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ACUTE ABDOMINAL PAININ CHILDREN
SETIA BUDI SALEKEDE
Department of Child Health, Medical School, University of Hasanuddin /
Wahidin Sudirohusodo Hospital, Makassar, Indonesia
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introduction
Common problem in children Can be self limiting or an emergency
problem
ACUTEABDOMINAL PAIN
Completing clinical evaluation is important
Consider the cause of pain (age & location,surgical case/)
DIAGNOSIS
CBC, urinalysis, stool or radiologicexamination
Differential diagnosis
Referral to surgery division
INVESTIGATIONS
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D E F I N I T I O NAbdominal pain is a pain
felt between chest andinguinal region
Acute abdominalpain
Recurrentabdominal pain
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ACUTE ABDOMINAL PAIN
Abdominal pain attack episode, sudden onset,
hours a week, and never had pain before,
could be persistent or remitting pain with mild
severe intensity, consider medical
intervention and surgical intervention if
needed to solve the cause of pain.
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RECURRENT ABDOMINAL PAIN
Apley Abdominal pain minimally three
times pain episode within three months with
severe enough intensity and may influence
activity.
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INCIDENCE
79.4%
20.6%
Acute Abdominal Pain in Children
Nonsurgical cases
Surgical cases
Cerrahpasa Medical School ER, Istanbul
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INCIDENCE
23.7%
15.4%
15.4%
9.4%
8%
28.1%
Nonsurgical cases (79.4%)
URTIUnknown AAP
Gastroenteritis
Constipation
UTI
Others
Cerrahpasa Medical School ER, Istanbul
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INCIDENCE
81.7%
18.3%
Surgical Cases (20.6%)
Unknown
Appendicitis
Cerrahpasa Medical School ER, Istanbul
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INCIDENCE
11.8%
88.2%
Acute Abdominal Pain In Children
Surgical
Nonsurgical
Wahidin Sudirohusodo Hospital, Makassar
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INCIDENCE
44.7%17.9%
9%
6%3% 19.4%
Nonsurgical Cases (88.2%)
DiarrheaDHF
URTI
Constipation
UTI
ANSAP
Wahidin Sudirohusodo Hospital, Makassar
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INCIDENCE
66.7%
33.3%
Surgical Cases (11.8%)
Unknown
Appendicitis
Wahidin Sudirohusodo Hospital, Makassar
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PATHOGENESIS
Vascular Disorder
Inflammation
Obstruction
Stretching of visceral
Peritoneum
Common causes
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PATHOPHYSIOLOGY
VISCERAL PAIN
SOMATIC PAIN
REFERRED PAIN
SOURCE OF ABDOMINAL PAIN
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Visceral pain
Visceral pain fibers: Bilateral, unmyelinated,
enter the spinal cord at multiple area
Visceral pain: Dull, early onset and poorly
localized
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Parietal pain
Caused by irritation of parietal peritoneal
fibers
Parietal pain fibers: myelinated , enter specific
dorsal root ganglia
Parietal pain: sharp, intense, discrete, late
onset, and localized to a dermatome
superficial to site of the painful stimulus
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Referred pain
Pain is felt at a site away from the pathological
organ
Pain is usually ipsilateral to the involved organ
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ETIOLOGY Age of onset
Location of pain :
Intra-abdominal disorder
Extra-abdominal disorder
Onset of abdominal pain
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AGE RELATED TO ABDOMINAL PAINDIFFERENTIAL DIAGNOSIS OF ACUTE ABDOMINAL PAIN BY PREDOMINANT AGE
Birth to one year Two to five years Six to 11 years 12 to 18 years
Infantile colic
Gastroenteritis
Constipation
Urinary tract infectionIntussusception
Volvulus
Incarcerated hernia
Hirschsprung's disease
Gastroenteritis
Appendicitis
Constipation
Urinary tractinfection
Intussusception
Volvulus
Trauma
Pharyngitis
Sickle cell crisis
Henoch-Schnlein
purpura
Mesenteric
lymphadenitis
Gastroenteritis
Appendicitis
Constipation Functional
pain Urinary tractinfection Trauma
Pharyngitis Pneumonia
Sickle cell crisis
Henoch-Schnlein
purpura
Mesenteric
lymphadenitis
Appendicitis
Gastroenteritis
Constipation
DysmenorrheaMittelschmerz
Pelvic inflammatory
disease
Threatened abortion
Ectopic pregnancy
Ovarian/testicular
torsion
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PAIN LOCATION
Intra-abdominal disorder
Extra-abdominal disorder
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Intra-abdominal
disorder
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PAIN LOCATION...Extra-Abdominal Causes of Abdominal Pain
Abdominal wall ThoracicRectus muscle hematoma Myocardial infarction
GU Pneumonia
Testicular torsion Pulmonary embolism
Infectious Radiculitis
Herpes zoster Toxic
Metabolic Black widow spider biteAlcoholic ketoacidosis Heavy metal poisoning
Diabetic ketoacidosis Methanol poisoning
Porphyria Scorpion sting
Sickle cell disease Opioid withdrawal
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ONSET OF ABDOMINAL PAIN
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AGE RELATED TO CLINICAL
MANIFESTATIONS
0 3 months Commonly described as vomiting
3 months
2 years Vomiting, sudden cry and histericcry without recent trauma
2 5 years Can show abdominal pain, but not
the exact location> 5 years Can show the location and severity
of abdominal pain
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CLINICAL EVALUATION
ANAMNESIS/
HISTORY OF
DISEASE
PHYSICALEXAMINATION
INVESTIGATION
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History
Age
Pain history (Pain location, Onset, Duration)
Recent trauma
Precipitating or Relieving factor
Associated symptoms
Gynecologic history
Past history
Drugs history
Family history
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Physical examination
General appearance
Vital signs
Abdominal examination Rectal and pelvic examination
Associated signs
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Investigation
Complete blood cell count
Urinalysis & stool
Plain-film abdominal radiographs USG
Endoscopy
CT scan
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DIAGNOSIS
Age and abdominal pain location were the key
for establishing the cause of abdominal pain.
Good and complete anamnesis, physical
examination and testing could lead to
accurate diagnosis of the underlying disease
causing acute abdominal pain for optimaltherapy.
G OS S (CO O )
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CAUSES OF ACUTE ABDOMINAL PAIN IN CHILDREN
Gastrointestinal causes Rupture of the spleen Hemolytic uremic syndrome
Gastroenteritis PancreatitisDrugs and toxins
Appendicitis Genitourinary causes Erythromycin
Mesenteric lymphadenitis Urinary tract infection Salicylates
Constipation Urinary calculi Lead poisoning
Abdominal trauma Dysmenorrhea Pulmonary causes
Intestinal obstruction Pelvic inflammatory disease PneumoniaPeritonitis Ectopic pregnancy Diaphragmatic pleurisy
Food poisoning Ovarian/testicular torsion Miscellaneous
Peptic ulcer Endometriosis Infantile colic
Meckels diverticulum Metabolic disorders Pharyngitis
Inflammatory bowel disease Diabetic ketoacidosis Angioneurotic edemaLactose intolerance Hypoglycemia
Liver, spleen, and biliary tract
disorders
Acute adrenal insufficiency
Hepatitis Hematologic disorders
Cholecystitis Sickle cell anemia
Cholelithiasis Henoch-Schnlein purpura
DIFFERENTIAL DIAGNOSIS (COMMON)
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MANAGEMENT
UNDERLYINGDISEASE
TREATMENTANALGETICS?
SURGERYCONSULTATION
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R E F F E R E D
INDICATION FOR SURGICAL CONSULTATIONS IN CHILDREN WITH ACUTEABDOMINAL PAIN
Severe or increasing abdominal pain with progressive
Signs of deterioration
Bile-stained or feculent vomitus
Involuntary abdominal guarding/rigidity
Rebound abdominal tenderness
Marked abdominal distension with diffuse tympany
Signs of acute fluid or blood loss into the abdomen
Significant abdominal trauma
Suspected surgical cause for the pain
Abdominal pain without an obvious etiology
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SUMMARY
A common problem which needs aprompt diagnosis.
Age and pain location were the key for
establishing the cause of abdominal pain. The accuracy of diagnosis was needed to
provide an optimal therapy.
Sign of surgical cases should refer tosurgery division.
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THANK YOU
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SUMMARY
Acute abdominal pain in children was a commonproblem to diagnosis. Age and abdominal painlocation were the key for abdominal pain caused.
Complete anamnesis/history of disease, physicalexamination and testing could diagnosisaccurately the underlying disease acuteabdominal pain. However, the accurate of
diagnosis was needed to give an optimal therapy.If there was sign of surgery cases on acuteabdominal pain in children, we can consult tosurgery division.
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DURATION AND SEVERITY
ACUTE ABDOMINAL PAIN
h ld b
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Evidence of trauma?
Fever?
Evidence of sickle cell
anemia?
Left-sided pain
Child abuse
Accidental injury
Urinary tract infection
PharyngitisGastroenteritis
Mesenteric lymphadenitis
Pneumonia
Appendicitis
Pelvic inflammatory disease
Sickle cell crisis
Constipation
Ovarian/testicular torsion
Middle to right-
sided pain?
Appendicitis
Ovarian/testicular torsion
Mesenteric lymphadenitis
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Present in other
household contacts?
Sexually active?
Paleness/purpura?
Blood in stool?
Food poisoning
Gastroenteritis
Pelvic inflammatory disease
Ectopic pregnancy
Hemolytic uremic syndromeHenoch-Schnlein purpura
Inflammatory bowel diseaseHemolytic uremic syndrome
Henoch-Schnlein purpura
Gastroenteritis
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Evidence of
obstruction?
Refer or observe
Malrotation
Intussusception
Volvulus
Hematuria? Renal calculi
Renal trauma
Urinary tract infection
DATA PRIMER SAKIT PERUT AKUT
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DATA PRIMER SAKIT PERUT AKUT
RSU Dr. Wahidin Sudirohusodo Tahun 2010
Jumlah Kasus SPA Jumlah (%)
Total 76 (100%)
Laki-laki 43 (56.5%)
Perempuan 33 (43.5%)
Nonbedah 67 (88.2%)Diare 30 (44.7%)
DBD 12 (17.9%)
ISPA 6 (9%)
Konstipasi 4 (6%)
ISK 2 (3%)
Nonspesifik 13 (19.4%)
Bedah 9 (11.8%)
Apendisitis 3 (33.3%)
Tidak diketahui 6 (66.7%)
Total Kunjungan Pasien tahun 2010: 2060 pasien
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Cullens Sign
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Grey Turners Sign
Mi l h
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Mittelschmerz
Ovulation pain; Midcycle pain
Lower-abdominal pain that is:
One-sided
Recurrent or with similar pain in past
Typically lasting minutes to a few hours, possibly
as long as 24-48 hours
Usually sharp, cramping, distinctive pain
Severe (rare)
May switch sides from month to month or from
one episode to another