1. ACUTE ABDOMEN
Department of Paediatrics
Pt. J. L. N. Hospital & Research centre
Bhilai
Dr. SUBODH KUMAR SAHA

2. TYPES OF ABDOMINAL PAIN
Visceral Pain - Dull
poorly localised,
usually periumbilical
Parietal pain - sharp,
intense,
discrete
Referred pain - same features as parietal
pain

3. Site of pain
Foregut structures epigastrium
(oesophagus & stomach)
Midgut structures periumbilical
(small intestine)
Hind gut structure lower abdomen
(large intestine & rectum)

4. Gastrointestinal causes
Gastroenteritis
Appendicitis
Mesenteric lymphadenitis
Constipation
Abdominal trauma

5. Gastrointestinal causes
Intestinal obstruction
Peritonitis
Food poisoning
Peptic ulcer
Meckel's diverticulum
Inflammatory bowel disease
Lactose intolerance

6. Liver, spleen & biliary tract
disorders
Hepatitis
Cholecystitis
Cholelithiasis
Splenic infarction
Rupture of the spleen
Pancreatitis

7. Genitourinary causes
Urinary calculi
Dysmenorrhea
Mittelschmerz
Pelvic inflammatory disease

8. Genitourinary causes
Threatened abortion
Urinary tract infection
Ectopic pregnancy
Ovarian/testicular torsion
Endometriosis
Hematocolpos

9. Metabolic disorders
Diabetic ketoacidosis
Hypoglycemia
Porphyria
Acute adrenal insufficiency

10. Hematologic disorders
Sickle cell anemia
Henoch-Schönlein purpura
Hemolytic uremic syndrome

11. Drugs and toxins
Erythromycin
Salicylates
Lead poisoning
Venoms

12. Pulmonary causes
Pneumonia
Diaphragmatic pleurisy

13. Miscellaneous
Infantile colic
Functional pain
Pharyngitis
Angioneurotic edema
Familial Mediterranean Fever

14. Familial mediterranian fever
Gene responsible is 17p13.3
Self limited brief episodes of fever
Polyserositis
Amyloidosis
Skin rash,myelgia
Spenomegaly
Pathogenesis : increased TNF,IL-6,IL8
Treatment : cholchicine

15. Differential Diagnosis of Acute
Abdominal Pain by Predominant Age
Birth to one year
Infantile colic
Gastroenteritis
Constipation
Urinary tract infection
Intussusception
Volvulus
Incarcerated hernia
Hirschsprung's disease

16. Two to five years
Gastroenteritis
Appendicitis
Constipation
Urinary tract infection
Intussusception

17. Two to five years
Volvulus
Trauma
Pharyngitis
Sickle cell crisis
Henoch-Schönlein purpura
Mesenteric lymphadenitis (adenovirus)

18. Six to 11 years
Gastroenteritis
Appendicitis
Constipation
Functional pain
Urinary tract infection

19. Six to 11 years
Trauma
Pharyngitis
Pneumonia
Sickle cell crisis
Henoch-Schönlein purpura
Mesenteric lymphadenitis

20. 12 to 18 years
Appendicitis
Gastroenteritis
Constipation
Dysmenorrhea
Mittelschmerz
Pelvic inflammatory disease
Threatened abortion
Ectopic pregnancy
Ovarian/testicular torsion

21. Evaluation of Acute Abdominal
Pain in Children
Pain History
Recent Trauma
Precipitating or Relieving Factors
Associated Symptoms Vomiting,
Diarrhea
Urinary frequency,
Dysuria,
Polyuria & polydipsia
Henoch - Schönlein purpura - Joint pain, rash, and
smoke-colored urine suggest

22. Gynecologic History.
History of sexual activity and contraception
Amenorrhea
Use of an IUD suggest - PID
Sudden onset of midcycle pain of short
duration suggests - mittelschmerz

23. Past history
A history of surgery
H/0 hospitalization
A history of similar pain

24. Drug Use
Iron
Erythromycin

25. Family History
Sickle cell anemia
Cystic fibrosis

26. PHYSICAL EXAMINATION
General Appearance
Vital Signs.
Tachycardia Hypotension
Fever Inflammation
Hypertension HUS & HSP
Kussmaul's Diabetic ketoacidosis.
respiration
Postmenarcheal Ectopic pregnancy
girl is in shock

27. Abdominal Examination.
Breathing pattern
Inspection
Palpation
Percussion
Auscultation

28. Rectal & Pelvic Examination
Tenderness
Presence of mass
Vaginal discharge,atresia, imperforate
hymen

29. Associated Signs
Pallor& jaundice SCA
Purpura&arthritis HSP
Cullens & Gray turner Internal hemorrhage
sign
Jaundice liver disease
Positive Murphy's Acute cholecystitis
sign

30. Investigations
 HB URINE X RAY Abd.
 TLC PUS CELLS USG
 DLC RBCS CT SCAN
 ESR
 SICKLING
 PS

31. Indications for Surgical
Consultations in Children
Severe or increasing abdominal pain with
progressive signs of deterioration
Bile-stained or feculent vomitus
Involuntary abdominal guarding/rigidity
Rebound abdominal tenderness

32. Indications for Surgical
Consultations in Children
Marked abdominal distension with diffuse
tympany.
Signs of acute fluid or blood loss
Significant abdominal trauma
Suspected surgical cause for the pain
Abdominal pain without an obvious etiology

33. Management
Treatment should be directed at the
underlying cause.

34. INTUSSUCEPTION
90% < 2 years of age
More commen in males
Associated with URI
Diarrhoea
rotavirus vaccine
hematoma(HSP)
Hemangioma
lymphoma

35. symptoms
 Pain abdomen of sudden onset
 Vomiting
 Sausage shaped mass
 Normal in between pain
 Blood stained finger on PR
examination

36. Investigations
Ba enema: Thin streak of Ba in intussuce-
ptum
USG: Target lesion in transverse plane

37. Treatment
 Reduction with air enema
 Reduction with saline enema
 Reduction with radiocontrast
material

38. Functional abdominal pain
Abdominal pain that cannot be
explained by structural, physiological or
pathological abnormality.

39. Functional abdominal pain includes several
different types of chronic abdominal pain
recurrent abdominal pain
three or more bouts of abdominal pain (belly ache) in
children 4-16 years old over a three-month period severe
enough to interfere with his/her activities.
located around the umbilicus
functional dyspepsia,
upper abdominal pain
nausea, vomiting,
irritable bowel syndrome (IBS).
pain relieved by motion
change in stool frequency
change in stool consistency

40. DIFFERENTIAL DIAGNOSIS OF CHRONIC
ABDOMINAL PAIN
CONSTIPATION
ACID REFLUX
LACTOSE INTOLERANCE
CHRONS DISEASE
ULCERATIVE COLITIS
PARASITIC INFESTATION
HEPATITIS
PANCREATITIS
UTI
APPENDICITIS
INTESTINAL INFECTION

41. Implications
Interference with school attendance
Depression
Anxiety
Emotional disturbances

42. Absence of red flag signs
Fever
Wt. loss
Poor growth
Joint pain
Mouth ulcer
Unusual rashes
Loss of appetite
Hemetemesis
Melena
Night time awakening due to pain or diarrhoea

43. Diagnosis
Normal physical examinations
Absence of abnormal pathological tests
Absence of red flag signs

44. Goals of management
Provide quality life through
Support
Education
Medication
Better coping skills

45. Management
Stick to the diagnosis
Avoid unnecessary invasive tests
Antispasmodics
Low dose tricyclic antidepressents
Avoid carbonated drinks
Psychological treatment : behavioural therapy
relaxation exercises
hypnosis

46. physician
Normal life
school parents

47. Colic
 Excessive paroxysmal crying
 Most often in evening hours
 Healthy baby
 Difficult to console
 Equal frequency in male & female

48. Wessels criteria
Cry lasting > 3 hrs
Occuring > 3 days
for > 3 weeks

49. Etiology
Increased level of motilin
lactalbumin
5 HIAA
Psychological stress
Drugs during pregnancy

50. Frequency
10 to 30 % Infants worldwide
Sex : Equal frequency
Age : 2 wks to 4 months

51. History
Diagnosis of exclusion
Evening hours
Peaks at 6 weeks
High pitched cry
Exclude other causes : hair in eye
strangulated hernia
ottitis
sepsis

52. Physical examination
Shows normal weight gain
Differential diagnosis
Overfeeding
Underfeeding
Milk Allergy
Early introduction of foods
GERD
No burping after feeds

53. MANAGEMENT
SIMETHICONE
Reduces the surface tension of bubbles
over intestinal surface.
Anticholinergic drugs
dicyclomine/ dicycloverine
relax muscles in the wall of the gut
side effects : drowsiness. Apnoea
diarrhoea constipation seizures

54. MANAGEMENT
Dietary management
Elimination of cows milk
eggs
wheat
nut products
Herbal tea
Car ride simulators
Reduced stimulation
Focussed parent counselling

55. Abdominal crisis sickle cell
anemia
 Belongs to a perticular community
 H/o blood transfusion,joint pain
 May be associated with jaundice
 Anemia

56. Abdominal crisis in SCA
Sequestration crisis
Sudden enlargement of spleen
Shock
Pallor
Treatment: Blood transfusion

57. vaso occlusive crisis
Liver : microinfarct
Kidney: microscopic hematuria
gross hematuria
proteinuria
Spleen: infarct

58. Treatment of VOC
Blood transfusion low Hb
IV fluides dehydration
NSAID Acetaminophen
ibuprofen
neproxen
Opioides morphine

59. NONSURGICAL CAUSES OF
ABDOMINAL PAIN
PULMONARY Lobar pneumonia
pleurisy
pulmonary embolism
Cardiac myocarditis
pericarditis
CCF
Metabolic Diabetes mellitus
acute adrenal insufficiency
acute intermittent porphyria
Poisons
Drugs

60. NONSURGICAL CAUSES OF
ABDOMINAL PAIN
 Pancreatitis
 Cholecystitis
 Sickle cell crisis
 Familial mediterrenian fever
 Hereditory angioneurotic oedema

61. NONSURGICAL CAUSES OF ABDOMINAL
PAIN
Pyelonephritis
UTI
Abdominal migrain
Abdominal epilepsy
Functional abdominal pain

62. INTUSSUCEPTION

63. INTUSSUCEPTION

64. INTUSSUSCEPTION

65. CROHN’S DISEASE

66. INTUSSUCEPTION

67. MALROTATION

68. URETERAL CALCULUS

69. APPENDICITIS USG

70. APPENDICITIS WITHOUT PERFORATION

71. APPENDICITIS WITH PERFORATION

72. JEJUNAL ATRESIA

73. ATRESIA JEJUNUM

74. HIRSCHPRUNGS D/S

75. HIRSCHSPRUNGS

76. DUPLICATION CYST

77. DUPLICATION CYST

78. ROUND WORM

79. TORSION OVARY

80. ASCARIS

81. Pelvic inflammatory disease
 Endometritis
 Tubo ovarian abscess
 Salpingitis
 Pelvic peritonitis

82. PID
Lowner abdominal pain
Abnormal vaginal discharge
Adnexal temderness
Painful cervical movement
Dysmenorrhoea

83. Causes of PID
 N. gonorrhoeae
 C.trachomatis
 B hemolytic streptococci
 Peptostreptococus
 E.coli
 Gardnerella
 Mycoplasma hominis

84. THANK YOU