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Published on : Mar 14, 2014
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Slide 1 - ABDOMINAL PAIN in the PEDIATRIC PATIENT Tim Weiner, M.D. Dept. of Surgery University of North Carolina at Chapel Hill
Slide 2 - 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
Slide 3 - 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
Slide 4 - Diagnosis by Location gastroenteritis early appendicitis PUD pancreatitis non-specific colic early appendicitis constipation UTI pelvic appendicitis biliary hepatitis appendicitis enteritis/IBD ovarian spleen/EBV constipation non-specific ovary
Slide 5 - 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
Slide 6 - The Abdominal Examination breath sounds Murphy’s sign “sausage” Dance’s sign rebound tender at McBurney’s point cecal “squish” hernias torsion breath sounds spleen edge constipation Rovsing’s sign
Slide 7 - 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
Slide 8 - 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
Slide 9 - 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
Slide 10 - Further Work-up CBC and differential Urinalysis X-rays (KUB, CXR) US Abdominal CT Stool cultures Liver, pancreatic function tests (Rehydrate, ?antibiotics, ?analgesiscs)
Slide 11 - 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
Slide 12 - Operate NOW Vascular compromise malrotation and volvulus incarcerated hernia nonreduced intussusception ischemic bowel obstruction torsed gonads Perforated viscus Uncontrolled intra-abdominal bleeding
Slide 13 - Operate SOON Intestinal obstruction Non-perforated appendicitis Refractory IBD Tumors
Slide 14 - 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)
Slide 15 - 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
Slide 16 - 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
Slide 17 - The “Medical Bellyache” Pneumonia Mesenteric adenitis Henoch-Schonlein Purpura Gastroenteritis/colitis Hepatitis Swallowed FB Porphyria Functional ileus UTI Constipation IBD “flare” rectus hematoma
Slide 18 - 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
Slide 19 - 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
Slide 20 - 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
Slide 21 - 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
Slide 22 - 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.”