Abdominal pain in children
Prof. (Dr. Ms.)Sushmita Bhatnagar
B.J.Wadia Hospital for childrenBombay hospital
Joint Secretary - Association of Medical Consultants
Abdominal pain
ACUTECHRONIC
Abdominal pain is one of the most common reason for which parents take the child to a doctor.
Surgical causes of abdominal pain
• Intestinal obstruction
• Perforation of bowel
• Infections - Gall bladder, appendix, meckel's diverticulum,
• Constipation - due to Hirschsprung's disease
• Volvulus
• Intussusception
• Kidney stones
• Chronic Pancreatitis
• Tumors/cysts
• Hernia
• Trauma
What is significant pain?
ANY PAIN WHICH INTERRUPTS ACTIVITY OF CHILD AND DISTURBS SLEEP
RED FLAGS1. Weight loss2. Failure to thrive3. Fever with pain4. Severe diarrhoea/vomiting or both5. Family history6. Severe right lower abdominal pain
Abdominal pain: evidence-based data
Abdominal pain: appendicitis or not?
Abdominal pain: evidence-based data
• Appendicitis– Incidence
• 11/10,000 population per year• Highest in males 10-14 years (27/10,000)• Highest in females 15-19 years (20/10,000)• Male:female ratio: 1.4:1• Life time risk:
– Males: 8.6%; Females: 6.7%
• Perforation: 18% ; highest in < 5 and >65 y.o.
Appendicitis: evidence-based data
• Signs and symptoms– Neonates:
• Abdominal distension• Vomiting• Fever• Hypothermia• Respiratory distress
Appendicitis: evidence-based data
• Signs and symptoms– 3 years and under
• Diffuse abdominal pain• Fever• Vomiting• Diarrhea• Abdominal distension• Diffuse abdominal tenderness
Appendicitis: evidence-based data
• Signs and symptoms– Older children
• Abdominal pain• Vomiting• Fever• Anorexia• Pain with movement or cough• Localized RLQ tenderness• Diffuse/rebound tenderness
Abdominal pain: evidence-based data
• Radiologic studies– Ultrasound
• Appendiceal diameter or >6 mm• Target sign with 5 concentric layers• Distension or obstruction of the lumen• High echogenicity around the appendix• Pericecal or perivesical fluid• Appendix wall > 2 mm• Absence of appendiceal peristalsis
– Can confirm but not exclude appendicitis
Abdominal Pain: Evidence-based Data
• Radiologic studies– CT scan
• Enlarged appendiceal diameter (> 6 mm)• Appendiceal wall thickening (> 1 mm)• Periappendiceal inflammatory changes
including fat streaks, phlegmon, fluid collection, and/or extraluminal gas
• Other findings: appendicalith, abscess, arrowhead sign, or cecal bar
– Sensitivity 87 – 100 %, Specificity 89 – 98%
Treatment of appendicitis
• Conservative management– Antibiotics – IV hydration
• Surgery– Laparoscopic– Open
Treatment of appendicitis• Conservative management
– IV and oral antibiotics• Cefotaxime + (ofloxacin +tinidazole)• Ciprofloxacin and metronidazole + (ciprofloxacin +
tinidazole)
– Advantages• Less pain• Shorter recovery time• Avoid complications of surgery and anesthesia
Functional abdominal Pain (FAP)Real pain; not faking or malingeringWhy does it occur
abnormal bowel reactivity to physiologic stimuli (meal, gut distention, hormonal), noxious stressful stimuli (inflammatory procees), psychological stressful stimuli (parental seperation, anxiety) Leading to the development of visceral hyperalgesia
Symptoms of chronic or recurrent abdominal pain in children where there is no identifiable structural, inflammatory, infectious, neoplastic or metabolic cause.
FAP is a POSITIVE diagnosis and not a failure to the true cause of the pain
Chronic Abdominal Pain in children
One of the most common complaints in children and adolescents13% of Middle School aged; 17% of High School aged children experience weekly abdominal pain (Hyams JS et al J Pediatr. 1996)Functional Abdominal Pain was found in 15% of school aged children (Youssef NN. Clinical Pediatrics 2007)10-15% of school age children seek help
10-15% more have symptoms but never seek medical attention10% have an organic causeFemales>malesHigher in > 10 years oldPrevalence increases during school, not vacations
Drug Action Indication Risk
PeppermintOil
? Smooth MuscleRelaxation
IBS None
FiberStoolBulking
ConstipationPredominant
Bowel obstruction
Lactose FreeDiet / Lactaid
EliminatesLactose
Lactase Deficiency None
Probiotics Replacement of “Toxic Bacteria”
S/P Antibiotics / Enteritis
Systemic Translocation
Drug Action Indication Risk
PEG Stool Softner Constipation Dehydration / Bowel Obstruction
H2 Blocker Histamine Antagonist Dyspepsia Tachyphalaxis after
2 weeks
PPI Inhibits Acid Production
Dyspepsia / PUD
?Osteopenia/Bacterial
Overgrowth/ Gastronoma
Serotonin 2A Antagonist
Serotonin Blockade
Abdominal Migraine /
Anxiety
Drowsiness, Dizziness
Anti - Tricyclics Anti - Depressant Depression Dependancy / Suicide / Arrythmias
Drug Action Indication
Mylicon Anti - Flatulance Excessive/Discomfort/ Gas Pains
Bentyl Anti - Spasmodic (AS) Spasms / Cramping
Levsin AS, Sedation Spasms / Cramping
DonnatolAS, Sedation Spasms / Cramping
Drotaverine AS Spasms/ Cramping
Thank you!