Tashannuj e Shikam (Abdominal colic) - PowerPoint Presentation

Slide1

Tashannuj e Shikam (Abdominal colic)

Dr M

Anas

Asstt

Professor,

Atfal

D/o

Amraz

e

Niswan

wa

Atfal

Slide2

Tashannuj e Shikam

Abdominal pain is one of the most common reason for which parents take the child to a doctor

. It has a varied etiology from benign to life threatening conditions. Lower lobe pneumonia has been accounted for 2.5 to 5% of abdominal pain.

Slide3

Acute

Organic

Inorganic

/ Idiopathic/ functional

Chronic

Organic

Inorganic/ Idiopathic/ functional

Here again there may be many

variations

Slide4

Causes

Infants and young children <2yr

: Colic, acute gastroenteritis,

intussusception

,

malrotation

of gut with

volvulus

, incarcerated hernia, trauma,

necrotising

enterocolitis

Preschool children 2-5 yrs:

acute

gastroenteriris,UTI

, constipation,

intussusception

, acute appendicitis,

malrotation

of gut with

volvulus

, intestinal perforation with peritonitis,

choledochal

cyst, lower lobe pneumonia,

incarcerated

hernia, torsion testes, acute pancreatitis, diabetic

ketoacidosis

,

Henoch

scholen

purpura

,

meckel

diverticulum

, trauma.

Older children and adolescents:

acute

gastroenteriris,UTI

, gastritis,

acute

appendicitis,

crohn

disease, constipation,

dysmenorrhoea

, PID, ectopic pregnancy, renal calculi,

acute

pancreatitis,

cholecystitis

, trauma, hepatitis, testicular or

ovarion

torsion, intestinal obstruction, perforation or peritonitis.

Slide5

Visceral pain

Visceral pain results when nerves within the gut detect

injury.

• The nerve fibers responsible for visceral sensation are

nonmyelinated

and mediate pain sensation, which is

vague, dull, slow in onset, and poorly localized.

• A variety of stimuli, including normal peristalsis and various

chemical and osmotic states, activate these fibers to some

degree, allowing some sensation of normal activity.

• Regardless of the stimulus, visceral pain is perceived when

a threshold of intensity or duration is crossed.

•

Lower degrees of activation may result in perception of

nonpainful

or perhaps vaguely uncomfortable sensations,

whereas more intensive stimulation of these fibers results

in pain.

•

Overactive sensation may be the basis of some kinds of

abdominal pain, such as functional abdominal pain.

Slide6

Somatic Pain

In contrast to visceral pain,

somatic pain results when overlying

body structures are injured.

• Somatic structures include the parietal peritoneum, fascia, muscles,

and skin of the abdominal wall.

• In contrast to the vague, poorly localized pain emanating from

visceral injury, somatic

nociceptive

fibers are

myelinated

and are

capable of rapid transmission of well-localized painful stimuli.

• When intra-abdominal processes extend to cause inflammation or

injury to the parietal peritoneum or other somatic structures, poorly

localized visceral pain becomes well-localized somatic pain.

• In acute appendicitis, visceral

nociceptive

fibers are activated

initially by the early phases of the infection. When the inflammatory

process extends to involve the overlying parietal peritoneum, the

pain becomes more acute and localizes generally to the right lower

quadrant. This is called

somatoparietal

pain.

Slide7

Referred pain

Referred pain is a painful sensation in a body region distant from

the true source of pain.

• The physiologic cause is the activation of

spinal cord somatic

sensory cell bodies by intense signaling from visceral afferent

nerves, located at the same level of the spinal cord.

• The location of referred pain is predictable based on the locus of

visceral injury.

•

Cardiac visceral pain is referred to left-sided T1-5 somatic

segments, causing left shoulder and arm pain.

•

Stomach pain is referred to the

epigastric

and

retrosternal

regions,

• and

liver and pancreas pain is referred to the

epigastric

region.

•

Gall-bladder pain often is referred to the region below the right

scapula.

• Somatic pathways stimulated by small bowel visceral afferents

affect the

periumbilical

area, and a noxious event in the colon

results in

infraumbilical

referred pain.

Slide8

Acute Abdominal Pain

Distinguishing Features.

• Acute abdominal pain can signal the presence of

a dangerous

intra-abdominal process, such as appendicitis

orbowel

obstruction, or may originate from

extraintestinal

sources

, such as lower lobe pneumonia or urinary

tract stone

.

• Not all episodes of acute abdominal pain

require emergency

intervention.

• Appendicitis must be ruled out as quickly as possible; the

evaluation must be efficient, properly focused, and rapid.

• Only a few children presenting with acute abdominal pain

actually have a

surgical emergency.

• These surgical cases must be separated from cases that can

be managed conservatively.

Slide9

Initial Diagnostic Evaluation.

Important clues to the diagnosis can be

determined by

History and physical examination.

• The

onset of pain can provide some clues.

• Events that occur with a discrete, abrupt onset,

such as passage of a stone, perforation of

a

viscus

, or infarction, result in a sudden onset.

• Gradual onset of pain is common with infectious

or inflammatory causes, such as appendicitis and

IBD.

Slide10

A standard group of

laboratory tests usually

is

performed

for abdominal pain.

• An abdominal x-ray series also is

usually obtained

.

• Further

imaging studies may be warranted

to

identify

specific causes.

• CT can visualize the appendix if the

examination and

laboratory findings suggest a possibility

of appendicitis

but the diagnosis remains in doubt

.

•

If the history and other features

suggest

intussusception

, a barium or pneumatic (air

) enema

may be the first choice to diagnose

and treat

this condition with hydrostatic reduction

Slide11

Diagnostic Approach to AcuteAbdominal Pain

History- age of the patient, duration of pain

Onset and nocturnal episode

Sudden or gradual, prior episodes, association

with meals

, history of

injury

Frequency of pain

Association with meal and

defaecation

,

vomitting

, blood

instool,diarrhoea

, constipation or

obstipation

, joint pain,

dysuria

, jaundice, weight loss, drug history.

Nature Sharp versus dull, colicky or constant, burning

Location,

Epigastric

,

periumbilical

, generalized, right or

left lower

quadrant, change in location over time

Fever,

Presence suggests appendicitis or other infection

Extraintestinal

symptoms, Cough

,

dyspnea

,

dysuria

, urinary frequency,

flank pain

Course of

symptoms, Worsening

or improving, change in nature

or location

of pain

Slide12

History

Onset

Sudden or gradual, prior episodes, association with

meals, history of injury

Nature

Sharp versus dull, colicky or constant, burning

Location

Epigastric

,

periumbilical

, generalized, right or left

lower quadrant, change in location over time

Fever

Presence suggests appendicitis or other infection

Extraintestinal

symptoms

Cough,

dyspnea

,

dysuria

, urinary frequency, flank

pain

Course of symptoms

Worsening or improving, change in nature or

location of pain

Slide13

Physical Examination

General

Growth and nutrition, general

appearance, hydration, degree of

discomfort, body position

Abdominal

Tenderness, distention, bowel sounds,

rigidity, guarding, mass

Genitalia

Testicular torsion, hernia, pelvic

inflammatory disease, ectopic pregnancy

Surrounding Structures

Breath sounds,

rales

,

rhonchi

, wheezing,

flank tenderness, tenderness of

abdominal wall structures, ribs,

costochondral

joints

Rectal

Examination

Perianal

lesions, stricture, tenderness,

fecal impaction, blood

Slide14

Laboratory

CBC, C-reactive protein, ESR Evidence of infection or inflammation

AST, ALT, GGT,

bilirubin

Biliary

or liver disease

Amylase, lipase Pancreatitis

Urinalysis Urinary tract infection, bleeding due to stone

,

trauma

, or obstruction

Radiology Plain

flat and

upright abdominal films,

Bowel

obstruction,

appendiceal

fecalith

, free

intraperitoneal

air, kidney stones

CT scan Rule out abscess, appendicitis,

Crohn

disease

,

pancreatitis

, gallstones, kidney stones

Barium enema

Intussusception

,

malrotation

Ultrasound Gallstones, appendicitis,

intussusception

,

pancreatitis

, kidney stones

Endoscopy Upper

endoscopy Suspected peptic ulcer or

esophagitis

Diagnostic

Approach

to Acute

Abdominal Pain

Slide15

Differential Diagnosis

With acute pain, the urgent task of the clinician is

to rule out surgical emergencies.

•

In young children,

malrotation

, incarcerated

hernia, congenital anomalies, and

intussusception

are common concerns.

•

In older children and teenagers, appendicitis is

more common.

• An acute surgical abdomen is characterized by

signs of peritonitis, including tenderness,

abdominal wall rigidity, guarding, and absent or

diminished bowel sounds.

Slide16

Traumatic

Duodenal hematoma

Ruptured spleen

Perforated

viscus

Functional

Constipation*

Irritable bowel syndrome*

Dysmenorrhea

*

Mittelschmerz

(ovulation)*

Infantile colic*

Slide17

Infectious

Appendicitis*

Viral or bacterial gastroenteritis/adenitis*

Abscess

Spontaneous bacterial peritonitis

Pelvic inflammatory disease

Cholecystitis

Urinary tract infection*

Pneumonia

Bacterial

typhlitis

Hepatitis

Slide18

Genital

Testicular torsion

Ovarian torsion

Ectopic pregnancy

Genetic

Sickle cell crisis*

Familial Mediterranean fever

Porphyria

Metabolic

Diabetic

ketoacidosis

Inflammatory

Inflammatory bowel disease

Vasculitis

Henoch-Schönlein

purpura

*

Pancreatitis

Slide19

Obstructive

Intussusception

*

Malrotation

with

volvulus

Ileus

*

Incarcerated hernia

Postoperative adhesion

Meconium

ileus

equivalent (cystic

fibrosis)

Duplication cyst, congenital

stricture

Biliary

Gallstone

Gallbladder

hydrops

Biliary

dyskinesia

Peptic

Gastric or duodenal ulcer

Gastritis*

Esophagitis

Renal

Kidney stone

Hydronephrosis

Slide20

Distinguishing Features of Abdominal Pain in Children

Disease

Onset

Location

Referral

Quality

Comments

Intestinal obstruction

Acute or

gradual

Periumbilical

-lower

abdomen

Back

Alternating

cramping (colic)

and painless

periods

Distention,

obstipation

, bilious

emesis, increased

bowel sounds

Appendicitis

Acute

Periumbilical

or

epigastric

; localizes

to right lower

quadrant

Back or

pelvis if

retrocecal

Sharp, steady

Nausea, emesis,

local tenderness, ±

fever, avoids

motion

Meckel

diverticulum

Recurrent

Periumbilical

-lower

abdomen

None

Sharp

Hematochezia

;

painless unless

intussusception

,

diverticulitis, or

perforation

Inflammatory bowel

disease

Recurrent

Depends on site of

Involvement

Dull

cramping

tenesmus

Fever, weight loss,

±

hematochezia

Slide21

Disease

Onset

Location

Referral

Quality

Comments

Functional: irritable

bowel syndrome

Recurrent

Periumbilical

,

splenic

and

hepatic

flexures

None

Dull,

crampy

,

intermittent; duration 2 hr

Family stress, school phobia, diarrhea and constipation;

hypersensitive to pain

Esophageal reflux

Recurrent,

after meals,

at bedtime

Substernal

Chest

Burning,

Sour taste in

mouth,Sandifer

syndrome

Duodenal ulcer

Recurrent,

before

meals, at

night

Epigastric

Back

Severe burning,

gnawing

Relieved by food, milk,

antacids; family

history important; GI

bleeding

Pancreatitis

Acute

Epigastric

hypogastric

Back

Constant, sharp,

boring

Nausea, emesis,

marked tenderness

Slide22

Acute Appendicitis

Commonest surgical emergency more common in older children, may occurs due to obstruction by

fecolith

or lymphoid tissue

e.g

following viral infection. PVF is presentation

Hgm

shows TLC raised polymorph raised

Usg

–

dialated

lumen of > 6mm, tubular

aperistaltic

structure, not compressible, surrounded by fluid. Sensitivity 85-90% and specificity 95-100%

Slide23

Intussusception

Common b/w 3mths to 6yr, telescoping of proximal

segement

into distal

segement

, may be

ileocolic

,

colocolic

,

ileoileal

.

Most common during weaning period when new food is introduced, vaccination, URTI

Classical triad- abdominal pain, red currant jelly stool and

alpable

mass is seen in few cases

USG investigation of choice- dough nut sign

Barium enema shows claw sign

Slide24

Gall stones

3 types- cholesterol > 50%, pigment stones (common in pts of hemolytic

anaemia

), mixed stones

Risk factors-

Anaemia

, obesity,

ileal

resection, drugs

ceftriaxone

, progressive familial

intrahepatic

cholestasis

typeIII

Pain in

Rt

upper quadrant or

epigastrium

radiate to

Rt

shoulder,

Icterus

and back radiation suggest stone in CBD

TSB,

Alk

phos

raised. Raised amylase suggest pancreatitis. USG is investigation of choice. MRCP or ERCP for CBD stones

Slide25

Choledochal cyst

Abnormal cystic

dialatation

of

biliary

tree single or multiple.

Present as

biliary

atresia

n neonates, in older children – recurrent pain, obstructive

jaundic

, or mass in

rt

hypochondrium

USG is inv of choice

Slide26

Intussusception

Acute

Periumbilical

-lower

abdomen

None Cramping, with

painless periods

Guarded position

with knees pulled

up, currant jelly

stools, lethargy

Slide27

Chronic Abdominal Pain

Chronic

abdominal pain is defined as the occurrence

of multiple episodes/ continuous

abdominal pain

for

at

least

2 months

that

are severe enough to cause some limitation of activity

.

Prevalance

0.5- 19%

• Recurrent abdominal pain is a common problem

in children

, affecting more than 10% of children at some

time during

childhood.

• The peak incidence occurs between ages 7 and 12 years.

• Although the differential diagnosis of recurrent

abdominal pain

is fairly extensive , most children with this

condition are

not found to have a serious (or even identifiable

) underlying

illness causing the pain

. As per Rome III criteria, 75% of cases of such cases have “Abdominal pain related to functional gastrointestinal disorder”.

Slide28

Abdominal pain related to functional gastrointestinal disorder

It is diagnosed – “pain +

nt

atleast

once a week in the

preceeding

2mths &the

bsence

of an organic cause such as inflammatory, anatomic, metabolic and

neoplastic

process” the pain is

periumblical

and clearly localized.

It is defined by ‘visceral

hyperalgesia

’

Types – Functional dyspepsia, IBS, abdominal Migraine, childhood functional abdominal pain syndrome

Slide29

Contd

Functional

dyspepsia- persistent or recurrent pain or discomfort above

umblicus

& not relieved by defecation nor associated with a change in stool frequency or form

IBS- abdominal pain improvement with defecation, onset

associated with a change in stool

frequency & associated with a change in consistency of stool

Slide30

Contd.

Abdominal Migraine- paroxysmal episode of intense, acute

periumblical

pain lasting for an hour or more with intervening periods of normal health lasting weeks to months, pain interfere with normal activity & associated with 2 or more of- anorexia, nausea,

vomitting

, headache, photophobia and pallor

Childhood

functional abdominal pain

syndrome- episodic or continuous pain, one or more of these symptoms at least 25% of time some loss of daily functioning, headache, limb pain, or difficulty in sleeping. It is most common

Slide31

Differential Diagnosis of Recurrent Abdominal Pain

Functional abdominal pain*

Irritable bowel syndrome*

Chronic pancreatitis

Gallstones

Peptic disease

Duodenal ulcer

Gastric ulcer

Esophagitis

Lactose intolerance*

Slide32

Fructose

malabsorption

Inflammatory bowel disease*

Crohn

disease

Ulcerative colitis

Constipation*

Obstructive

uropathy

Congenital intestinal malformation

Malrotation

Duplication cyst

Stricture or web

Celiac disease

Slide33

The most common disorder to consider is

functional

abdominal pain.

• Children with functional pain have pain

that characteristically

occurs daily or nearly every day, is

not associated

with or relieved by eating or defecation, and

is associated

with significant loss of the ability to

function normally

.

• These children typically have personality traits that include

a tendency toward anxiety and perfectionism, which

result in

stress at school and in novel social situations.

• The parents typically state that the child enjoys going

to school

, but the pain often is worst at the start of the school

day and before returning to school after vacations.

• A child with suspected functional pain must be

evaluated carefully

to exclude other causes of discomfort.

Slide34

Contd.

Functional abdominal pain differs from

irritable

bowel syndrome (IBS) in minor ways.

• Children with IBS have pain beginning with

a change

in stool frequency or consistency, a

stool pattern

fluctuating between diarrhea

and constipation

, and relief of pain with defecation.

• Symptoms in IBS are linked to gut motility

.

•

Pain is commonly accompanied in both groups of

children by school avoidance, secondary gains

, anxiety

about imagined causes, lack of

coping skills

, and disordered peer relationships.

Slide35

Distinguishing Features.

One needs to distinguish between functional pain

and IBS and more serious underlying disorders.

• When taking the history, the pediatrician should

ask about the

warning signs for underlying

illness.

• If any warning signs are present, further

investigation is necessary.

• Even if the warning signs are absent, some

laboratory evaluation is warranted.

Slide36

Warning Signs of Underlying Illness inRecurrent Abdominal Pain

Vomiting

Abnormal screening laboratory study

Fever

Bilious emesis

Growth failure

Pain awakening child from sleep

Weight loss

Location away from

periumbilical

region

Blood in stools or emesis

Delayed puberty

Slide37

The physician and the parents must feel assured that

no serious illness is being missed; a judicious

laboratory evaluation after a careful history and

complete physical

examination can accomplish this.

• One mistake that must be avoided in treating recurrent

pain is performing too many tests.

• When the physician responds to each normal test with

an order for another one, the parents and child may

think that there is a serious illness that is being missed.

• Instead of being reassured by normal tests, the child's

parents are made to believe that the mystery is

deepening with every subsequent normal test result.

• The initial evaluation recommended in avoids these

problems.

Slide38

While waiting for laboratory and ultrasound results, a

3-day trial of

a lactose-free diet should be instituted to rule out lactose

intolerance.

• If tests are normal and no warning signs are present, testing should

be stopped.

• If there are warning signs, worrisome symptoms, progression of

symptoms, or laboratory abnormalities that suggest a specific

diagnosis, additional investigation may be necessary.

• If

antacids consistently relieve pain, an upper GI endoscopy is

indicated.

• If the child is losing weight, a barium upper GI series with a small

bowel follow-through or contrast CT is a good idea to look for

evidence of CD.

•

Celiac disease also should be considered.

Slide39

Treatment of Recurrent Abdominal Pain

A child who is kept home or sent home from school

because of pain receives a lot of attention for the

symptoms, is excused from responsibilities, and

withdraws from full social functioning.

• This situation rewards complaints and increases the

child's anxiety about health.

• When the child observes that the adults are worried,

the child worries too.

• To break this cycle of pain and disability, the child must

return to normal activities immediately, even before

all test results are available.

Slide40

Contd.

The child should not be sent home from school with

stomachaches; rather, the child may be allowed to take a

short break from class in the nurse's office until the

cramping abates.

• It is useful to inform the child and the parents that the pain

is likely to be worse on the day the child returns to school.

• Anxiety worsens

dysmotility

and pain perception.

• Sometimes, medications can be helpful.

•

Fiber supplements are useful to manage symptoms of IBS.

• In difficult and persistent cases,

amitriptyline

or a selective

serotonin reuptake inhibitor may be beneficial.

Slide41

Outcome

After 5 years,



1/3 of children with RAP will have resolution of

their pain,



1/3 continue to complain of the same

symptoms, and



1/3 will have a different recurrent pain

complaint.