ACUTE ABDOMINAL PAIN

IN CHILDREN

Dr. Hj. Nurhaedah Tangim Sp.A

Bagian Ilmu Keseheatan Anak Fakultas Kedokteran Universitas Alkhairaat

RSU ANUTAPURA PALU
 introduction
ACUTE • Common problem in children
ABDOMINAL • Can be self limiting or an emergency
PAIN problem

• Completing clinical evaluation is important

DIAGNOSIS • Consider the cause of pain (age & location,
surgical case/≠)

• CBC, urinalysis, stool or radiologic

examination
INVESTIGATIONS • Differential diagnosis
• Referral to surgery division
 DEFINITION
Abdominal pain is a pain
felt between chest and
inguinal region
Acute abdominal Recurrent
pain abdominal pain
 ACUTE ABDOMINAL PAIN

Abdominal pain attack episode, sudden onset,

hours – a week, and never had pain before,
could be persistent or remitting pain with mild
– severe intensity, consider medical
intervention and surgical intervention if
needed to solve the cause of pain.
 RECURRENT ABDOMINAL PAIN

Apley  Abdominal pain minimally three

times pain episode within three months with
severe enough intensity and may influence
activity.
 INCIDENCE
Acute Abdominal Pain in Children

20.6%

Nonsurgical cases
79.4%
Surgical cases

Cerrahpasa Medical School ER, Istanbul

 INCIDENCE
Nonsurgical cases (79.4%)

28.1% 23.7%

URTI
Unknown AAP
Gastroenteritis
Constipation
UTI
9. 15.4% Others
8% 4
% 15.4%

Cerrahpasa Medical School ER, Istanbul

 INCIDENCE
Surgical Cases (20.6%)

18.3%

Unknown
Appendicitis

81.7%

Cerrahpasa Medical School ER, Istanbul

 INCIDENCE
Acute Abdominal Pain In Children

11.8%

Surgical
Nonsurgical

88.2%

Wahidin Sudirohusodo Hospital, Makassar

 INCIDENCE
Nonsurgical Cases (88.2%)

6% 3% 19.4%
9%
Diarrhea
DHF
URTI
Constipation
UTI
17.9 ANSAP
%
44.7%

Wahidin Sudirohusodo Hospital, Makassar

 INCIDENCE
Surgical Cases (11.8%)

33.
3%
Unknown
Appendicitis

66.7%

Wahidin Sudirohusodo Hospital, Makassar

 PATHOGENESIS
• Common causes

Vascular Disorder
Inflammation
Obstruction
Stretching of visceral
Peritoneum
 PATHOPHYSIOLOGY

SOURCE OF ABDOMINAL PAIN

 VISCERAL PAIN

 SOMATIC PAIN

 REFERRED PAIN
 Visceral pain

• Visceral pain fibers: Bilateral, unmyelinated,

enter the spinal cord at multiple area

• Visceral pain: Dull, early onset and poorly

localized
 Parietal pain
• Caused by irritation of parietal peritoneal
fibers

• Parietal pain fibers: myelinated , enter specific

dorsal root ganglia

• Parietal pain: sharp, intense, discrete, late

onset, and localized to a dermatome
superficial to site of the painful stimulus
 Referred pain

• Pain is felt at a site away from the pathological

organ

• Pain is usually ipsilateral to the involved organ

ETIOLOGY
• Age of onset
• Location of pain :
– Intra-abdominal disorder
– Extra-abdominal disorder
• Onset of abdominal pain
 AGE RELATED TO ABDOMINAL PAIN
DIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMINAL PAIN BY PREDOMINANT AGE
Birth to one year Two to five years Six to 11 years 12 to 18 years
Infantile colic Gastroenteritis Gastroenteritis Appendicitis
Gastroenteritis Appendicitis Appendicitis Gastroenteritis
Constipation Constipation Constipation Functional Constipation
Urinary tract infection Urinary tract pain Urinary tract Dysmenorrhea
Intussusception infection infection Trauma Mittelschmerz
Volvulus Intussusception Pharyngitis Pneumonia Pelvic inflammatory
Incarcerated hernia Volvulus Sickle cell crisis disease
Hirschsprung's disease Trauma Henoch-Schönlein Threatened abortion
Pharyngitis purpura Ectopic pregnancy
Sickle cell crisis Mesenteric Ovarian/testicular
Henoch-Schönlein lymphadenitis torsion
purpura
Mesenteric
lymphadenitis
 PAIN LOCATION

• Intra-abdominal disorder

• Extra-abdominal disorder
 ON
TI
C A
LO
IN
PA
Intra-abdominal
disorder
 PAIN LOCATION...
Extra-Abdominal Causes of Abdominal Pain
Abdominal wall Thoracic
Rectus muscle hematoma Myocardial infarction

GU Pneumonia

Testicular torsion Pulmonary embolism

Infectious Radiculitis

Herpes zoster Toxic

Metabolic Black widow spider bite

Alcoholic ketoacidosis Heavy metal poisoning

Diabetic ketoacidosis Methanol poisoning
Porphyria Scorpion sting
Sickle cell disease Opioid withdrawal
ONSET OF ABDOMINAL PAIN
 AGE RELATED TO CLINICAL
MANIFESTATIONS
0 – 3 months Commonly described as vomiting

3 months – Vomiting, sudden cry and histeric

2 years cry without recent trauma
2 – 5 years Can show abdominal pain, but not
the exact location
> 5 years Can show the location and severity
of abdominal pain
CLINICAL EVALUATION
 History
• Age
• Pain history (Pain location, Onset, Duration)
• Recent trauma
• Precipitating or Relieving factor
• Associated symptoms
• Gynecologic history
• Past history
• Drugs history
• Family history
 Physical examination
• General appearance
• Vital signs
• Abdominal examination
• Rectal and pelvic examination
• Associated signs
 Investigation
• Complete blood cell count
• Urinalysis & stool
• Plain-film abdominal radiographs
• USG
• Endoscopy
• CT scan
 DIAGNOSIS

• Age and abdominal pain location were the key

for establishing the cause of abdominal pain.
• Good and complete anamnesis, physical
examination and testing could lead to accurate
diagnosis of the underlying disease causing
acute abdominal pain for optimal therapy.
 DIFFERENTIAL DIAGNOSIS (COMMON)
CAUSES OF ACUTE ABDOMINAL PAIN IN CHILDREN
Gastrointestinal causes Rupture of the spleen Hemolytic uremic syndrome
Gastroenteritis Pancreatitis Drugs and toxins
Appendicitis Genitourinary causes Erythromycin
Mesenteric lymphadenitis Urinary tract infection Salicylates
Constipation Urinary calculi Lead poisoning
Abdominal trauma Dysmenorrhea Pulmonary causes
Intestinal obstruction Pelvic inflammatory disease Pneumonia
Peritonitis Ectopic pregnancy Diaphragmatic pleurisy
Food poisoning Ovarian/testicular torsion Miscellaneous
Peptic ulcer Endometriosis Infantile colic
Meckel’s diverticulum Metabolic disorders Pharyngitis
Inflammatory bowel disease Diabetic ketoacidosis Angioneurotic edema
Lactose intolerance Hypoglycemia
Liver, spleen, and biliary tract Acute adrenal insufficiency
disorders
Hepatitis Hematologic disorders
Cholecystitis Sickle cell anemia
Cholelithiasis Henoch-Schönlein purpura
 MANAGEMENT

UNDERLYING DISEASE SURGERY

ANALGETICS?
TREATMENT CONSULTATION
 REFFERED
INDICATION FOR SURGICAL CONSULTATIONS IN CHILDREN WITH ACUTE
ABDOMINAL PAIN
Severe or increasing abdominal pain with progressive
Signs of deterioration
Bile-stained or feculent vomitus
Involuntary abdominal guarding/rigidity
Rebound abdominal tenderness
Marked abdominal distension with diffuse tympany
Signs of acute fluid or blood loss into the abdomen
Significant abdominal trauma
Suspected surgical cause for the pain
Abdominal pain without an obvious etiology
 SUMMARY

• A common problem which needs a

prompt diagnosis.
• Age and pain location were the key for
establishing the cause of abdominal
pain.
• The accuracy of diagnosis was needed
to provide an optimal therapy.
• Sign of surgical cases should refer to
surgery division.
THANK YOU
Acute abdominal pain in children was
SUMMARY
a common problem to diagnosis. Age
and abdominal pain location were
the key for abdominal pain caused.
Complete anamnesis/history of
disease, physical examination and
testing could diagnosis accurately the
underlying disease acute abdominal
pain. However, the accurate of
diagnosis was needed to give an
optimal therapy. If there was sign of
surgery cases on acute abdominal
pain in children, we can consult to
surgery division.
DURATION AND SEVERITY
ACUTE ABDOMINAL PAIN
 Child abuse
Evidence of trauma?
Accidental injury

Urinary tract infection

Fever?
Pharyngitis
Gastroenteritis
Mesenteric lymphadenitis
Pneumonia
Appendicitis
Pelvic inflammatory disease

Evidence of sickle cell Sickle cell crisis

anemia?

Constipation
Left-sided pain Ovarian/testicular torsion

Appendicitis
Middle to right-
Ovarian/testicular torsion
sided pain?
Mesenteric lymphadenitis
 Present in other Food poisoning
household contacts? Gastroenteritis

Sexually active? Pelvic inflammatory disease

Ectopic pregnancy

Paleness/purpura? Hemolytic uremic syndrome

Henoch-Schönlein purpura

Blood in stool?
Inflammatory bowel disease
Hemolytic uremic syndrome
Henoch-Schönlein purpura
Gastroenteritis
 Hematuria? Renal calculi
Renal trauma
Urinary tract infection

Evidence of Malrotation
obstruction? Intussusception
Volvulus

Refer or observe
 DATA PRIMER SAKIT PERUT AKUT
RSU Dr. Wahidin Sudirohusodo Tahun 2010
Total Kunjungan Pasien tahun 2010: 2060 pasien
Jumlah Kasus SPA Jumlah (%)
Total 76 (100%)
Laki-laki 43 (56.5%)
Perempuan 33 (43.5%)
Nonbedah 67 (88.2%)
Diare 30 (44.7%)
DBD 12 (17.9%)
ISPA 6 (9%)
Konstipasi 4 (6%)
ISK 2 (3%)
Nonspesifik 13 (19.4%)
Bedah 9 (11.8%)
Apendisitis 3 (33.3%)
Tidak diketahui 6 (66.7%)
Cullen’s Sign
Grey Turner’s Sign
 Mittelschmerz
• Ovulation pain; Midcycle pain
• Lower-abdominal pain that is:
 One-sided
 Recurrent or with similar pain in past
 Typically lasting minutes to a few hours, possibly
as long as 24-48 hours
 Usually sharp, cramping, distinctive pain
 Severe (rare)
 May switch sides from month to month or from
one episode to another
 Begins midway through the menstrual cycle