Abdominal Pain and vomiting in Children

Erick Kan

Abdominal Pain

• Frequent reason for children to be taken to the doctor

• The causes are many and diverse– Surgery– Medical origin

Abdominal pain in the first 3 months of life

• Surgical causes ;– Malrotation with volvulus

• Vomiting, abdominal pain, abd distention and constipation

• Medical– Infantile colic

• Common in the first few weeks of life• The cause is poorly understood• Infants; screaming, draw up the legs and is unable to be comforted• No vomiting, normal bowel action, thriving well infants• The colic almost invariably disappears by the fourth month of age• Treatment is supportive

– Gastro oesophageal Reflux

Abdominal pain later in the first year

• Intussusceptions• Distal ileum telescopes into adjoining distal bowel, resulting intestinal

obstruction• More likely in the infants 3 – 18 months• Suddenly develops periodic screaming attacks of pain and vomiting,

The infants are pale, lethargic and unwell• Congestion of the intussusceptum may lead to passage of

bloodstained or red currant stool• A vague mass may be felt in the right or left upper quadrants of the

abdomen• X ray shows unusual bowel gas distribution or features of obstruction• Barium enema must be performed unless the child has peritonitis• Treatment ; Gas enema is the treatment of choice• Surgery : Enema reduction has failed• Clinical evidence of necrotic bowel : peritonitis, sepsis

» Evidence of pathologic lesion• DD; gastroenteritis, volvulus, band from Meckel diverticulum,Hernia

strangulata

Acute abdominal pain in older children

• Children in this age often present with abd pain without no specific cause is found

• Constipation and mesenteric adenitis are probably the most common non surgical causes

Acute abdominal pain in older children

• Acute appendicitis– May occur at any age, but rare under 5 years of age– The most important and consistent features is localised abd

pain.– The pain may be intermitten and colickly initially, situated in the

epigastrium or periumbilical region, but soon shifts to the right iliac fossa. Pain in the right iliac fossa

– Vomitting, temp slightly eleveted– PE : Tenderness and guardiang localised to the right iliac fossa– Rectal examination is only indicated if a pelvic appendix or pelvic

collection is suspected– Lab and radiology are rarely helpful– DD; Mesenteric adenitis (meckel diverticulitis), strangulated

inguinal hernia, renal colic,pyelonephritis, HSP,constipation, cholecistitis, pancreatitis and UTI etc

Acute abdominal pain in older children

• Gastro Oesophageal reflux– Common in infancy, sometimes persist into

later childhood– Symptoms of belching, acid regurgitation and

intermittent vomiting– Sign : substernal and epigastric pain– Dx : Oesophageal PH monitoring,

Oesophagoscopy and biopsy– Tx : Medical : H2 receptor antagonis

– Surgical correction : Fundoplication

Recurrent abdominal pain in children

• Personality of the child

• Family environment

• Medical ; inflammatory bowel disease,malabsopstion

• Surgery

Vomiting in the neonatal period

• In the early weeks of life, many normal newborn regurgitate after feeds.– Medical

• Cerebral hypoxia• Subdural hematoma• Hypoglicemia• Systemic infection• Malrotation• Renal disease• Adrenal insuficiency• Inborn metabolic error

Vomiting in the neonatal period

Surgery (Bowel obstruction) : • In doudenal obstructions, vomiting appears early

and is bile stained• Obstruction beyond the duodenum,vomiting

commence slightly later and is associated with abd distension

– TRIAD• Bile stained vomiting• Failure to pass meconium• Abdominal distension

Vomiting in the neonatal period

• Surgery (CAUSES)– Neonatal bowel obstruction– Hirschprung’s disease– Necrotising enterocolitis– Meconium ileus– Malrotation with volvulus– Atresia - duodenal atresia/stenosis, jejunal atresia,

ileal atresia– oesophageal atresia– Imperforate anus– Others – intestinal duplication, antral webs etc

Vomiting in infancy

• A common non specific symptom in infancy

• Infection

• Malabsorption

• Gastroenteritis

• Intussusception (invagination)

• Strangulated inguinal hernia

Vomiting in infancy

• GER :– The most common cause of vomiting in

infancy– These infants usually thrive well, PE reveals

no abnormality– Dx is made from hystory, can be confirm by

barium swallow or continous 24 hours oesophageal PH monitoring

– Occasionaly, the child may fail to thrive or suffer repeated aspiration

Vomiting in infancy

• Pyloric stenosis– The onset is sudden, between the second and sixth

week of life.– The vomiting is forceful and rapidly become projectile– The vomitus is not bile stained, but may contain

altered blood– The dx is made clinically by feeling the thickened

pylorus (pyloric tumor) in the midline epigastrium– Pyloric stenosis can also be shown on Ultrasound and

barium meal– Tx ; Pyloromyotomy

Vomiting in Older children

• Usually associated with infection• The possibility of an intracranial neoplasm

should always be considered with a child with unexplained vomiting

• Migraine ; pallor and vomiting• Acute appendicitis and peritonitis• Poisoning : vomiting and respiratory and

circulatory collapse• Psychologycal causes :absence of abnormal

physical signs• Cyclical vomiting

Management

• Establish intravenous access, and measure electrolytes if the patient appears dehydrated, and cultures of blood and stool if potentially septic.

• Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)

• Keep the patient fasted until surgical assessment

• Provide adequate analgesia • Place a nasogastric tube if bowel obstruction

Notes• Acute appendicitis must be considered in any child with severe

abdominal pain. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical - no laboratory or radiological tests are required.

• The peak age for intussusception is 6-12 months. Plain AXR may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflations or barium enema.

• Vomiting is rarely due to constipation.

• Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (eg. family, school issues) need to be considered. These children should be referred for general paediatric assessment.