Introduction

Why is abdominal pain important to pediatric surgeons?

Acute abdominal pain in children is one of the more frequent reasons for emergency room visits and pediatric surgical consultations. Acute appendicitis was responsible for nearly 90,000 pediatric emergency department visits during 2013 in the United States [1]. Both medical and surgical diagnoses present with acute abdominal pain and the incidence of these varies with age and gender.

What is the general approach to optimize diagnostic testing?

Through the assessment of symptoms (duration, intensity), physical exam findings and consideration of the incidence of specific etiologies, the differential diagnosis of acute abdominal pain can be narrowed to facilitate efficient use of diagnostic testing. This approach leverages pretest probability to increase the diagnostic yield of laboratory tests and imaging studies.

content in this topioc is referenced in SCORE Abdominal Pain overview

Epidemiology

The most common surgical cause of abdominal pain in children is appendicitis. Other causes may be suspected based on symptoms and age.

What are the most common surgically treated causes of pediatric acute abdominal pain?

The most common surgical cause of acute abdominal pain in children is acute appendicitis. Within specific age groups other medical and surgical causes of acute abdominal pain should also be considered.

Common causes of pediatric abdominal pain

Age group

Diagnoses

any age

intestinal malrotation/volvulus

mechanical bowel obstruction

  • adhesive
  • intraluminal – foreign body (non-neonate/infant), distal intestinal obstruction syndrome (cystic fibrosis), constipation

Meckel diverticulitis

neutropenic enterocolitis

perforated viscus

newborn

neonatal obstruction, congenital lesion internal hernia/volvulusomphalomesenteric duct remnant, duplication cyst, mesenteric cyst

necrotizing enterocolitis

incarcerated inguinal hernia

infant

intussusception

incarcerated inguinal hernia

nonaccidental abdominal trauma

Hirschsprungassociated enterocolitis

abdominal/retroperitoneal neoplasm

toddler

intussusception

appendicitis– complicated

non-accidental abdominal trauma

Hirschsprungassociated enterocolitis

abdominal/retroperitoneal neoplasm

pneumonia

pre-adolescent child

appendicitis

  • acute
  • complicated

gallstone complications – pigment gallstones

  • cholecystitis
  • choledocholithiasis
  • gallstone pancreatitis

epiploic fat torsion/infarction

omental torsion/infarction

Henoch-Schonlein purpura

viral gastroenteritis

ovarian torsion (female)

adolescent

appendicitis

gallstone complications – pigment and cholesterol gallstones

  • cholecystitis
  • choledocholithiasis
  • gallstone pancreatitis
  • biliary dyskinesia

gastroesophageal reflux

inflammatory bowel disease

ovarian pathology (female)

  • torsion
  • ruptured cyst

pelvic inflammatory disease(female)

perforated gastric/duodenal ulcer

epiploic fat torsion/infarction

omental torsion/infarction

Henoch-Schonlein purpura

urinary tract infection

urolithiasis

Several factors such as season, region and race/ethnicity account for the variable incidence of some diagnoses. Viral infections associated with gastrointestinal symptoms typically occur seasonally and regionally [2]. Vaccination and indirectly, access to care may impact disease incidence. For example, rotavirus infection is most prevalent in areas where vaccination rates are low [3]. Race and/or ethnicity impacts the prevalence of conditions which indirectly lead to acute abdominal pain. Hemoglobinopathies which are more common in particular races or ethnic groups, such as sickle cell disease in African-Americans or thalassemia in individuals of Mediterranean descent, predispose to formation of pigment gallstones which in turn may cause acute abdominal pain (biliary colic, acute cholecystitis, choledocholithiasis, or gallstone pancreatitis).

Presentation

The initial presentation in patients with abdominal pain can be associated with obstruction, inflammation or both.

What features aid in characterizing abdominal pain?

When considering the underlying cause of acute abdominal pain in children the presenting symptoms, physical examination findings and initial laboratory studies can be grouped into patterns associated with intestinal obstruction, inflammatory processes or mixed obstructive/inflammatory presentation. By determining the pattern of abdominal pain and considering age, gender and comorbidities, the likely diagnoses can be narrowed. Confirmatory laboratory testing, imaging and initial treatment can then be tailored to the leading diagnoses.

Abdominal pain pattern

Diagnoses

obstruction

congenital

intestinal malrotation/volvulus

internal hernia/volvulus

omphalomesenteric duct remnant/Meckel diverticulum

intestinal duplication cyst

mesenteric cyst

incarcerated inguinal hernia

intraluminal obstruction

functional obstruction

acquired

intussusception

adhesive bowel obstruction

Crohn disease partial obstruction, stricture

superior mesenteric artery syndrome

intraluminal obstruction

  • foreign bodies
  • Henoch-Schonlein purpura
  • constipation

inflammation

appendicitis

  • acute
  • complicated/perforated

gallstone complications

  • cholecystitis
  • choledocholithiasis/cholangitis

pancreatitis

pelvic inflammatory disease

other intestinal

perforated viscus

peptic ulcer disease

foreign bodies

nonaccidental abdominal trauma

pneumonia

viral mesenteric adenitis/gastroenteritis

obstruction and inflammation

intestinal obstruction with ischemic/infarcted bowel

complicated appendicitis

inflammatory bowel disease

functional obstruction

other

abdominal/retroperitoneal neoplasm

ovarian pathology

  • torsion
  • ruptured cyst

epiploic fat torsion/infarction

omental torsion/infarction (male>female)

biliary dyskinesia

gastroesophageal reflux

What are the critical components of the history when evaluating a child with abdominal pain?

Because characteristics of abdominal pain are challenging to articulate the nature of the pain can be conveyed through a series of questions. The parents of younger children can provide insight based on their observations. It is often difficult for children younger than ten years to pin point their symptoms and they may only describe a generalized feeling of pain, nausea and discomfort. Relevant features of abdominal pain include

  • abdominal pain features
    • pattern – constant, intermittent
    • character – dull, sharp, crampy
    • intensity – increasing, stable/constant vs intermittent, decreasing; impact on normal activities
    • location – migratory or consistent location, distribution
  • associated symptoms
    • nausea, emesis – emesis color
    • diarrhea, constipation, obstipation; stool color/presence of blood
    • constitutional – fever, malaise, lethargy
    • other – cough, sore throat, dysuria
  • duration (time from onset) and sequence of symptoms
  • exacerbating and/or relieving factors

Emesis (especially if bilious), obstipation and intermittent abdominal pain imply presence of intestinal obstruction or disordered motility such as an ileus. Nonspecific symptoms such as fever, malaise and constant pain in a persistent location may be caused by inflammatory conditions. Cough, sore throat or dysuria suggests a potential medical cause of abdominal pain. Also important to assess is a prior history that includes comorbidities, previous symptoms, operations, ill contacts, recent travel and any trauma.

What are the critical parts of the physical exam when evaluating a child with abdominal pain?

A careful physical exam is essential but potentially challenging especially in young children. Observation of a child’s appearance and movement while obtaining his or her history provides insight into the degree of discomfort. Utilizing some means of distracting the sick child may be the only way to obtain a good abdominal exam. Warming the hands or examining younger children and infants while still clothed or in their parents arms may be necessary to help the child relax in order to allow the exam to proceed. Pertinent findings include distension and pain with palpation and/or percussion while noting the degree of tenderness and location. Adjunct maneuvers include assessing costovertebral angle tenderness and referred pain from costochrondritis as well as the presence of Rovsing, obturator and psoas signs. Other physical exam components may also support a non-abdominal source for symptoms such as diminished breath sounds for pneumonia or pharyngeal erythema/tonsillar enlargement with Streptococcal pharyngitis.

Assessment

Laboratory tests and imaging should be tailored to the history and exam findings.

What laboratory tests can help determine the type of abdominal pain and leading diagnoses?

Laboratory tests can help categorize the abdominal pain as possibly related to intestinal obstruction, inflammation, a combination of inflammation and obstruction or neither. Elevatations of white blood count (especially with neutrophilia), C-reactive protein or the erythrocyte sedimentation rate support an inflammatory process such as appendicitis, Meckel diverticulitis or intestinal perforation/peritonitis. Direct hyperbilirubinemia, elevated alkaline phosphatase or gamma-glutamyl transferase (GGT), mildly elevated aspartate transaminase (AST) and alanine transaminase (ALT) are suggestive of biliary obstruction whereas marked transaminase elevation implies hepatic inflammation or hepatocellular damage (ischemia/reperfusion, toxin exposure). Amylase and lipase elevation are encountered with pancreatitis and the urinalysis may point to a genitourinary source.

Type of gall bladder disease

Presentation

biliary colic

intermittent mild to moderate right upper quadrant (RUQ) pain

nausea alone may be presenting symptom

normal labs

cholecystitis

severe right upper quadrant pain/tenderness, fever

increased alkaline phosphatase, GGT, WBC

choledocholithiasis

right upper quadrant pain, jaundice

increased bilirubin (direct)/AST/ALT/alkaline phosphatase, GGT

fever (cholangitis)

gallstone pancreatitis

right upper quadrant/epigastric pain, radiation to back

increased amylase, lipase

transient increase in bilirubin (direct)/AST/ALT/ alkaline phosphatase

What imaging is most appropriate for the leading diagnoses?

The potential diagnostic contribution of imaging can be increased by considering the potential relevant findings and predictive value of the study for the leading diagnosis.

  • abdominal radiograph
    • intestinal perforation
    • intestinal obstruction, ileus
  • upper gastrointestinal series (UGI)/small bowel follow-through (SBFT)
    • intestinal malrotation
    • mechanical bowel obstruction
      • superior mesenteric artery syndrome
      • adhesive bowel obstruction
    • Crohn disease
  • abdominal/pelvic ultrasound
    • intussusception
    • appendicitis
    • abdominal/retroperitoneal/pelvic mass
      • intestinal duplication cyst
      • mesenteric cyst
      • neoplasm
    • gall bladder disease
    • renal pathology
    • ovarian pathology (cyst, torsion)
  • abdominal/pelvic computerized tomography (CT)
    • intestinal perforation
    • intestinal obstruction
    • appendicitis (American College of Radiology has recommended use of ultrasound prior to CT for evaluation of right lower abdominal pain in children to minimize radiation exposure [4])
    • abdominal/retroperitoneal/pelvic mass
      • intestinal duplication cyst
      • mesenteric cyst
      • neoplasm
    • Crohn disease, colitis
    • pancreatitis
    • hepatic pathology
    • renal pathology
  • abdominal/pelvic magnetic resonance imaging (MRI)/enterography
  • abdominal MRI/magnetic resonance cholangiopancreatography
    • hepato-pancreatico-biliary pathology

Image modality

Key findings

Associated diagnoses

abdominal radiograph

normal bowel gas pattern

constipation

appendicitis

malrotation with volvulus

gastric distension

gastroenteritis

superior mesenteric artery syndrome

loss of psoas shadow

focal ileus

scoliosis

fecalith

appendicitis

bowel dilation predominantly left upper quadrant

proximal small bowel obstruction

gastroenteritis

pancreatitis

bowel dilation except right lower quadrant

distal small bowel obstruction

paucity of gas in right lower quadrant/ascending colon

adipose rose sign

intussusception

displacement of bowel loops

abdominal/retroperitoneal mass

diffuse bowel dilation

gastroenteritis or other ileus (pneumonia, urinary tract infection)

colonic air fluid levels

gastroenteritis

colitis

pneumatosis

necrotizing enterocolitis

neutropenic enterocolitis

colon cut off sign

Hirschsprung associated enterocolitis

appendicitis

pneumoperitoneum

perforated viscus (gastric/duodenal ulcer, Meckel diverticulum, intestinal perforation due to non-accidental trauma, perforated appendicitis (rare))

Upper gastrointestinal series +/- small bowel follow through

delayed passage of contrast from stomach

gastroenteritis

bird beak in proximal duodenum

malrotation with volvulus

dilated proximal duodenum, delayed contrast passage across vertebral body

superior mesenteric artery syndrome

Contrast enema

inspissated stool

distal intestinal obstruction syndrome (DIOS)

saw toothing of colon

colitis

Ultrasound

target sign

intussusception

non-compressible tubular structure in right lower quadrant (greater than 7 mm diameter)

appendicitis

loculated/complex pelvic fluid with hyperemia

complicated appendicitis

pelvic inflammatory disease

inversion of mesenteric vessels

malrotation

gall bladder wall thickening, pericholecystic fluid, sonographic Murphy sign

cholecystitis

bile duct dilation

choledocholithiasis

pancreatic edema, peripancreatic fluid

pancreatitis

pelvic fluid, decompressed ovarian cyst

ruptured ovarian cyst

ovarian enlargement, hypoperfusion

ovarian torsion

cystic lesion (thick walled – bowel signature)

intestinal duplication cyst

cystic lesion (thin walled)

mesenteric cyst

echogenic fat - ovoid

epiploic fat torsion

echogenic fat – swirling blood vessels anterior to bowel, right greater than left

omental torsion

Computerized tomography/magnetic resonance imaging

pancreatic edema, hypoperfusion, peripancreatic fluid

pancreatitis

bowel wall thickening, phlegmon, abscess

Crohn disease

small bowel dilation, transition zone

intestinal obstruction

whirlpool sign

intestinal volvulus

What is the role of clinical scores in determining the diagnosis?

The Alvarado Score [5] and Pediatric Appendicitis Score (PAS) [6] combine symptoms (abdominal pain migration, anorexia, nausea/vomiting), signs (right lower quadrant tenderness, signs of peritoneal irritation by rebound or percussion tenderness, fever) and laboratory results (white blood count, percent neutrophils or absolute neutrophil count) to estimate likelihood of appendicitis in children.

In the initial report regarding the PAS, Samuels noted the prospective sensitivity to be 1, specificity 0.87, positive predictive value 0.90 and negative predictive value 1 with a cutoff point of greater than or equal to eight for appendicitis and less than or equal to five for not being appendicitis. Patients scoring six to seven were unclear [6]. Alvarado did not report initial thresholds for high or low likelihood of appendicitis. Multiple investigators have studied potential cut points primarily in children’s hospitals [7][8]. The scores may perform differently in a community hospital setting. Most studies report a mid-range of scores which lack sufficient predictive value. Rather these scores are used to indicate need for further studies (e.g. imaging).

Appendicitis clinical scores

Alvarado

PAS

Predictor

Detail

Value

Detail

Value

symptoms

migration

1

1

anorexia

1

1

nausea-vomiting

1

1

signs

tenderness right lower quadrant

2

2

rebound pain

rebound

1

cough/ percussion/ hopping

2

fever

≥37.3 C

1

≥38.0 C

1

laboratory

leukocytosis

≥10,000/mm3

2

≥10,000/mm3

1

neutrophilia

≥75%

1

≥7500/mm3

1

total

10

10

Additional attempts to develop predictive tools have been hampered by poor inter-rater reliability for examination findings [9]. Kharbanda developed an algorithm to identify children at low risk for appendicitis with the goal of eliminating unnecessary diagnostic imaging for children [10]. The algorithm was refined and tested prospectively at multiple institutions and the components included absolute neutrophil count (ANC), right lower quadrant (RLQ) tenderness and pain with walking, jumping or coughing.

  • ANC ≤6750/mm3 and
    • No maximal tenderness in RLQ
      • or
    • Maximal tenderness in RLQ, but no abdominal pain with walking/jumping/coughing

For children designated as not having appendicitis the sensitivity was 98.1% (97.0 to 98.9), specificity 23.7% (21.7 to 25.9), negative predictive value 95.3% (92.3 to 97.0) and positive predictive value 44.9% (42.8 to 47.0).

Medical Treatment

Dehydrated patients should be resuscitated during the initial evaluation and throughout serial clinical monitoring.

How should patients be managed while the diagnosis is uncertain?

When the etiology accounting for acute abdominal pain is not clearly established during the initial evaluation serial observation of a child’s symptoms and physical exam evolution can be valuable to distinguish surgical from nonsurgical etiologies. Outpatient observation is reasonable for the child with mild symptoms and easy access to medical care. Those children whose symptoms are more severe or worrisome as well as those with poor access to medical care require hospitalization with administration of intravenous fluids and bowel rest (especially if symptoms follow an obstructive pattern, i.e. abdominal distension, emesis, obstipation). Improvement in symptoms points to a self limited process (such as viral gastroenteritis), whereas failure to improve and a worsening clinical exam indicate a need to further investigate the source of abdominal pain.

What are the medically treated causes of acute abdominal pain which are difficult to distinguish from those treated surgically?

The differential diagnosis of a child with acute abdominal pain includes disorders which are primarily treated nonoperatively. By organ system/region these include

  • abdominal/gastrointestinal
    • viral gastroenteritis, mesenteric adenitis
    • infectious colitis
    • Henoch-Schonlein purpura
    • inflammatory bowel disease (Crohn, ulcerative colitis)
    • pancreatitis
    • omental, epiploic fat infarct
  • genitourinary
    • urinary tract infection
    • pelvic inflammatory disease
    • ovarian cyst
  • on-abdominal
    • Streptococcal pharyngitis
    • pneumonia (right lower lobe)

Indications for Surgery

Patients with evidence of complete intestinal obstruction, peritonitis or a diagnosis of a surgical etiology should be explored.

What are the indications for operative exploration?

Indications for operative exploration can be categorized in the context of presenting symptoms and suspected diagnosis:

  • evidence of complete bowel obstruction, intestinal volvulus, or vascular compromise of abdominal structures
    • malrotationwith bilious emesis
    • closed loop bowel obstruction (e.g. postoperative adhesions, omphalomesenteric duct remnant, intestinal duplication cyst)
    • non-reducible intussusception
    • ovarian torsion
  • acute abdomen/peritonitis, intestinal perforation
  • diagnosis of surgical etiology
    • appendicitis
    • cholecystitis, complicated gallstone disease (choledocholithiasis, gallstone pancreatitis)
    • Meckel diverticulitis
    • intestinal mass (duplication cyst, mesenteric cyst, intussusception with suspected pathologic lead point)

Surgical intervention for omental epiploic fat torsion/infarction is controversial.

The nonoperative treatment of acute appendicitis is currently being investigated (see Appendicitis Medical Treatment). The need for interval appendectomy after nonoperative treatment of complicated appendicitis is also under investigation (see Appendicitis Indications for Surgery).

Surgical Decision Making

What is the role of diagnostic laparoscopy?

Despite the availability of advanced imaging the cause for acute abdominal pain is not always identified. In cases where symptoms are persistent or worsening, laparoscopy may serve as a diagnostic adjunct and provide potential for definitive treatment when a surgical etiology is identified [11].

Research and Future Directions

What decision aids might expedite the diagnosis of appendicitis?

Because of the varied presentation and potential diagnosis associated with pediatric acute abdominal pain, methods to increase diagnostic efficiency (speed, reduction of abdominal CT scans, accuracy) have been investigated. Expediting diagnosis of acute appendicitis has been explored both through serologic testing and integration of diagnostic methods (clinical scores and imaging). Biomarkers such as urine leucine–rich α-2-glycoprotein (LRG), serum C-reactive protein (CRP) and procalcitonin have been investigated as a method to distinguish appendicitis from other diagnoses and gauge appendicitis severity [12][13][14]. Other strategies to expedite diagnosis combine biomarkers, clinical prediction scores and imaging or automate risk estimation through use of the electronic medical record [15][16].

Perspectives and Commentary

To submit comments about this topic please contact the editors at NaT@eapsa.org.

Resident and Students

Problem : Acute Abdominal Pain

Likely diagnoses: appendicitis, intussusception, Meckel diverticulitis, incarcerated hernia, ovarian torsion, intestinal obstruction (e.g. Hirschsprung disease), volvulusand nonsurgical causes

There are many causes of abdominal pain. The goal is to determine the specific cause and whether it is life threatening. The differential diagnosis includes

Abdominal pain - newborn to one month of age

Pain is difficult to assess in the newborn. Most of the time, surgery will be consulted for irritability and abdominal distention. There are many causes of abdominal distention and irritability. The goal is to determine the specific cause and whether it is life threatening. Differential Diagnosis:

Key history points

Most of the history will be obtained from nurse or parent. Obtain a careful feeding history such as when the feedings started at what quantity, frequency, route and type of formula or breast milk.

Are there bowel movements, when was first meconium seen, when was last bowel movements and what was the quality, amount and consistency? Any blood?

Is there bilious or nonbiliousemesis?

Is there abdominal distention? When did distention start?

What is the birth history (estimated gestational age, complications, medications, viral infections (i.e. TORCH), prenatal care)?

Are there signs of sepsis (apnea, bradycardia, hypothermia)?

NEC is more common with premature neonates. Volvulus commonly presents with bilious emesis. HD is associated with a failure to pass meconium in first 48 hours. Duodenal atresia is often diagnosed prenatally and frequently seen in patients with trisomy 21.

Key physical exam findings

Abdominal distension (location and severity)

Abdominal wall erythema or edema

Tenderness

Capillary refill (to assess volume status)

Differential diagnosis

Necrotizing enterocolitis (NEC), malrotation with volvulus, Hirschsprung disease (HD), duodenal atresia, intestinal atresia (jejunal, ileal, or colonic),meconium ileus/plug, nonsurgical causes (e.g. sepsis with ileus, feeding intolerance)

Imaging

A two view abdominal radiograph is useful to differentiate between the different causes of abdominal pain and distention. NEC will have pneumatosis intestinalis and loops of bowel that remain fixed and unchanged in position on subsequent radiographs. Look for signs of perforation (i.e. pneumoperitoneum). HD and intestinal atresias will show dilated loops of bowel. Duodenal atresia will show a double bubble sign.

An upper gastrointestinal contrast series can show signs of malrotation such as ligament of Treitz on the right side, corkscrew appearance of the duodenum or bird’s beak appearance of the duodenum if there is volvulus and obstruction.

A contrast enema is useful in differentiating HD, intestinal atresia and meconium ileus/plugs. In HD a transition zone may be present where a narrow aganglionic rectum gives way to a dilated colon more proximally. Intestinal atresias and meconium ileus will show a microcolon due to disuse of the colon. Contrast enema will identify meconium plugs and will often be therapeutic.

Indications for surgery

Immediate surgery is indicated if there is concern for perforation. For extremely sick neonates with NEC who may not tolerate laparotomy under general anesthesia an alternative is bedside primary peritoneal drainage which consists of placement of a penrose drain into the abdomen under local anesthetic. Immediate surgery is also indicated for patients with malrotation and midgut volvulus.

In patients without signs of perforation, the timing of surgery will be determined based on the diagnosis and need for additional studies.

Patients with possible HD need to have the diagnosis confirmed with suction rectal biopsy. Patients with duodenal atresia require an echocardiogram prior to surgery . Patients with intestinal atresia typically go to the operating room within 24 hours. Patients with meconium ileus should have an attempt at decompression with contrast enema. If not successful, then surgery is indicated urgently. Patients with a meconium plug rarely requires surgery but consideration should be given for a suction rectal biopsy to rule out HD.

Preoperative preparation

The initial treatment should include intravenous (IV) fluids, oro- or nasogastric tube decompression. The required laboratory studies include a complete blood count with differential, basic metabolic panel with consideration for arterial or venous blood gases.

Patients with significant ileus should begin parenteral nutrition.

Broad spectrum antibiotics should be started for those with NEC or perforation.

Operative consent points

The specific surgery will depend on the diagnosis. In addition to the standard risks of bleeding, infection, injury to surrounding structures and need for reoperation discuss

NEC - a laparotomy is performed with resection of any necrotic segments of bowel. Usually an ileostomy and mucous fistula are created.

Malrotation and midgut volvulus - a Ladd procedure is performed which consists of untwisting of the volvulus in a counter clockwise fashion (or resection if grossly necrotic), division of the Ladd bands, appendectomy, widening the base of the mesentery and placing the small bowel on the right and colon on the left. Also consent for possible bowel resection in case there is ischemic bowel from the volvulus.

HD - A one or two stage operation can be performed. A two stage operation consists of first performing a leveling colostomy. A one stage pull through operation can be performed open, laparoscopically, or trans-anally. The decision depends on surgeon preference.

Duodenal atresia - A duodenoduodenostomy is performed. Also consent for possible Ladd procedure if malrotation is found. The same operation is performed if an annular pancreas is found.

Jejunoileal atresia - Usually a limited bowel resection and primary anastomosis is performed. The consent should also include a possible ostomy and discussion of the risk of leak or stricture.

Other procedures - It is common to place durable intravenous access at the time of surgery - either a tunneled (i.e.Broviac) or nontunneled catheter. Check with team and if planned, make sure it is on the consent with its associated complications including bleeding, collapsed lung and infection.

When to call the next level

In general, all newborn consults should be discussed immediately with a senior resident, fellow or attending surgeon. If the neonate is stable and there is low concern for perforation the call can be made after imaging studies are obtained. If there is high concern for perforation on exam or if the baby is unstable then call immediately.

Abdominal pain - infant (one month to one year), toddler (one to five years), preschooler

Infants and toddlers may have difficulty communicating that they are in pain. Often the parent will say he/she is irritable, walking funny or inconsolable.

Key physical exam findings

The most common physical findings are abdominal distension and tenderness to palpation. A rigid abdomen may be present if there is perforation and peritonitis. Intussusception may have a sausage shaped mass on the right side of the abdomen. Incarcerated hernia will have a tender bulge with possible overlying erythema in the groin. Ovarian torsion will have tenderness, minimal peritoneal signs and possibly a palpable mass. Volvulus will have tenderness and possible rebound and guarding if ischemic bowel is present.

Differential diagnosis

Intussusceptionis more common in children less than three years of age. Appendicitis becomes more common in children over three years of age. Incarcerated inguinal hernia is more common in infants.

Imaging

Ultrasound (US) is often used as a screening tool. It will show a noncompressible tubular structure in acute appendicitis. A wall thickness greater than two mm and total diameter greater than 6 mm is consistent with apendicitis. An appendicolith may also be seen.

In intussusception US will show a target sign. An air or contrast enema is both diagnostic and therapeutic for ileocolic intussusception once the diagnosis is made. Radiographic reduction of the intussusception is the treatment of choice if there is no concern for perforation. US will also be able to diagnose ovarian torsion. If ovarian torsion is present an ovarian mass or cyst may also be identified.

If the ultrasound is nondiagnostic for acute appendicitis, a computerized tomography (CT) scan with intravenous contrast may be performed. In addition to an enlarged appendix, the CT may show an appendicolith, fat stranding and possible phlegmon or abscess. CT scans are rarely utilized in children of this age.

A Meckel scan is a nuclear medicine study that identifies ectopic gastric mucosa if it is present in the Meckel diverticulum.

A contrast enema is useful in diagnosing HD as it may show a transition zone where a narrow aganglionic rectum gives way to a dilated colon more proximally.

Indications for surgery

Immediate surgery is indicated if there is a concern for intestinal perforation. Incarcerated hernias that cannot be reduced also require urgent intervention. Sedation may be administered in the emergency department with reattempt at reduction. An asymptomatic Meckel diverticulum found incidentally on imaging does not need surgery. Meckel diverticulitis will often be diagnosed at the time of surgery for presumed appendicitis. It is rare that a bleeding Meckel diverticulum will require an urgent operation. Intussusception requires surgery if it cannot be otherwise radiographically reduced by contrast enema. Acute appendicitis typically requires appendectomy. Exceptions to this include early appendicitis that may be treated with antibiotics if preferred by the family and patients with an abscess who are well appearing. Ovarian torsion requires urgent operative reduction.

Observation with serial abdominal exams is a reasonable choice if the patient has equivocal findings of appendicitis.

Preoperative preparation

Empiric therapy includes IV fluids, antibiotics for perforation or acute appendicitis. Required labs include a CBC with differential, basic metabolic panel, urinalysis and possibly C-reactive protein. Most patients will benefit from imaging prior to operative intervention.

Operative consent points

In addition to the standard risks of bleeding, infection and injury to surrounding structures the specific risks of surgery will depend on the diagnosis. Most of the operations can be performed laparoscopically, but all patients should be also consented for possible open procedures. For Meckel diverticulum, a diverticulectomy can be performed or a segmental bowel resection with a primary anastomosis. Acute appendicitis is treated surgically with appendectomy. If an intussusception can not be reduced radiographically, operative reduction is performed. If this is unsuccessful, resection and anastomosis is necessary. If an incarcerated hernia cannot be reduced at the bedside, it must be surgically reduced and herniorraphy performed. A bowel resection may be required if there is strangulated bowel. For ovarian torsion, the ovary is reduced and left in place. The ovary should not be removed unless there is an obvious solid mass that is the cause of the torsion. For suspected HD, an open rectal biopsy will typically be required to make the diagnosis. Once the diagnosis is made, a leveling colostomy is typically performed followed by a pull through procedure at a later date.

Complications

There is a small risk for wound infection or abscess formation following surgery. This risk is higher for perforated appendicitis or perforated viscous. The risk of recurrent intussusception is roughly five percent. The recurrence rate is similar following radiographic and surgical reduction of intussusception.

Postoperative care

After operative reduction of the intussusception, the infant should be monitored for 12 to 24 hours in the hospital so that diet can be advanced and to look for recurrence. All postoperative patients should be monitored for pain control and advancement of diet. Antibiotics are typically discontinued unless there was a perforation or abscess.

When to call the next level

If the infant, toddler or child is stable and there is low concern for perforation, the call can be made after initial imaging studies are obtained. If there is a high concern for perforation on exam or hemodynamic instability then call immediately.

Abdominal pain – child five to 13 years

There are many causes of abdominal pain and the goal is to determine the specific cause and whether it is life threatening. At beginning consultation, keep in mind diagnoses that require quick intervention and escalate the consult accordingly for worrisome signs.

Key history points

Most surgical problems are likely to have associated gastrointestinal symptoms (e.g. nausea, vomiting, anorexia) and abdominal distension. In severe cases, patients may present with signs and symptoms of sepsis.

Appendicitis- pain that migrates to the right lower quadrant over 12 to 18 hours associated with fever and vomiting

Cholecystitis- colicky postprandial right upper quadrant pain becoming constant with vomiting, fever, jaundice, clay colored stools, dark urine, history of parenteral nutrition as an infant or newborn and bleeding disorders

Obstruction – bilious emesis, history of abdominal surgery, when was last bowel movement or flatus?

Ovarian torsion– sudden onset of pain with few gastrointestinal symptoms

Renal colic – also sudden onset usually in flank with few gastrointestinal symptoms except nausea with pain episodes

Pancreatitis– epigastric pain radiating to the back, history of gallstones, jaundice

Key physical exam findings

Look for tachycardia and fever. Malaise and poor perfusion may be present. The abdominal exam should focus on distension, tenderness, rebound tenderness, and guarding. A positive Murphy sign indicates cholecystitis. Small bowel obstruction will have abdominal distention with minimal tenderness. If tenderness is present in patients with intestinal obstruction consider possible ischemic bowel. Ovarian torsion will have tenderness, minimal peritoneal signs and possibly a palpable mass. Pancreatitis will have tenderness in the epigastric region.

Differential diagnosis

Appendicitis, cholecystitis, small bowel obstruction (SBO), ovarian torsion, nonsurgical causes (e.g.pancreatitis, inflammatory bowel disease). This is partial list and the key is determining quickly if early surgical intervention is needed (e.g. perforated appendicitis) or if the work up can progress while diagnostic (e.g. imaging, labs, repeat exams) and therapeutic (e.g.fluid resuscitation) interventions are initiated.

Nonsurgical causes of abdominal pain

The common causes of abdominal pain in this age group that elicit pediatric surgery consults include dehydration from infectious enteritis, right lower lobe pneumonia causing abdominal pain, kidney stones, pyelonephritis and pancreatitis. These are very common so taking care of the patient by hydrating them and taking a careful hiistory will help to cure the disease while making the diagnosis in many instances.

Imaging

Abdominal radiographs may show distended bowel and air fluid levels in a small bowel obstruction. Otherwise, plain films are not helpful. Residents should know which films are needed for each age group that constitute an acute abdominal series.

Ultrasound is a good initial study and will show a noncompressible tubular structure in acute appendicitis with a wall thickness greater than two mm and total diameter greater than six mm. An appendicolith may also be seen. In patients with cholecystitis, US will show gallstones, a gallbladder wall greater than four mm and edema. US may identify dilated common bile or intrahepatic ducts. Ultraosund will also be able to diagnose ovarian torsion. If ovarian torsion is present, an ovarian mass or cyst may be the etiology. Ultrasound can also visualize an edematous pancreas suggestive of pancreatitis.

If an US is nondiagnostic for acute appendicitis, a CT scan with IV and oral contrast may be performed. Also consider serial abdominal exams if the patient has equivocal findings of appendicitis. CT may show an enlarged appendix, appendicolith, fat stranding or a possible phlegmon/abscess. In intestinal obstruction, a CT scan may show proximally dilated bowel with a transition point. Noncontrast CT scans are much less sensitive in diagnosing the cause of abdominal pathology.

Indications for surgery

Immediate surgery is indicated if there is a concern for intestinal perforation. Acute appendicitis requires surgery. Exceptions to this include early appendicitis that may be treated with antibiotics if preferred by the family, and patients with an abscess who are well appearing. If bowel rest and decompression are insufficient in resolving a small bowel obstruction then surgery will be necessary. Patients with cholecystitis will need a cholecystectomy performed but if they are too sick to tolerate surgery they may first undergo percutaneous drainage. Ovarian torsion requires urgent operative reduction.

Preoperative preparation

Empiric therapy includes IV fluids (20 mL/kg bolus which may be repeated), nasogastric tube for decompression of obstruction if bilious vomiting, antibiotics for perforation, acute appendicitis or cholecystitis. Labs include a CBC with differential, basic metabolic panel, urinalysis, liver function tests, lipase/amylase and consider a C-reactive protein and lactate if severely ill. Most patients will benefit from some additional imaging prior to operative intervention. Imaging should correspond to history and physical exam.

Operative consent points

In addition to the standard risks of bleeding, infection and injury to surrounding structures, the specific risks will depend on the diagnosis and procedure. Most of the operations are done laparoscopically, but all patients should be also consented for possible open procedures. Acute appendicitis is treated surgically with appendectomy. Obstruction is treated with lysis of adhesions and possible bowel resection and anastomosis. Cholecystitis is treated with cholecystectomy with a possible intraoperative cholangiogram or possible common duct exploration if deemed necessary by the surgeon. For ovarian torsion, the ovary is reduced and left in place. The ovary should not be removed unless there is an obvious solid mass that is the cause of the torsion. If there is evidence of a systemic inflammatory response or diffuse peritonitis, ask your chief or attending if central venous access should be part of the consent.

Complications

There is a small risk for wound infection or abscess formation following surgery. This risk is higher for perforated appendicitis or perforated viscous. Complications following cholecystectomy include, bile leak, common bile or common hepatic duct injury and retained common bile duct stone. If a bowel resection is required for treatment of intestinal obstruction the complications include anastomotic leak or stricture.

Postoperative care

All postoperative patients should be monitored for pain control and advancement of diet. Antibiotics are usually discontinued unless there was a perforation or abscess.

When to call the next level

If the child is stable and there is low concern for perforation, the call can be made after the initial labs and imaging studies are obtained. If there is high concern for perforation on exam or if the child is unstable then call immediately.

Abdominal pain – adolescent male

There are many causes of abdominal pain, the goal is to determine the specific cause and most importantly whether it is life-threatening.

Key history points

Most surgical problems are likely to have associated gastrointestinal symptoms (e.g. nausea, vomiting, anorexia) and abdominal distension. In severe cases, patients may present with signs and symptoms of sepsis.

Appendicitis- pain that migrates to the right lower quadrant over 12 to 18 hours associated with fever and vomiting

Cholecystitis- colicky postprandial right upper quadrant pain becoming constant with vomiting, fever, jaundice, clay colored stools, dark urine, history of parenteral nutrition as an infant or newborn and bleeding disorders

Obstruction – bilious emesis, history of abdominal surgery, when was last bowel movement or flatus?

Testicular torsion– sudden onset of scrotal pain with few gastrointestinal symptoms

Renal colic – also sudden onset usually in flank with few gastrointestinal symptoms except nausea with pain episodes

Pancreatitis– epigastric pain radiating to the back, history of gallstones, jaundice

Key physical exam findings

Look for tachycardia and fever. Malaise and poor perfusion may be present. The abdominal exam should focus on distension, tenderness, rebound tenderness, and guarding. A positive Murphy sign indicates cholecystitis. Small bowel obstruction will have abdominal distention with minimal tenderness. If tenderness is present in patients with intestinal obstruction consider possible ischemic bowel. Testicular torsion will have tenderness, swelling and color change of scrotal skin, absence of cremasteric reflex. Pancreatitis will have tenderness in the epigastric region.

Differential diagnosis

Appendicitis, cholecystitis, small bowel obstruction (SBO), testicular torsion, nonsurgical causes (e.g.pancreatitis, inflammatory bowel disease). Remember that teenagers may present with abdominal pain from a trauma but be unwilling to admit the trauma that caused the injury. This is partial list and the key is determining quickly if early surgical intervention is needed (e.g. perforated appendicitis) or if the work up can progress while diagnostic (e.g. imaging, labs, repeat exams) and therapeutic (e.g.fluid resuscitation) interventions are initiated.

Nonsurgical causes of abdominal pain

The common causes of abdominal pain in this age group that elicit pediatric surgery consults include dehydration from infectious enteritis, right lower lobe pneumonia causing abdominal pain, kidney stones, urinary tract infection such as pyelonephritis and pancreatitis. These are very common so taking care of the patient by hydrating them and taking a careful history will help to cure the disease while making the diagnosis in many instances.

Imaging

Abdominal radiographs may show distended bowel and air fluid levels in a small bowel obstruction. Otherwise, plain films are not helpful. Residents should know which films are needed for each age group that constitute an acute abdominal series.

Ultrasound is a good initial study and will show a noncompressible tubular structure in acute appendicitis with a wall thickness greater than two mm and total diameter greater than six mm. An appendicolith may also be seen. In patients with cholecystitis, US will show gallstones, a gallbladder wall greater than four mm and edema. US may identify dilated common bile or intrahepatic ducts. Ultrasound will also be able to diagnose testicular torsion. Ultrasound can also visualize an edematous pancreas suggestive of pancreatitis.

If an US is nondiagnostic for acute appendicitis, a CT scan with IV and oral contrast may be performed. Also consider serial abdominal exams if the patient has equivocal findings of appendicitis. CT may show an enlarged appendix, appendicolith, fat stranding or a possible phlegmon/abscess. In intestinal obstruction, a CT scan may show proximally dilated bowel with a transition point. Noncontrast CT scans are much less sensitive in diagnosing the cause of abdominal pathology.

Indications for surgery

Immediate surgery is indicated if there is a concern for intestinal perforation. Acute appendicitis requires surgery. Exceptions to this include early appendicitis that may be treated with antibiotics if preferred by the family, and patients with an abscess who are well appearing. If bowel rest and decompression are insufficient in resolving a small bowel obstruction then surgery will be necessary. Patients with cholecystitis will need a cholecystectomy performed but if they are too sick to tolerate surgery they may first undergo percutaneous drainage. Testicular torsion requires urgent operative reduction.

Preoperative preparation

Empiric therapy includes IV fluids (20 mL/kg bolus which may be repeated), nasogastric tube for decompression of obstruction if bilious vomiting, antibiotics for perforation, acute appendicitis or cholecystitis. Labs include a CBC with differential, basic metabolic panel, urinalysis, liver function tests including bilirubin, lipase/amylase and consider a C-reactive protein and lactate if severely ill. Most patients will benefit from some additional imaging prior to operative intervention. Imaging should correspond to history and physical exam.

Operative consent points

In addition to the standard risks of bleeding, infection and injury to surrounding structures, the specific risks will depend on the diagnosis and procedure. Most of the operations are done laparoscopically, but all patients should be also consented for possible open procedures. Acute appendicitis is treated surgically with appendectomy. Obstruction is treated with lysis of adhesions and possible bowel resection and anastomosis. Cholecystitis is treated with cholecystectomy with a possible intraoperative cholangiogram or possible common duct exploration if deemed necessary by the surgeon. For testicular torsion, the testis is reduced may be left in place. If there is evidence of a systemic inflammatory response or diffuse peritonitis, ask your chief or attending if central venous access should be part of the consent.

Complications

There is a small risk for wound infection or abscess formation following surgery. This risk is higher for perforated appendicitis or perforated viscous. Complications following cholecystectomy include, bile leak, common bile or common hepatic duct injury and retained common bile duct stone. If a bowel resection is required for treatment of intestinal obstruction the complications include anastomotic leak or stricture.

Postoperative care

All postoperative patients should be monitored for pain control and advancement of diet. Antibiotics are usually discontinued unless there was a perforation or abscess.

When to call the next level

If the teenager is stable and there is low concern for perforation, the call can be made after the initial labs and imaging studies are obtained. If there is high concern for perforation on exam or if the child is unstable then call immediately. Suspicion of a testicular torsion justifies an immediate call for help to minimize delay to surgery.

Abdominal pain – adolescent female

There are many causes of abdominal pain and the goal is to determine the specific cause and whether it is life threatening.

Key history points

Most surgical problems are likely to have associated gastrointestinal symptoms (e.g. nausea, vomiting, anorexia) and abdominal distension. In severe cases, patients may present with signs and symptoms of sepsis.

Appendicitis- pain that migrates to the right lower quadranrt over 12 to 18 hours associated with fever and vomiting

Cholecystitis- colicky postprandial right upper quadrant pain becoming constant with vomiting, fever, jaundice, clay colored stools, dark urine, history of parenteral nutrition as an infant or newborn and bleeding disorders

Obstruction – bilious emesis, history of abdominal surgery, when was last bowel movement or flatus?

Ovarian torsion– sudden onset of pain with few gastrointestinal symptoms

Renal colic – also sudden onset usually in flank with few gastrointestinal symptoms except nausea with pain episodes

Pancreatitis– epigastric pain radiating to the back, history of gallstones, jaundice

Key physical exam findings

Look for tachycardia and fever. Malaise and poor perfusion may be present. The abdominal exam should focus on distension, tenderness, rebound tenderness, and guarding. A positive Murphy sign indicates cholecystitis. Small bowel obstruction will have abdominal distention with minimal tenderness. If tenderness is present in patients with intestinal obstruction consider possible ischemic bowel. Ovarian torsion will have tenderness, minimal peritoneal signs and possibly a palpable mass. Pancreatitis will have tenderness in the epigastric region. Pelvic inflammatory disease and ectopic pregnancy can have pelvic pain and cervical motion tenderness. Pancreatitis will have tenderness in the epigastric region.

Differential diagnosis

Appendicitis, cholecystitis, small bowel obstruction, ovarian torsion and nonsurgical. Many key differential diagnoses in the teenage female relate to the reproductive system.

Nonsurgical causes of abdominal pain

The common causes of abdominal pain in this age group that elicit pediatric surgery consults include dehydration from infectious enteritis, right lower lobe pneumonia causing abdominal pain, pregnancy, pelvic inflammatory disease, inflammatory bowel disease, renal stones, urinary tract infection such as pyelonephritis and pancreatitis. These are very common so taking care of the patient by hydrating them and taking a careful history will help to cure the disease while making the diagnosis in many instances.

Preoperative preparation

Empiric therapy includes IV fluids (20 mL/kg bolus which may be repeated), nasogastric tube for decompression of obstruction if bilious vomiting, antibiotics for perforation, acute appendicitis or cholecystitis. Labs include a CBC with differential, basic metabolic panel, urinalysis, liver function tests including bilirubin, lipase/amylase and consider a C-reactive protein and lactate if severely ill. Most patients will benefit from some additional imaging prior to operative intervention. Imaging should correspond to history and physical exam.

Imaging

Abdominal radiographs may show distended bowel and air fluid levels in a small bowel obstruction. Otherwise, plain films are not helpful. Residents should know which films are needed for each age group that constitute an acute abdominal series.

Ultrasound is a good initial study and will show a noncompressible tubular structure in acute appendicitis with a wall thickness greater than two mm and total diameter greater than six mm. An appendicolith may also be seen. In patients with cholecystitis, US will show gallstones, a gallbladder wall greater than four mm and edema. US may identify dilated common bile or intrahepatic ducts. Ultrasound may also be able to diagnose ovarian torsion but the presence of ovarian blood flow is unreliable. Ultrasound can also visualize an edematous pancreas suggestive of pancreatitis.

If an US is nondiagnostic for acute appendicitis, a CT scan with IV and oral contrast may be performed. Also consider serial abdominal exams if the patient has equivocal findings of appendicitis. CT may show an enlarged appendix, appendicolith, fat stranding or a possible phlegmon/abscess. In intestinal obstruction, a CT scan may show proximally dilated bowel with a transition point. Noncontrast CT scans are much less sensitive in diagnosing the cause of abdominal pathology.

Indications for surgery

Immediate surgery is indicated if there is a concern for intestinal perforation. Acute appendicitis requires surgery. Exceptions to this include early appendicitis that may be treated with antibiotics if preferred by the family, and patients with an abscess who are well appearing. If bowel rest and decompression are insufficient in resolving a small bowel obstruction then surgery will be necessary. Patients with cholecystitis will need a cholecystectomy performed but if they are too sick to tolerate surgery they may first undergo percutaneous drainage. Ovarian torsion requires urgent operative reduction. Ectopic pregnancy justifies a referral to a gynecology experienced service.

Operative consent points

In addition to the standard risks of bleeding, infection and injury to surrounding structures, the specific risks will depend on the diagnosis and procedure. Most of the operations are done laparoscopically, but all patients should be also consented for possible open procedures. Acute appendicitis is treated surgically with appendectomy. Obstruction is treated with lysis of adhesions and possible bowel resection and anastomosis. Cholecystitis is treated with cholecystectomy with a possible intraoperative cholangiogram or possible common duct exploration if deemed necessary by the surgeon. For ovarian torsion, the ovary is reduced and left in place. The ovary may be biopsied or a cyst drained but not removed unless there is an obvious solid mass that is the cause of the torsion. If there is evidence of a systemic inflammatory response or diffuse peritonitis, ask your chief or attending if central venous access should be part of the consent.

Complications

There is a small risk for wound infection or abscess formation following surgery. This risk is higher for perforated appendicitis or perforated viscous. Complications following cholecystectomy include, bile leak, common bile or common hepatic duct injury and retained common bile duct stone. If a bowel resection is required for treatment of intestinal obstruction the complications include anastomotic leak or stricture.

Postoperative care

All postoperative patients should be monitored for pain control and advancement of diet. Antibiotics are usually discontinued unless there was a perforation or abscess.

When to call the next level

If the teenager is stable and there is low concern for perforation, the call can be made after the initial labs and imaging studies are obtained. If there is high concern for perforation on exam or if the child is unstable then call immediately. Suspicion of an ovarian torsion justifies an immediate call for help to minimize delay to surgery.

Authors: Genia Dubrovsky MD, Wolfgang Stehr MD and Steven Lee MD

Editors: Joseph Iocono MD and Kenneth Gow MD

Additional Resources

APSA Standardized Toolbox of Education for Pediatric Surgery (STEPS) presentation on Appendicitis

Discussion Questions and Cases

To submit interesting or controversial cases which display thoughtful patient management please contact the editors at NaT@eapsa.org.

Discussion questions in SCORE Abdominal Pain conference prep

References

  1. HCUP Nationwide Emergency Department Sample (NEDS) 2013. Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Available at: http://hcupnet.ahrq.gov…; accessed Dec. 31, 2015
  2. Thongprachum A et al: Four-year study of viruses that cause diarrhea in Japanese pediatric outpatients. J Med Virol 87:1141, 2015  [PMID:25881021]
  3. Sahni LC et al: Variation in rotavirus vaccine coverage by provider location and subsequent disease burden. Pediatrics 135:e432, 2015  [PMID:25583918]
  4. American College of Radiology ACR Appropriateness Criteria. Right Lower Quadrant Pain—Suspected Appendicitis. Available at: https://acsearch.acr.org…; accessed Dec. 31, 2015
  5. Alvarado A: A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 15:557, 1986  [PMID:3963537]
  6. Samuel M: Pediatric appendicitis score. J Pediatr Surg 37:877, 2002  [PMID:12037754]
  7. Goldman RD et al: Prospective validation of the pediatric appendicitis score. J Pediatr 153:278, 2008  [PMID:18534219]
  8. Bhatt M et al: Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Acad Emerg Med 16:591, 2009  [PMID:19549016]
  9. Kharbanda AB et al: Interrater reliability of clinical findings in children with possible appendicitis. Pediatrics 129:695, 2012  [PMID:22392173]
  10. Kharbanda AB et al: Validation and refinement of a prediction rule to identify children at low risk for acute appendicitis. Arch Pediatr Adolesc Med 166:738, 2012  [PMID:22869405]
  11. Hoffenberg EJ et al: Outcome after exploratory laparoscopy for unexplained abdominal pain in childhood. Arch Pediatr Adolesc Med 151:993, 1997  [PMID:9343009]
  12. Kentsis A et al: Detection and diagnostic value of urine leucine-rich α-2-glycoprotein in children with suspected acute appendicitis. Ann Emerg Med 60:78, 2012  [PMID:22305331]
  13. Huckins DS et al: A novel biomarker panel to rule out acute appendicitis in pediatric patients with abdominal pain. Am J Emerg Med 31:1368, 2013  [PMID:23891596]
  14. Gavela T et al: C-reactive protein and procalcitonin are predictors of the severity of acute appendicitis in children. Pediatr Emerg Care 28:416, 2012  [PMID:22531196]
  15. Zouari M et al: Predictive value of C-reactive protein, ultrasound and Alvarado score in acute appendicitis: a prospective pediatric cohort. Am J Emerg Med Oct 22  [PMID:26577432]
  16. Deleger L et al: Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department. J Am Med Inform Assoc 20:e212, 2013  [PMID:24130231]

Media

malrotation with volvulus

Abdominal radiograph in two week old baby with malrotation/volvulus

malrotation with volvulus

UGI

Tapering duodenum in child with malrotation/volvulus

intestinal obstruction

Computerized tomography scan showing distal intestinal obstruction; etiology was omphalomesenteric duct remnant (Meckel diverticulum) adherent to umbilicus

distal small bowel obstruction

Abdominal radiograph showing dilated loop of small bowel consistent with distal small bowel obstruction; baby had an incarcerated right inguinal hernia.

appendicitis

Ultrasound showing dilated tubular structure in right lower quadrant with hyperemia by Doppler; structure was noncompressible

distal intestinal obstruction syndrome

Water-soluble contrast enema in a child with cystic fibrosis and abdominal pain; inspissated stool was evacuated.

intussusception

Paucity of bowel gas in toddler with severe, colicky abdominal pain; intussusception was identified by ultrasound.

intussusception

Ultrasound showing "target" sign in toddler with intussusception

mesenteric cyst

Ultrasound showing thin-walled cystic abdominal mass which on additional images was bilobed

ruptured ovarian cyst

Ultrasound showing enlarge ovary without perfusion; during laparoscopy for presumed ovarian torsion, ruptured hemorrhagic cyst was found.

ovarian torsion

Ultrasound showing enlarged ovary without blood flow; ovarian torsion identified on laparoscopy.

intestinal volvulus

Computerized scan demonstrating swirling of mesenteric blood vessels; during laparoscopy, segmental jejunal volvulus identified due to jejunal duplication cyst.

necrotizing enterocolitis

Abdominal radiograph showing pneumatosis intestinalis of ascending colon

Hirschsprung associated enterocolitis

Abdominal radiograph showing diffuse colon dilation without rectal gas in infant who underwent endorectal pullthough procedure for Hirschsprung disease

perforated viscus

Abdominal radiograph shows free intraperitoneal air in fussy infant; on laparoscopy, perforated Meckel diverticulum was found.

cholecystitis

Ultrasound reveals gall bladder full of stones with gall bladder wall thickening.

intestinal duplication cyst

Ultrasound shows large intraabdominal cyst with slightly thick wall; jejunal duplication cyst found on laparoscopy

Crohn disease

Computerized tomography scan shows thickening of terminal ileum without surrounding fat stranding or fluid collection

superior mesenteric artery syndrome

Abdominal radiograph shows markedly distended, fluid-filled stomach

superior mesenteric artery syndrome

Upper gastrointestinal series shows enlarged stomach, dilated proximal duodenum with delayed contrast passage across vertebral body into decompressed duodenum

colitis

Abdominal radiograph showing "thumb-printing" of the ascending colon in teenage girl with infectious colitis; she developed hemolytic uremic syndrome.

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Last updated: August 3, 2018

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TY - ELEC T1 - Acute Abdominal Pain ID - 829151 A1 - Saito,Jacqueline,MD, MSCI Y1 - 2018/08/03/ PB - Pediatric Surgery NaT UR - https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829151/all/Acute_Abdominal_Pain ER -