Emergency Management of Acute Abdomen in Children

Abstract

Acute abdomen can be defined as a medical emergency in which there is sudden and severe pain in abdomen with accompanying signs and symptoms that focus on an abdominal involvement. It accounts for about 8 % of all children attending the emergency department. The goal of emergency management is to identify and treat any life-threatening medical or surgical disease condition and relief from pain. In mild cases often the cause is gastritis or gastroenteritis, colic, constipation, pharyngo-tonsilitis, viral syndromes or acute febrile illnesses. The common surgical causes are malrotation and Volvulus (in early infancy), intussusception, acute appendicitis, and typhoid and ischemic enteritis with perforation. Lower lobe pneumonia, diabetic ketoacidosis and acute porphyria should be considered in patients with moderate-severe pain with little localizing findings in abdomen. The approach to management in ED should include, in order of priority, a rapid cardiopulmonary assessment to ensure hemodynamic stability, focused history and examination, surgical consult and radiologic examination to exclude life threatening surgical conditions, pain relief and specific diagnosis. In a sick patient the initial steps include rapid IV access and normal saline 20 ml/kg (in the presence of shock/hypovolemia), adequate analgesia, nothing per oral/IV fluids, Ryle's tube aspiration and surgical consultation. An ultrasound abdomen is the first investigation in almost all cases with moderate and severe pain with localizing abdominal findings. In patients with significant abdominal trauma or features of pancreatitis, a Contrast enhanced computerized tomography (CECT) abdomen will be a better initial modality. Continuous monitoring and repeated physical examinations should be done in all cases. Specific management varies according to the specific etiology.

Lower Lobe Pneumonia Presenting with a Picture of Acute Abdomen: Case Report

“…For example, the T9 dermatome is shared by the lungs and abdomen; therefore, a case of lower right lobe pneumonia may lead to a symptom of abdominal pain [5]. Lower lobe pneumonia cases account for 2-5% of the patients who present to emergency services with a picture of acute abdomen [6]. In cases where abdominal pain is accompanied by signs such as fever and cough, pulmonary pathologies are strongly considered.…”

An Ignored Cause of Acute Abdomen: Lower Lobe Pneumonia

“…T9 dermatomu akciğer ve karın tarafından paylaşıldığı için pnömonili hastalar karın ağrısı ile başvurabilmekte-dirler (5) . Alt lob pnömonileri acil servislere akut batın tablosu ile başvuran hastaların %2 ile 5'ini oluşturmaktadır (6) . Karın ağrısına ateş ve öksürük gibi bulguların eşlik ettiği olgularda akciğer patolojileri ön planda düşünülmektedir.…”

The role of US examination in the management of acute abdomen

“…The differential diagnosis of acute abdomen in children varies according to the age, these are reported in Table 2 [20]. The pain is often due to a wide range of mild self-limiting medical causes, but it sometimes may be due to an acute potentially life threatening, surgical/medical illness (8%), so that the goal of emergency management is to ensure that life-threatening surgical causes are not missed [20]. These include appendicitis, non -reducibile intussusception, intestinal obstruction, incarcerated hernia, volvulus, ovarian/testicular torsion, perforated viscus with diffuse peritonitis, rupture tumor.…”

“…CT and US have been less well evaluated in children than in adults, but there is increasing data on imaging use in the paediatric population. Several factors are unique in children, including increased radiosensitivity to ionizing radiation and smaller body size and less body fat, favouring the initial use of US [20]. Even if procedural imaging depends on clinical manifestation and clinical suspicion of the etiology of acute abdomen, US abdomen examination is the first investigation in almost all cases with moderate and severe abdominal pain.…”

“…Doppler flow may be used to identify complications like bowel ischemia. If signs of intussusception are not identified by US, proceeding with a barium or air enema should still be considered, if the clinical suspicion is high [20]. Alternatively hepatobiliary disease and acute pancreatitis are easily confirmed by US and liver/pancreatic function tests.…”