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ABDOMINAL PAIN in the PEDIATRIC PATIENT. Tim Weiner, M.D. Dept. of Surgery University of North Carolina at Chapel Hill. In General. Common problems occur commonly intussusception in the infant appendicitis in the child The differential diagnosis is age-specific

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abdominal pain in the pediatric patient

ABDOMINAL PAIN in the PEDIATRIC PATIENT

Tim Weiner, M.D.

Dept. of Surgery

University of North Carolina

at Chapel Hill

in general
In General
  • Common problems occur commonly
    • intussusception in the infant
    • appendicitis in the child
  • The differential diagnosis is age-specific
  • In pediatrics most belly pain is non-surgical
    • “Most things get better by themselves. Most things, in fact, are better by morning.”
  • Bilous emesis in the infant is malrotation until proven otherwise
  • A high rate of negative tests is OK
the history
The History
  • Pain (location, pattern, severity, timing)
    • pain as the first sx suggests a surgical problem
  • Vomiting (bile, blood, projectile, timing)
  • Bowel habits (diarrhea, constipation, blood, flatus)
  • Genitourinary complaints
  • Menstrual history
  • Travel, diet, contact history
diagnosis by location
Diagnosis by Location

gastroenteritis

early appendicitis

PUD

pancreatitis

spleen/EBV

constipation

non-specific

ovary

biliary

hepatitis

appendicitis

enteritis/IBD

ovarian

non-specific

colic

early appendicitis

constipation

UTI

pelvic appendicitis

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

breath sounds

Murphy’s sign

“sausage”

Dance’s sign

rebound

tender at McBurney’s point

cecal “squish”

breath sounds

spleen edge

constipation

Rovsing’s sign

hernias

torsion

relevant physical findings
Relevant Physical Findings
  • Tachycardia
  • Alert and active/still and silent
  • Abdominal rigidity/softness
  • Bowel sounds
  • Peritoneal signs (tap, jump)
  • Signs of other infection (otitis, pharyngitis, pneumonia)
  • Check for hernias
blood in the stool
Blood in the Stool
  • Newborn
    • ingested maternal blood, formula intolerance, NEC, volvulus, Hirschsprung’s
  • Toddler
    • anal fissures, infectious colitis, Meckel’s, milk allergy, juvenile polyps, HUS, IBD
  • 2 to 6 years
    • infectious colitis, juvenile polyps, anal fissures, intussusception, Meckel’s, IBD, HSP
  • 6 years and older
    • IBD, colitis, polyps, hemorrhoids
blood in the vomitus
Blood in the Vomitus
  • Newborn
    • ingested maternal blood, drug induced, gastritis
  • Toddler
    • ulcers, gastritis, esophagitis, HPS
  • 2 to 6 years
    • ulcers, gastritis, esophagitis, varices, FB
  • 6 years and older
    • ulcers, gastritis, esophagitis, varices
further work up
Further Work-up
  • CBC and differential
  • Urinalysis
  • X-rays (KUB, CXR)
  • US
  • Abdominal CT
  • Stool cultures
  • Liver, pancreatic function tests
  • (Rehydrate, ?antibiotics, ?analgesiscs)
relevant x ray findings
Relevant X-ray Findings
  • Signs of obstruction
    • air/fluid levels
    • dilated loops
    • air in the rectum?
  • Fecalith
  • Paucity of air in the right side
  • Constipation
operate now
Operate NOW
  • Vascular compromise
    • malrotation and volvulus
    • incarcerated hernia
    • nonreduced intussusception
    • ischemic bowel obstruction
    • torsed gonads
  • Perforated viscus
  • Uncontrolled intra-abdominal bleeding
operate soon
Operate SOON
  • Intestinal obstruction
  • Non-perforated appendicitis
  • Refractory IBD
  • Tumors
appendicitis
Appendicitis
  • Common in children; rare in infants
  • Symptoms tend to get worse
  • Perforation rarely occurs in the first 24 hours
  • The physical exam is the mainstay of diagnosis
  • Classify as simple (acute, supparative) or complex (gangrenous, perforated)
incidental appendectomy
Incidental Appendectomy
  • Can be done by inversion technique
  • Absolute indication
    • Ladd’s procedure
  • Relative indications
    • Hirschsprung’s pullthrough
    • Ovarian cystectomy
    • Intussusception
    • Atresia repair
    • Wilms’ tumor excision
    • CDH
intussusception
Intussusception
  • Typically in the 8-24 month age group
  • Diagnosis is historical
    • intermittent severe colic episodes
    • unexplained lethargy in a previously healthy infant
  • Contrast enema is diagnostic and often therapeutic
  • Post-op small bowel intussusception
the medical bellyache
The “Medical Bellyache”
  • Pneumonia
  • Mesenteric adenitis
  • Henoch-Schonlein Purpura
  • Gastroenteritis/colitis
  • Hepatitis
  • Swallowed FB
  • Porphyria
  • Functional ileus
  • UTI
  • Constipation
  • IBD “flare”
  • rectus hematoma
laparoscopy
Laparoscopy
  • Diagnosis
    • non-specific abdominal pain
    • chronic abdominal pain
    • female patients
    • undescended testes
    • trauma
  • Treatment
    • appendicitis
    • Meckel’s diverticulum
    • cholecystitis
    • ovarian detorsion/excision
    • lysis of adhesions
the neurologically impaired patient
The Neurologically Impaired Patient
  • The physical exam is important for non-verbal patients
  • The history is important for the spinal cord dysfunction patient
  • Close observation and complementary imaging studies are necessary
the immunologically impaired patient
The Immunologically Impaired Patient
  • A high index of suspicion for surgical conditions and signs of peritonitis may necessitate operation
    • perforation
    • uncontrolled bleeding
    • clinical deterioration
  • Blood product replacement is essential
  • Typhlitis should be considered; diagnosis is best established by CT
the teenage female
The Teenage Female
  • Menstrual history
    • regularity, last period, character, dysmenorrhea
  • Pelvic/bimanual exam with cultures
  • Pregnancy test/urinalysis
  • US
  • Laparoscopy
  • Differential diagnosis
    • mittelschmerz, PID, ovarian cyst/torsion, endometriosis, ectopic pregnancy, UTI, pyelonephritis
in summary
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.”