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Abdominal Pain The Approach to the Child with Abdominal Pain David J. Worhunsky, MD Assistant Professor of Surgery Pediatric Surgery 12 September 2020 @UKPedSurg Disclosures • None Pediatric Abdominal Pain (AP) Incidence • 5‐10% of all ED visits by pediatric patients (Caperell et al, Pediatrics 2013) • 9% of childhood visits to primary care Cost • Limited data • Uruguayan study suggests 3.8% of all health care spending (Saps et al, JPGN 2008) The Problem (i.e., Educational Need) Definitive diagnosis can be challenging but life‐altering or even life‐saving • Why so difficult? 1) All children with abdominal pain (out/inpatient) only 5‐10% have an underlying organic disease (Much higher among patients presenting to the emergency department) The Problem Definitive diagnosis can be challenging but life‐altering or even life‐saving • Why so difficult? 2) Some have a limited pathophysiologic explanation (e.g., URI, pneumonia) The Problem Definitive diagnosis can be challenging but life‐altering or even life‐saving • Why so difficult? 3) Most are nonsurgical in nature, some non‐abdominal in origin URI with or without otitis or sinusitis (24%) AP of unclear etiology (15%) Gastroenteritis (15%) Constipation (9%) UTI (8%) The Problem Definitive diagnosis can be challenging but life‐altering or even life‐saving • Why so difficult? 4) Surgical etiology present in up to 20% timely identification/management can be life‐ saving/altering The Problem Definitive diagnosis can be challenging but life‐altering or even life‐saving • Why so difficult? 5) Differential diagnosis is broad and can seem overwhelming… Can we simplify this? Differential Diagnosis Based on Age Any Age Newborn 2‐12 mo 1‐5 yo 5‐12 yo > 12 yo UTI UTI UTI Constipation Colic Colic Functional Functional Non‐urgent Group A Strep Group A Strep Group A Strep Urgent URI HSP HSP DKA Non‐surgical Acute gastro DKA DKA Duplication cyst Inguinal hernia Duplication cyst Abdominal/RP tumor Biliary colic Biliary colic Referral Abdominal/RP tumor IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma Adapted from Smith and Fox. Emerg Med Clin N Am 2016 Differential Diagnosis Based on Age Any Age Newborn 2‐12 mo 1‐5 yo 5‐12 yo > 12 yo UTI UTI UTI Constipation Colic Colic Functional Functional Non‐urgent Group A Strep Group A Strep Group A Strep Urgent URI HSP HSP DKA Non‐surgical Acute gastro DKA DKA Duplication cyst Inguinal hernia Duplication cyst Abdominal/RP tumor Biliary colic Biliary colic Referral Abdominal/RP tumor IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma Adapted from Smith and Fox. Emerg Med Clin N Am 2016 Differential Diagnosis Based on Age Any Age Newborn 2‐12 mo 1‐5 yo 5‐12 yo > 12 yo UTI UTI UTI Constipation Colic Colic Functional Functional Non‐urgent Group A Strep Group A Strep Group A Strep Urgent URI HSP HSP DKA Non‐surgical Acute gastro DKA DKA Duplication cyst Inguinal hernia Duplication cyst Abdominal/RP tumor Biliary colic Biliary colic Referral Abdominal/RP tumor IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma Adapted from Smith and Fox. Emerg Med Clin N Am 2016 Differential Diagnosis Based on Age Any Age Newborn 2‐12 mo 1‐5 yo 5‐12 yo > 12 yo UTI UTI UTI Constipation Colic Colic Functional Functional Non‐urgent Group A Strep Group A Strep Group A Strep Urgent URI HSP HSP DKA Non‐surgical Acute gastro DKA DKA Duplication cyst Inguinal hernia Duplication cyst Abdominal/RP tumor Biliary colic Biliary colic Referral Abdominal/RP tumor IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma Adapted from Smith and Fox. Emerg Med Clin N Am 2016 Goals for this talk IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma Hernia Examine and refer Trauma/NAT Refer to center with pediatric trauma/forensic peds Obstructions Refer to center with pediatric GI/surgical expertise Neonatal intestinal obstruction Refer (2+ day conference) Goals/Objectives for this Talk (Outline) IRA/volvulus Appendicitis Incarcerated hernia Appendicitis Urgent Neonatal Ovarian torsion Meckel diverticulitis Intussusception Intussusception Ovarian torsion obstruction Ectopic pregnancy Surgical Bowel obstruction Trauma/NAT Appendicitis (comp) Biliary tract (comp) Trauma/NAT Biliary tract (comp) Evaluation Perforated viscus IBD IBD Trauma 1) Intestinal rotation abnormality (IRA) +/‐ volvulus 2) Appendicitis 3) Intussusception 4) Ovarian torsion 5) Biliary tract disease 6) Constipation Epidemiology of Intestinal Rotation Abnormality Incidence varies in the literature Autopsy series suggest an incidence of 5/1000 or 0.5% Incidence of volvulus only 1/6000 or 0.017% • Only 1/30 patients with malrotation will develop volvulus Nomenclature Old terminology: Malrotation Newer terminology: Intestinal rotation abnormality • More inclusive Nonrotation Incomplete rotation (malrotation) with or without volvulus Reverse rotation Paraduodenal and paracolic hernias Clinical Presentation Bilious emesis in a neonate is a surgical emergency until proven otherwise • Must rule out midgut volvulus Surgical cause of bilious emesis found in 38% of neonates Know that 60% of work‐up will be negative! Clinical Presentation Bilious emesis in a neonate is a surgical emergency until proven otherwise • Must rule out midgut volvulus What counts as bilious? • “It looks green to me, how about to you?” • “I can’t tell if it is more green or yellow.” • If “bilious” or “green” is mentioned or even questioned volvulus until proven otherwise Clinical Presentation Bilious emesis due to malrotation/volvulus: • Due to extrinsic obstruction of duodenum (twisted bowel or Ladd bands) Late signs (usually associated with necrotic bowel) • Abdominal distension • Hematemesis • Hematochezia • Hemodynamic instability Assessment Start with clinical exam: • High suspicion Operative exploration • Neonate in extremis Operative exploration • Clinical deterioration Operative exploration • Inability to obtain upper GI Operative exploration Clinically stable with suspicion urgent Upper GI contrast study • Does not wait until morning • No plain radiograph (XR) findings that can exclude IRA/volvulus Upper Gastrointestinal (GI) Series Gold standard 4 Components to a Normal UGI Study 1 Contrast leaves stomach from patient’s left to right (AP view) 2 Contrast moves posteriorly through retroperitoneal 2nd portion (lateral view) 3 Contrast crosses midline from patient’s right to left (AP view) 4 DJ junction located at same height as duodenal bulb/pylorus (AP/lateral views) Requires technical expertise Acute Appendicitis Incidence • 1 per 1000 in the U.S., overall lifetime risk around 8% with peak in teen years • Most common surgical emergency in children • ~75,000 appendectomies performed annually in children in the U.S. Cost • Mean cost of $9000; higher when complicated/perforated Pathophysiology of Acute Appendicitis Mostly thought to be due to obstruction of the appendiceal lumen • Lymphoid hyperplasia, fecoliths, parasites (e.g., enterobius vermicularis), tumors Luminal obstruction may not account for all cases Final pathway is common regardless of cause: invasion of appendiceal wall by intraluminal bacteria Pathophysiology of Acute Appendicitis Uncomplicated (early) Appendicitis Complicated Appendicitis Pathophysiology of Acute Appendicitis Uncomplicated (early) Appendicitis Complicated Appendicitis Preoperative antibiotics alone 4‐10 days of antibiotics Home same day or next 7‐10 day hospital stay <2% complication rate 20% complication rate Limited activity restrictions Emesis/diarrhea common Back to school in 2‐3 days Out of school for 2‐3 weeks Phone follow‐up Close clinic follow‐up Pathophysiology of Acute Appendicitis Uncomplicated (early) Appendicitis Complicated Appendicitis Two different diseases with very different clinical course How do we accurately diagnose appendicitis? How do we not miss early appendicitis? How do we triage complicated appendicitis? Diagnosis of Acute Appendicitis Appendicitis is a Clinical Diagnosis! Labs History WBC Acute onset Neutrophils Will not improve Exam Imaging CRP Periumbilical RLQ Focal RLQ tenderness Ultrasound Procalcitonin
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