Angie Green RGN, RN ( Child) BSc ( Hons).
Objectives
 Discussion of age specific abdominal presentation in
infants and children
 Red flags
Causes

Medical
 DKA
 IBS
 Gastroenteritis ( bacteria or viral)
 Constipation
 Flatulence
 Mesenteric lymphadenitis
 GI bleed
 UTI
 Ureteric calculi
 Hepatitis
 Cholecystitis
 Pancreatitis
 Sickle cell anaemia/crises
 Henoch-Schönlein purpura

Surgical

Bowel obstruction

Trauma

Appendicitis

Hernia

Peritonitis

Testicular torsion

Referred Pain

Drugs/toxins

Gynae

Obstetric
Neonatal Period
 3/52 baby girl
 Breast fed
 Feeding well
 Episode of fresh blood in
small vomit after feed
Blood in vomit
 Breast fed
 Well baby
 No co-morbidity
 Thorough assessment
 Reassurance
 Advice to mum
 Risk of mastitis
 Midwife
 Safety netting
 1 day old baby boy
 Refusing feeds
 Dribbling saliva
 Choking/cyanotic episodes
when feeding
Oesophageal atresia +/- fistula
1 in 2500-3000 births
Diagnosis of OA
 Unable to pass NGT
 Pass a radio-opaque tube and order AP
and lateral XRays of the chest and
upper abdomen
Prognosis
 Dependant on anomalies- 97% with no
other anomalies, 22% with major
cardiac anomalies
 Newborn
 Bile stained vomits
 Continued vomiting long
after feeds
 Absent bowel movements
 Absent urination after first
voidings
Duodenal Atresia
 1:10,000 live births
 Plain abdominal xray

“double-bubble” sign of gas in
the stomach with a distended
duodenum
 Approx 8% of infants with
Down’s have DA
 Surgery
Meconium Ileus
 Abdominal distension
 Failure to pass meconium
 Obstruction of the dital
ileum from inspissated
meconium
 Usually a manifestation of
CF ( and the earliest)
What is the possible diagnosis?
Hirschsprung’s Disease
 Affects 1:5000
 Boys more than girls
 98% diagnosed in newborns
 Abdominal distension
 Vomiting- may be bilious
 Not passing stool
Hirschsprung’s in an 8 year old
 Not feeding/gaining
weight
 Evidence of ? Pneumonia
 Decreased unilateral AE
 Increasing resp distress
and cyanosis
Congenital Diaphragmatic Hernia
 Antenatally
 Late presentation (5%)
 Incidental finding on CXR
 Mediastinal shift
 Shift of cardiac impulse
 Surgical intervention
Infants
 Volvulus
 Intussusception
 Pyloric stenosis
 GORD
 Hernia presentation
Inguinal Hernia
 Majority of cases male
 Incidence in full term newborn 3.5%
 Pre-term incidence as high as 60%
 Risk of developing intestinal
incarceration and strangulation
 70% of cases- able to reduce hernia
and convert to elective procedure
 May only be evident when infant
crying or straining
Inguinal Hernia
Umbilical hernia
 Occurs in about 10 % of all babies.
 More often in girls than in boys.
 More often in premature babies.
 Develops when muscle layers
around umbilicus do not meet and
close after birth
 Majority will have closed without
surgery by age 5 yrs
GORD
 Usually commences in first
six weeks
 Majority resolves by 1yr
 Non forceful
 Coughing, hiccups
 Swallowing, gulping
 Discomfort during or after
feeding
Management of GORD
 Feeding in upright
position
 Feed thickener
 Pre-thickened formula
 Left lateral after feeding
 Gaviscon
 Smaller more frequent
 Ranitidine
feeds
 Raising head end of cot
 Omeprazole
 Domperidone
Pyloric Stenosis
 More common in boys than girls
 First born most commonly affected
 Family history in 10% patients
 Unexplained hypertrophy of the circular muscles of the pylorus develops
 Short history of forceful vomiting in a baby of 2-8weeks of age
 Vomit may contain altered blood, non bile stained
 Upper abdo may be distended, visible gastric peristalsis may be seen after
feed
 Olive-sized mass palpable at pylorus
Pyloric stenosis
 Bilious vomiting
 Clinical signs of shock
Intussusception
 Affects more boys than girls
 Presentation 6 months-2rs
 1:1000 live births
 May be associated with- weaning, gastroenteritis, URTI
 Caused by telescoping of the bowel usually at the ileocaecal region
 Colicky pain and vomiting, may be bile stained
 ‘red-currant-jelly stool’
 Paucity of abdo contents in RIF, mass felt in R hypochondriac or epigastrium
 Reocurrence in less than 5%
Intussusception
Volvulus

Malrotation of bowel may predispose infant to
volvulus

Bowel become twisted

Up to 90% in children younger than 1yr
( up to 60% in 1st month of life)

Male: female presentations 2:1

Babies who present in first week of life tend to
have more severe obstruction

Bilious vomiting, apnoeic episodes, bloody stool,
abdo pain, shock

Time critical referral
 Immediate referral for
upper GI contrast
 Surgical management
Toddlers/Pre-school
 Diarrhoea and Vomiting
 Constipation
 Meckels Diverticulum
 Wilm’s Tumour
 GI bleed
 Appendicitis
Diarrhoea and Vomiting
 10% of children under 5
 Diagnosis
years with gastroenteritis
present to healthcare
services
 16% of medical
presentations to major
paed ED
 Assessment of dehydration
and shock
 Fluid management
 Nutrition management
 Advice
Constipation

Affects 5-30% of all children

Underestimation of the impact on child and
family- poor clinical outcome

Presents normally as AAP and/or anal bleeding

Diagnosis made on Hx

May be able to palpate a loaded descending
colon, full rectum

Consistency not frequency

Grunting in infants, clenching buttocks, rocking
up and down on toes, turning red in the face

Anal fissure
Idiopathic Constipation


Hx
Soiling

Excessive flatulence

Foul smelling wind and stools

Irregular consistency of stools

Withholding

Lack of energy

Irritable mood
Do not request AXR for diagnosis of idiopathic
constipation

Treatment not dietary intervention alone

Treatment will be needed for several months

Children who are not toilet trained to remain on
treatment until toilet training well established

May need to consider behavioural referral
Acute GI Bleed

History

Examination

Quantity

ENT

Vomit largely blood or contained streaks of

Bowel sounds++ may be indication of ongoing
blood


Clots?

PR bleed- fresh or tarry
bleed


PMH

NSAI’s

FH
Investigations


PR
bloods
Management

IV access

Fluid

Refer

NBM
Meckel’s Diverticulum
 Most common GI defect ( 2% of all
infants)
 Contains stomach/pancreatic tissue
 Peak age for symptoms prior to 2 yrs
 boys: girls 3:1
 PR bleed
 Blood in stool, mucous
 Abdo pain
 Sepsis/ peritonitis/bowel obstruction
 Surgical intervention
Wilms’ Tumour
 Childhood cancer of the kidney
(nephroblastoma)
 One of the most common types
of childhood cancer 1:10,000
 70 per year in UK
 Children under 5 years
 More girls than boys
Wilm’s Tumour
 Painless swelling in abdomen
 Haematuria, unwell,
hypertension, weight loss, loss
of appetite
 USS, CT, biopsy
 Staging
 Radiotherapy, chemo,
nephrectomy,
School age/teenage
 Constipation
 Appendicitis
 Chronic abdominal pain
 Mesenteric adenitis
 Torsion
 Gynae/obstetric related
Acute Appendicitis
 Peak incidence at 12 years of age
 4:1000 children aged 5-14yrs
 Viral infection, constipation,
dehydration may precede presentation
 The classic history of anorexia and
vague periumbilical pain, followed by
migration of pain to RLQ and
associated fever and vomiting is
observed in fewer than 60% of
patients.
Atypical
 Acute onset of severe pain
Considerations
 The progression from obstruction to
 Vomiting prior to pain
perforation usually takes place over 72
 Diarrhoea
hours.
 High fever
 A delay in the diagnosis of
appendicitis is associated with rupture
and associated complications,
especially in young children.
Examination
 Mc Burney’s point
 Rovsing sign
 Psoas sign
 Obturator sign
 Try to avoid eliciting
rebound tenderness
 Cough
 Predicted value of
hopping?
Mesenteric Adenitis
 Poorly defined symptoms
 MA is self limited inflammatory process that affects the mesenteric lymph nodes in RLQ
 Thought that inflammation of mesenteric lymph nodes leads to peritoneal reaction
 Association with strep URTI
 Site of tenderness may shift when child moves position
 ‘active observation’ useful
 Leucocytosis is common
 Diagnosis is one of exclusion
 Ultrasound
 A persisting localized tenderness lasting more than 3-6hrs may warrant surgical
exploration
Testicular Torsion

Teenage boys

May occur from strenuous exercise or injury, or
no apparent cause

Sudden and severe pain.

Swelling and tenderness on the side of scrotum
that is affected (more often on the right side).

The testicle becomes sore and extremely tender.

Associated nausea and vomiting

The scrotum may also become red and inflamed

Surgery needed within 6 hours

Bi-lateral tethering

Cremasteric reflex
Recurrent Abdominal Pain
 Apley (1958)
-Waxes and wanes
-Occurs with three episodes
within a three-month period of
time
-Is severe enough to affect a
child's activities
• Age group 4-12 yrs
Significant because…
- One of the most common
symptoms of childhood
- Morbidity, lost school days
- Health resources
- Chronic- increasing anxiety
- Organic and functional
disorders
Clinical features
Organic
Non organic
Site of pain
Flanks, suprapubic, RUQ,
RLQ
Central, epigastric
Family History- particularly of abdo
pain, headache and depression
Less likely, but take note of
IBS
Likely
Psychological factors – particularly
anxiety
Less likely
Likely, especially
anxiety
Headache
Less likely
More likely
Alarm symptoms
Vomiting generally equally
likely but beware persistent
or significant vomiting.
Chronic severe diarrhoea
more likely.
Unexplained fever.
Gastrointestinal blood loss.
Alarm symptoms less
likely
Abnormal signs
Present
Absent
Abnormal growth/ and or weight
loss
Present
Absent
Abnormal investigations
Expected
Not found
Abdominal presentations in children
 Not small adults
 Assessment difficult
 Age related
 Exclusion criteria
 Red Flags
Top tips
 It is vital that the initial contact
with the child is not painful
 Useful to ascertain child's
baseline level of response
 With repeated episodes of AP
over prolonged period always
consider child protection issues
 Examination, examination,
examination!
References

Aspenuld, G. Langer, J. (2007) Current Management of hypertrophic pyloric stenosis Seminars in Pediatric Surgery 16,p 2733.

Banez,G (2008) Chronic abdominal pain in children: what to do following the medical evaluation Current Opinion in
Pediatrics. 20(5):p571-5.

Berger et al (2007)Chronic abdominal pain in children. BMJ. May 12;334(7601):p997-1002.

Craig WR, Hanlon–Dearman A, Sinclair C, et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal
reflux in children under two years. In: The Cochrane Library, Issue 2, 2006.

Dhroove G. et al ( 2010) A Million Dollar work up for abdominal pain- is it worth it? Journal of Pediatric Gastroenterology &
Nutrition. 51(5):p579-83,

Dixon, M. crawford, D. Teasdale, D. Murphy, J. (2009) Nursing the Highly Dependent Child or Infant Blackwell Publishing
Ltd, Oxford.

Dufton et al (2009) Anxiety and Somatic complaints in children with recurrent abdominal pain and anxiety disorders Journal
of Pediatric Psychology. 34(2):p176-86.

El-Matary et al (2004)Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J
Pediatr.163(10)p584-8.

Epsein et al (2008) Clinical Examination Fourth Edition Elsevier Ltd, London.Hennely, K. Bachur, R. ( 2011)
Appendictis Update Current Opinion in Pediatrics 23,(3) p 281–285

Hysia, R (2010) Pediatrics, Gastrointestinal bleeding http://emedicine.medscape.com/article/802064-overview

Kanto, W. (2002) Bilious vomiting- Is it That Bad? Journal Watch Pediatrics and Adolescent Medicine August 12.

Kessmann J. Hirschsprung's Disease: Diagnosis and Management. Am Fam Phys. 2006;74:1319-1322.

Minks, R. Pediatric Appendicitis Clinical Presentation http://emedicine.medscape.com/article/926795-clinical

NICE (2010) Constipation in Children and Young People

NICE (2009) Diarrhoea and Vomiting in Children

Ramchandani, P. et al ( 2011) An Investigation of Health Anxiety in families where Children have Recurrent Abdominal Pain
Journal of Pediatric Psychology. 36(4):409-19, 2011

Wyllie R. (2007) Intestinal atresia, stenosis, and malrotation. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier