Dr M Anas Asstt Professor Atfal Do Amraz e Niswan wa Atfal Tashannuj e Shikam Abdominal pain is one of the most common reason for which parents take the child to a doctor ID: 911233
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Slide1
Tashannuj e Shikam (Abdominal colic)
Dr M
Anas
Asstt
Professor,
Atfal
D/o
Amraz
e
Niswan
wa
Atfal
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.
Slide3Acute
Organic
Inorganic
/ Idiopathic/ functional
Chronic
Organic
Inorganic/ Idiopathic/ functional
Here again there may be many
variations
Slide4Causes
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.
Slide5Visceral 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.
Slide6Somatic 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.
Slide7Referred 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.
Slide8Acute 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.
Slide9Initial 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.
Slide10A 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
Slide11Diagnostic 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
Slide12History
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
Slide13Physical 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
Slide14Laboratory
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
Slide15Differential 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.
Slide16Traumatic
Duodenal hematoma
Ruptured spleen
Perforated
viscus
Functional
Constipation*
Irritable bowel syndrome*
Dysmenorrhea
*
Mittelschmerz
(ovulation)*
Infantile colic*
Slide17Infectious
Appendicitis*
Viral or bacterial gastroenteritis/adenitis*
Abscess
Spontaneous bacterial peritonitis
Pelvic inflammatory disease
Cholecystitis
Urinary tract infection*
Pneumonia
Bacterial
typhlitis
Hepatitis
Slide18Genital
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
Slide19Obstructive
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
Slide20Distinguishing 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
Slide21Disease
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
Slide22Acute 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%
Slide23Intussusception
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
Slide24Gall 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
Slide25Choledochal 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
Slide26Intussusception
Acute
Periumbilical
-lower
abdomen
None Cramping, with
painless periods
Guarded position
with knees pulled
up, currant jelly
stools, lethargy
Slide27Chronic 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”.
Slide28Abdominal 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
Slide29Contd
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
Slide30Contd.
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
Slide31Differential Diagnosis of Recurrent Abdominal Pain
Functional abdominal pain*
Irritable bowel syndrome*
Chronic pancreatitis
Gallstones
Peptic disease
Duodenal ulcer
Gastric ulcer
Esophagitis
Lactose intolerance*
Slide32Fructose
malabsorption
Inflammatory bowel disease*
Crohn
disease
Ulcerative colitis
Constipation*
Obstructive
uropathy
Congenital intestinal malformation
Malrotation
Duplication cyst
Stricture or web
Celiac disease
Slide33The 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.
Slide34Contd.
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.
Slide35Distinguishing 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.
Slide36Warning 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
Slide37The 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.
Slide38While 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.
Slide39Treatment 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.
Slide40Contd.
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.
Slide41Outcome
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.