectomy –Intussusception –Atresia repair –Wilms’ tumor excision –CDH

16 Intussusception u Typically in the 8-24 month age group u Diagnosis is historical –intermittent severe colic episodes –unexplained lethargy in a previously healthy infant u Contrast enema is diagnostic and often therapeutic u Post-op small bowel intussusception

17 The “Medical Bellyache” u Pneumonia u Mesenteric adenitis u Henoch-Schonlein Purpura u Gastroenteritis/colitis u Hepatitis u Swallowed FB u Porphyria u Functional ileus u UTI u Constipation u IBD “flare” u rectus hematoma

18 Laparoscopy u Diagnosis –non-specific abdominal pain –chronic abdominal pain –female patients –undescended testes –trauma u Treatment –appendicitis –Meckel’s diverticulum –cholecystitis –ovarian detorsion/excision –lysis of adhesions

19 The Neurologically Impaired Patient u The physical exam is important for non- verbal patients u The history is important for the spinal cord dysfunction patient u Close observation and complementary imaging studies are necessary

20 The Immunologically Impaired Patient u A high index of suspicion for surgical conditions and signs of peritonitis may necessitate operation –perforation –uncontrolled bleeding –clinical deterioration u Blood product replacement is essential u Typhlitis should be considered; diagnosis is best established by CT

21 The Teenage Female u Menstrual history –regularity, last period, character, dysmenorrhea u Pelvic/bimanual exam with cultures u Pregnancy test/urinalysis u US u Laparoscopy u Differential diagnosis –mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis

22 In Summary “My dear surgeon, beware- haste not, Pleads the child silently, Listen to my mother, and then- Examine and again examine me: This will improve my lot And assure you accuracy.”

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