8. • Basic labs work up
– POCT glucose
– BUN, Cr, Elyte
– UA, UPT
– Toxico
– CBC not useful for screening
test
9. • Imaging
– Plain film abdomen
– US
– CT (radiation
exposure 600 times of plain
film, risk develop CA)
10. Pain management
• Opiates does not negatively
impact patient care.
• Although physical examination
findings can change after the
administration of opiates
• There is no evidence that this
changes final management or
outcome
11. Common Parenteral Analgesics for
Abdominal Pain in Children
Drug Dose
Morphine 0.05–0.1 milligram/kg/dose IV every 4 h in
sulfate neonates.
0.1 milligram/kg/dose IV every 2–4 h in infants
and children.
Hydromorphone 0.015 milligram/kg/dose IV every 3–6 h if 6 mo
old and <50 kg.
If weighing >50 kg, use adult dosing.
Fentanyl 1–2 micrograms/kg/dose IV every 30–60 min.
Ketorolac 0.5 milligram/kg/dose IV every 6 h (maximum of
30 milligrams per dose) if 6 mo old.
12. • Special Considerations
1. Neonates and Young Infants (0 to 3 Months)
2. Older Infants and Toddlers
(3 Months to 3 Years Old)
3. Children (3 to 15 Years of Age)
13. Neonates and Young Infants (0 to 3 Months)
Other urgent
Life-threatening
conditions include
• Necrotizing enterocolitis • Incarcerated hernias
(NEC) • Testicular torsion
• Malrotation with midgut • Nonaccidental trauma.
volvulus
14. Neonates and Young Infants (0 to 3 Months)
• S&S
• Inconsolability or lethargy associated with
poor feeding
• Constant pain + sudden in onset
• Episodic, paroxysmal pain suggests infant
colic, intussusception, or gastroenteritis.
• Pain related to feeds suggests
gastroesophageal reflux disease.
15. S&S
• Bilious vomiting (bright yellow or green)
malrotation with volvulus or intussusception
• Any change in stooling pattern
• Timing of passing the first stool
16. PE
• If the infant is crying, one must rely heavily on
observation, though auscultation and
palpation remain important.
• Undress
• Scrotum
• Check for other causes
17. Malrotation and Volvulus
• Life-threatening complication
• Malrotation of the midgut
occurs in 1 in 6000 births
• 90% of complications
occurring in the first year of
life
18.
19.
20. Clinical Features
• No significant past medical
history
• Abrupt onset of constant
abdominal pain, bilious
vomiting, abdominal
distention, and irritability.
• As bowel ischemia
progresses, shock and
peritonitis develop.
21. • Ill appearing
• Shock
• Ominous signs include
tachypnea, grunting
respirations, and jaundice.
• Diffusely tender and distended
and may be rigid
• Rarely, a mass can be palpated.
• Intermittent volvulus may
present with stable vital signs
and focal tenderness on
abdominal examination.
23. Imaging
• Plain abdominal radiographs
– a loop of bowel overriding the liver
– evidence of obstruction, including air
fluid levels and a paucity of gas
• Upper GI series
– "bird's beak" appearance of the
duodenum at the site twisting, and
may be seen to the right of the spine
• CT scan of the abdomen and pelvis
with oral contrast
– intestinal malrotation
25. Necrotizing Enterocolitis
• Premature and weigh <1500
grams at birth
• Full-term infants at higher
risk
– congenital heart disease
– other disorders that place the
infant under significant stress
(e.g., sepsis, respiratory
distress).
26. S&S
• Poor feeding
• Lethargy
• Abdominal distention, and
tenderness
• Signs of sepsis
• Pneumoperitoneum
27. Investigation
• CBC
• Serum electrolytes
• Septic work up (blood, urine,
and cerebrospinal fluid
cultures)
• A cross-table lateral view of
the abdomen
– dilated loops of bowel
– abnormal gas pattern
– pneumatosis intestinalis
28. Treatment
• Bowel rest (NPO)
• Aggressive IV hydration
• Broad-spectrum antibiotics (to
cover abdominal/gut flora)
• Consultation with a pediatric
surgeon
• Should be admitted to a
neonatal or pediatric intensive
care unit
29. Incarcerated Hernia
• Inguinal hernias occur in up
to 5%
• More common in children
born prematurely
• Incarceration occurs in up to
one third of cases
• Highest in the first year of
life.
30. Clinical Features
• Irritability, poor
feeding, vomiting, and an
inguinal or scrotal mass
• DDx
– Hydrocele of the cord or the
scrotum
– Undescended testicle
– Torsion of the testicle
– Torsion of the appendix testis
– Inguinal lymphadenopathy
– Inguinal node abscess
– Orchitis
– Inguinal or scrotal trauma
31. Treatment
• Medical, and
sometimes, surgical
emergency
• Manual reduction of the
incarcerated hernia is often
possible early in the course
of disease.
33. Manual reduction
• Sedation
• Once the hernia is reduced,
arrange follow-up in 24 to 48
hours with a pediatric
surgeon
• One third of children will
redevelop incarceration
34. Older Infants and Toddlers
(3 Months to 3 Years Old)
DDX
• Intussusception
• Acute gastroenteritis
• Constipation
• Urinary tract infection (UTI)
• Testicular torsion
• Accidental and nonaccidental trauma
• Malrotation with midgut volvulus and appendicitis are rare
35. S&S
• Pulling up of legs in association with episodic
pain followed by periods of normal behavior
or lethargy Intussusception
• Pain with urinationUTI
• Day care attendance and sick contacts should
be noted when fever, vomiting, and diarrhea
are present together Infectious
gastroenteritis
36. PE
• Vary greatly in their ability to cooperate with a
physical examination, and stranger anxiety
• Avoiding direct eye contact
• Look first and then feel.
• Non-touch maneuvers and observations
• Ask a parent to palpate the child's abdomen
while you observe
37. Colic
• "rule of threes“
• Crying >3 hours per day for
>3 days per week for >3
weeks
• Starts in the first week of life
• Resolves by 3 to 4 months of
age
• Colic is a diagnosis of
exclusion.
39. Pathophysiology
• Leading points
– Lymphoid hyperplasia
– Meckel diverticulum, intestinal
polyps, congenital duplications,
lymphosarcoma, or as a
complication of HSP
Ileum invaginates into the upper colon bringing the
mesentery with it (ileocolic) constriction of the
mesentery obstructs venous return engorgement of the
intussusceptum
Bowel ischemia
40. Clinical Features
• Infant aged 6 to 18 months old
• Sudden onset of colicky pain
• Episodes of pain
– shorter with increasing duration
• Vomiting is rare in the first few hours
• The classic "currant jelly" stool is a late
manifestation
• Stool is usually guaiac positive even in the
absence of gross blood
41. Clinical Features
• Apathy or lethargy may be
the only presenting sign
• Sausage-shaped mass on the
right side of the abdomen
• Absence of a mass should
not delay further
investigation
• An ileoileal intussusception
may have a less typical
presentation
42. Diagnosis and Treatment
• Presumptive diagnosis is
usually made by history
alone
• Well-appearing child with a
normal examination does
not exclude the diagnosis
43. Imaging
• Plain films of the abdomen
may suggest a mass or filling
defect in the right lower
quadrant of the abdomen
• US is highly sensitive and
specific for diagnosis.
• Air contrast enema :both
diagnostic and frequently
curative
Pediatric surgeon should be consulted before
diagnostic air enema
44. Air contrast enema
• After successful reduction in
radiology, children are
generally admitted for
observation
• 5% to 10% recurrence rate,
usually within the first 24 to
48 hours after reduction
46. Constipation
• Infrequent, dry, hard stools
• Defects in filling or emptying
the rectum
• May be a sign of either a
pathologic or functional
process
47. • In infancy
– Maternal drugs
– Congenital GI anomalies
– Cystic fibrosis
– Hirschsprung disease
– Poor intake
– Anal fissures
• In older children
– Chronic medical conditions such as anorexia nervosa, cerebral
palsy, neuromuscular disease, spinal cord abnormalities,
depression, sickle cell disease (secondary to opiate use), or
hypothyroidism
– Acute - dehydration, electrolyte abnormalities (hypercalcemia
or hypokalemia), or drug ingestions (diuretics, antihistamines,
anticholinergics, or narcotics)
History is the key to the diagnosis of constipation
48. Questions to Ask about
Constipation
• The frequency and texture of the
stools
• The presence of blood on the stool
• The association of pain with
defecation
• A history of waxing and waning of
hard stools and watery diarrhea
suggesting overflow incontinence
49. • Rectal examination
– presence of stool
– rectal tone sensation
– size of the anal vault
• Palpate the abdomen for the
presence of a mass
50. Treatment
• Disimpaction with a glycerin
suppository in infants and
bisacodyl suppository in
adolescents
• Sodium phosphate (e.g.,
Fleet Enema®) or soap suds
enemas
51. Treatment of Constipation in
Children >1 year of age
Osmotic laxatives: polyethylene glycol (1–2 packs/d with 8 oz of
water or juice)
Lubricants: mineral oil (1–3 cc/kg/d) (should be used with
caution in young children and those at risk for aspiration)
Stool softeners: docusate sodium
Stimulant laxatives
Senna (for 2–6 y olds: sennosides: 3.75 milligrams/d;
maximum of 15 milligrams/d; for 6–12 y olds: sennosides: 8.6
milligrams once a day, maximum of 50 milligrams/d)
Bisacodyl ( if >6 years old): 5–10 milligrams at bedtime or
breakfast
52. Children (3 to 15 Years of Age)
Common cause Less common
• Appendicitis • DKA
• Constipation • Inflammatory bowel disease
• pain secondary to (IBD)
nonspecific viral syndrome • Cholelithiasis
• acute gastroenteritis • Sickle cell anemia
• strep pharyngitis • Henoch-Schönlein purpura
• UTI • Toxic ingestion
• pneumonia • Testicular ovarian
cyst, ectopic
pregnancy, pelvic
inflammatory disease, renal
53. S&S
• Verbalize the time of onset and location of the
pain by age 3 or 4 years old
• Older children may be able to characterize the
frequency and severity
54. PE
• Use verbal and tactile techniques
• Observation remains a key
• Note general appearance, position of comfort,
respiratory effort, and gait.
55. Appendicitis
• most common
• peak ages 9-12 yrs
• M>F
• Perforation rates approach
90% in children <4 years old.
56. • Vomiting may be the first
symptom noted by the parents.
• Peritoneal inflammation in
children can be elicited by asking
patients to walk, hop, or cough
• Assess for hernias in males and
females and perform a testicular
examination in all males
• A pelvic examination may be
needed in adolescent females
57. Diagnosis
• WBC <10,000/mm3 is a
strong negative predictor for
appendicitis
• Ambiguous cases, imaging
with ultrasonography or CT
are useful.
58. Treatment
• Once the diagnosis of
appendicitis is strongly
• NPO, IV hydration
• Antibiotic
– nonperforated
ampicillin/sulbactam or
cefoxitin
– Perforated
piperacillin/tazobactam
59. • Appendectomy is definitive
treatment (laparotomy or
laparoscopy)
• In ambiguous cases,
admission for serial
abdominal examination by a
surgeon is reasonable.
60. Nonspecific Abdominal Pain
• Largest single group of children
seen in the ED with acute
abdominal pain
• The key to the establishment
of nonspecific abdominal pain
as a working diagnosis is
reexamination in 24 hours and
repeated examinations over
time if symptoms continue.
61. Clinical features
• Nausea - most common symptom
after abdominal pain.
• Midepigastric or in the Lower half
• Tenderness is not usually severe, is
1/3 absent and 1/3 localized to the
right lower quadrant or
midepigastric
• Laboratory tests are usually normal
• Abdominal radiographs are also
normal.
follow-up is essential
62. Henoch-Schönlein Purpura
• Vasculitic disease of children
between 2 and 11 years
• Elevated IgA levels and IgA
deposits in the glomeruli and
vessel walls.
63. • Triad of acute onset of
– abdominal pain
– purpuric rash
– arthritis
• Diffuse and colicky +
vomiting
• Usually presents after the
rash
• 5% of cases of HSP are
associated with
intussusception
64. Palpable purpuric rash
• 50% of the cases
• typically present on the
lower extremities and
buttocks
Arthralgia or arthritis
• 25%, Joint symptoms are
migratory and usually involve
the knees and ankles with
periarticular swelling and
tenderness
• Painful edema of the feet
65. • Renal involvement
– not common
– any time in the course
– hematuria and hypertension
• Peripheral and central
nervous system, hematologic
system, and testes may also
be involved
67. Treatment
• Mainly supportive
• Hydration
• NSAIDs, such as ibuprofen
(10 milligrams/kg/dose every
6 to 8 hours) and ketorolac
• Corticosteroids (abdominal,
joint, and scrotal )
• Consultation with a pediatric
rheumatologist or
nephrologist
68. Cholecystitis
• Very rare in children
• Bile stones
– hemolytic disease (e.g., sickle
cell disease)
– total parenteral nutrition
69. • Restless and unable to lie still
• Right upper quadrant
tenderness and a positive
Murphy sign with or without
guarding
• US
70. Treatment
• Any child with evidence of
cholecystitis or cholangitis
should be admitted to the
hospital.
• IV hydration, bowel rest,
analgesics, and antibiotics, if
febrile.
71. • Antibiotics should target
gram-negative organisms and
Enterococcus.
– Ampicillin
– Gentamicin
– Ampicillin/sulbactam
– Piperacillin/tazobactam
72. Pancreatitis
• Extremely rare in infants
• Most commonly a secondary
process in children and
adolescents
• Diverse etiologies
74. Clinical Features
• Acute onset of epigastric
(occasionally periumbilical)
abdominal pain associated
with anorexia, nausea, and
vomiting.
• Dull and constant in the
epigastric region, pain may
radiate to the back
• Worsened by eating or lying
supine
75. • Risk factors
– Recent chemotherapy with L-
asparaginase
– Recent motor vehicle accident
with blunt trauma
– Past medical history of cystic
fibrosis
– Family history of pancreatitis
(hereditary)
76. • The specificity of serum
lipase for pancreatitis is
nearly 100%.
• The severity of the disease
does not correlate with the
degree of enzyme elevation.
• Obtain liver function
studies, as pancreatitis may
be secondary to liver or
biliary disease, and serum
electrolytes, including
calcium.
77. • Abdominal US is the
modality of choice to
visualize the head of the
pancreas and associated
anomalies.
78. • Children with pancreatitis usually undergo a
CT scan to rule out alternative diagnoses.
• ERCP or MRCP may be used for diagnosis and
management once the patient has been
stabilized and admitted to the hospital.
• Treatment is supportive.
79. Pneumonia
• The respiratory component
of the patient's history and
examination may be mild,
and the predominant
complaint may be abdominal
pain
• Several days of mild cough
precede the abdominal pain,
and if the child has emesis, it
is typically post-tussive in
nature.
80. • On physical examination,
specifically look for fever,
tachypnea, or hypoxia.
• The lung examination may
reveal rales, rhonchi, or
decreased air entry at the
base.
• Chest x-ray is needed to
confirm the diagnosis.
81. Group A Streptococcus Pharyngitis
• Typically affects children 4
years of age and older
• Fever, sore throat, tonsillar
erythema, and exudate with
anterior cervical
lymphadenopathy in the
absence of upper respiratory
tract symptoms.
82. • Fever and abdominal pain
with or without vomiting,
and without sore throat
• For this reason, all children
>3 years of age with
abdominal pain, especially if
febrile, deserve a thorough
oropharyngeal examination
83. • The treatment of choice for
Streptococcus pharyngitis
– a one-time IM dose of benzathine penicillin
– Amoxicillin has no advantage over penicillin other
than taste
– Erythromycin can be used in children with a
penicillin allergy.
Treatment reduces the duration of symptoms, time
absent from school, infectivity time, and rheumatic
complications when started within 10 days of
symptoms.
84. Renal Stones
• Melamine-tainted formula
was responsible for an
outbreak of urolithiasis in
children in China
• calcium (most common in
children), uric acid, or
struvite
85. • Unlike adults, children with
renal stones present with
abdominal pain less
frequently (approximately
50% of the time).
• An infant with
nephrolithiases may be
misdiagnosed as having
colic. A preschool child may
present with recurrent UTIs.
Microscopic hematuria may
87. • Melamine-induced renal stones have feeble or absent
acoustic shadows.38 Although hematuria and plain
abdominal films still appear in many clinical algorithms, the
weak LR of both tests, as shown in Table 124-7, do not
provide strong support for their use as sole predictors of
the presence of renal stones, although they may aid in the
diagnosis when considered along with the history and
physical examination of the child.39
• A basic metabolic panel with calcium, phosphorous, and
uric acid levels may help in identifying the type of stone
and underlying disease. The stone should be analyzed, if
passed, or a 24-hour urine collection for stone evaluation
should be performed.
88.
89. • ED management is centered on pain control. If
the child's pain cannot be controlled with oral
medication, the child is not tolerating oral
fluids, or there is evidence of renal
dysfunction, the child should be admitted to
the hospital. Morphine sulfate (0.1
milligram/kg every 2 to 4 hours, as needed, to
a maximum of 8 milligrams/dose IV) and/or
ketorolac (0.4 to 1.0 milligram/kg/dose every
12 hours, maximum of 30 milligrams/dose IV)
are effective analgesics for renal stones.
Depending on the type of stone, urine
alkalinization or diuretics may be added to the
treatment. Finally, if needed, a urologist may
perform extracorporeal shock wave lithotripsy
or stone removal using a rigid or flexible
endoscope.37
90.
91. Inflammatory Bowel Disease
• older children or teenagers,
and commonly the first
presentation involves severe
acute abdominal pain
92. • colicky and is associated with
diarrhea, which may be
bloody. Abdominal pain is
not the sole presenting
symptom, and IBD is
associated with fever, weight
loss, fatigue, and blood per
rectum.41 For example, 80%
of the patients with Crohn
disease have a history of
weight loss, and 20% have
93. • On physical examination,
tachycardia and hypotension
may be present secondary to
dehydration or anemia from
chronic blood loss.
Abdominal tenderness and
guarding may be localized
(especially to the right lower
quadrant in Crohn disease),
which can mimic
appendicitis. Patients with
94. • An abdominal CT is
commonly obtained to
evaluate for thickening of the
terminal ileum. Definitive
diagnosis requires endoscopy
and biopsy, and a pediatric GI
specialist should be
consulted for further
evaluation and management.
to inspect for rashes, jaundice, or bruising. of irritability such as hair tourniquets on the digits or penis, or corneal abrasion
symptoms can arise at any time in a person's life.
and may have signs of compensated or uncompensated Fever is not necessarily a presenting sign, and its absence can be helpful in distinguishing volvulus from septic shock.
The differential diagnosis for volvulus includes intussusception, duodenal stenosis or atresia (especially in infants with trisomy 21), bowel perforation from any cause, and sepsis
These studies may be normal with intermittent volvulus, and
Laboratory evaluation does not confirm the diagnosis but is useful to delineate complications of NEC (sepsis) and to narrow the differential diagnosis.
incidence of incarceration of inguinal hernias is highest in the first year of life.
simple inguinal hernia is often asymptomatic and incidentally noted as scrotal swelling or an inguinal mass during diaper change.
and short-acting agents such as fentanyl, propofol, or etomidate may be used.for elective surgical repair once the swelling has subsided
Vomiting is rare in the first few hours but usually develops after 6 to 12 hoursis present even then in only 50% of cases,8
Sausage-shaped mass on the right side of the abdomen At least one third
when the history is consistent
Us for patients with an atypical presentation in whom the diagnosis is ambiguous.prompt surgery can ensue if reduction is unsuccessful or if there is a complication
, as abdominal or sacral tumors are a rare but important cause of pathologic constipation
vomiting being more common in younger children and as the disease progresses.
. However, a low or normal WBC has consistently been shown to be correlated with decreased likelihood of appendicitis.23,24 A [LR– of 0.22].22white blood cell count (WBC) has insufficient sensitivity or specificity to confirm the diagnosis of appendicitis. Sterile pyuria can be seen with acute appendicitis
ambiguous cases, imaging with ultrasonography (Figure 124-5) or CT (Figure 124-6) are useful.
, although a mild leukocytosis is entirely compatible with nonspecific abdominal pain. Upon discharge, follow-up is essential, as other conditions may declare themselves with time.
(indistinguishable from IgA nephropathy)
Radiographic imaging is not routinely indicated unless intussusception or volvulus is suspected.
are the most common type of gallstones in children.
Pain can be insidious, with onset over a few days, then increasing exponentially over a few hours
34 Serum lipase rises within hours and remains elevated for up to 14 days.
rarely
There are no recommendations to culture or treat asymptomatic contacts of a patient with group A Streptococcus pharyngitis.36