Approach
• Nature of pain: Location, constant or intermittent, relation to eating, associated sxs
• PMH: Previous abdominal surgeries, prematurity
• Exam: Always perform genital exam in males to r/o testicular torsion
• Labs: CBC, CRP, BMP, UA, LFTs, lipase if in the upper abdomen
APPENDICITIS
Definition
• Inflammation of the appendix
History
• Diffuse/periumbilical pain → localizing to RLQ, anorexia, nausea, vomiting, irritability (may be the only sx in age <2), fever
Physical Findings
• RLQ tenderness, rebound/guarding, Rovsing sign (RLQ pain w/ palpation in LLQ), psoas sign (RLQ pain w/ hip extension), obturator sign (RLQ pain w/ leg flexion + internal hip rotation)
Evaluation
• Labs: CBC, UA (sterile pyuria/mild hematuria), hCG
• Imaging: U/S (90% sens: Much lower if perforated/large habitus/operator dependent), abdominal plain films (fecalith 10%), CT scan (95% sens/spec)
Treatment
• Surgical consult for operative management, abx (ampicillin 50 mg/kg, gentamicin 1 mg/kg + metronidazole 15 mg/kg or cefoxitin 20–40 mg/kg)
Disposition
• Admit
Pearls
• 90% of children <2 y/o have perforation at presentation (thinner walled/looser omentum → ↑ perforation)
• Young children may not have anorexia
INTUSSUSCEPTION
Definition
• Invagination of bowel into another, most commonly ileocolic (most frequent cause of SBO in <6 y/o)
History
• Age 3 mo–3 yr (peak 5–9 mo), lethargy, vomiting, intermittent fussiness/crying/inconsolability w/ drawing legs to chest, cramping abdominal pain
Physical Findings
• Not tender b/w episodes, abdominal tenderness, RUQ sausage-like mass, heme + stool, “currant jelly” stool (late finding in <1/3 of pts)
Evaluation
• Upright plain abdominal film to r/o free air: SBO/air outlining area/nl; U/S (definitive): Target, bull’s eye, doughnut, pseudokidney sign; barium/air/water enema: Diagnostic/therapeutic (90% successful)
Treatment
• Barium/air/water enema, NGT, surgical consult for operative management in case barium enema fails, hydration (severe dehydration is common), NPO
Disposition
• Admission for 24 h observation
Pearls
• <3 y/o likely idiopathic
• Barium enema is contraindicated if peritoneal signs
MALROTATION WITH MIDGUT VOLVULUS
Definition
• Malrotation & weak fixation of the duodenum & colon during embryologic development → twisting of the mesentery causing duodenal obstruction/SMA compression → necrosis
History
• Neonate (may be older), acute abdominal pain, bilious vomiting, ±distension, irritability/lethargy, FTT, mostly occur w/i 1st year of life
Physical Findings
• Ill appearing/dehydration, heme + stool/grossly bloody, abdominal tenderness, often peritoneal
Evaluation
• Upright plain films: “Double bubble” (dilated stomach & duodenum)/pneumatosis/SBO; U/S: “Whirlpool sign”; upper GI series (diagnostic): “Corkscrew sign”, coiled-spring appearance of jejunum
Treatment
• Immediate surgical consult for operative management, NGT, NPO, abx, fluids
Disposition
• Admission
INCARCERATED/STRANGULATED HERNIA
Definition
• Defects in the abdominal wall that allow protrusion of abdominal contents through the inguinal canal
History
• More commonly male, abdominal/groin/testicular pain, inguinal fullness w/ prolonged standing/coughing, vomiting, irritability in infants
Physical Findings
• Intestine/BS in scrotal sac
Evaluation
• Scrotal/abdominal U/S if physical exam is unclear, x-ray can be used to r/o free air
Treatment
• Reduction: Place in Trendelenburg → gentle pressure ± ice analgesic/benzodiazepines; >12 h concern for perforation/gangrene → surgical management
Disposition
• Admission if operative management required
MECKEL’S DIVERTICULUM
Definition
• Omphalomesenteric duct remnant w/ 60% containing heterotopic gastric (80%) or pancreatic tissue
History
• Any age (sxs usually begin <2 y/o), ±LLQ pain, melanotic stool (acid secretion → ulceration/erosion of mucosa), vomiting, sx of SOB, intussusception
Physical Findings
• LLQ mass, heme + stool/brisk bleeding, abdominal distension
Evaluation
• Technetium scan (Meckel’s scan): Identifies heterotopic gastric tissue (90% sens)
Treatment
• Type & cross/transfuse for brisk bleeding, surgical consult for Meckel’s diverticulectomy
Disposition
• Admit
NECROTIZING ENTEROCOLITIS (NEC)
Definition
• Inflammatory condition of intestinal wall
History
• Preterm neonate (10% full term), bilious vomiting, abdominal distension, bloody stool, feeding intolerance
Physical Findings
• Ill appearing, hypotension, lethargic, abdominal tenderness, heme + stools, diarrhea
Evaluation
• Abdominal x-ray: Pneumatosis intestinalis (75%); barium enema if x-ray is ambiguous
Treatment
• NPO, hydration/transfusion, NGT, abx (ampicillin/gentamicin/metronidazole), surgical consult
Disposition
• Admit
Pearls
• Bell stages: I. Vomiting/ileus, II. Intestinal dilation/pneumatosis on x-ray, III. Shock/perforation
• Cx: DIC, strictures, obstruction, fistulas, short gut syndrome
HIRSCHSPRUNG DISEASE
Definition
• Absence of ganglion cells in the myenteric plexus of the colon → constant contraction & proximal dilation → constipation (4:1 male predominance)
History
• Chronic constipation, delayed 1st meconium, FTT, abdominal distension, vomiting
Physical Findings
• Palpable stool in abdomen, tight sphincter, fecal mass in LLQ, no stool in rectal vault, “squirt” – explosive release of stool when finger is withdrawn
Evaluation
• Abdominal plain film: Dilated colon/fecal impaction/air fluid levels; barium enema; Dx → biopsy (aganglionosis) or anal manometry
Treatment
• Outpt surgical eval
Disposition
• D/c unless cx: Toxic mega colon, perforation, enterocolitis