Common abdominal emergencies in children
Section snippets
GENERAL APPROACH TO CHILDREN WITH ABDOMINAL EMERGENCIES
Pain is probably the most common reason that patients visit EDs to seek medical advice.18 Abdominal pain is a common complaint in children and is associated with a large number of gastrointestinal disorders. Nearly one third of children presenting to an ED with abdominal pain did not receive a specific diagnosis.41 Determining exact causes can be difficult. The emergency physician must be aware of stoic children who deny pain in fear of further medical intervention, and histrionic children who
APPENDICITIS
Appendicitis is the most common nontraumatic surgical emergency in children.15 There is a slight male predominance, with a peak incidence of 9 to 12 years of age.35 Although uncommon in infants and children under 2 years, neonatal cases have been reported.32 Diagnosis is particularly challenging in this younger age group.
HYPERTROPHIC PYLORIC STENOSIS
Pyloric stenosis, an idiopathic hypertrophy of the pyloric muscle, is the most common pediatric surgical condition that causes emesis.23 The etiology is unknown. Pyloric stenosis occurs in about 1 in 250 births; first-born boys are at increased risk.25 There is a male-to-female ratio of 4:1.
INTUSSUSCEPTION
Intussusception, an invagination of the proximal portion of the bowel into an adjacent distal bowel segment, is a common cause of intestinal obstruction in infants,24 second only to an incarcerated inguinal hernia as the cause of intestinal obstruction in infants.51 The peak incidence of intussusception is at 10 months of age, with a range of 3 months to 2 years. Pathologic lead points are commonly noted in older children, with Meckel's diverticulum being the most common.29 In children younger
MALROTATION AND MIDGUT VOLVULUS
Volvulus results from an incomplete rotation and an abnormal fixation of the bowel during embryonic development. This malrotation predisposes the bowel to twist on itself, leading to bowel obstruction and vascular compromise. Volvulus occurs in 68% to 71% of neonatal malrotation cases.56 Patients with malrotation may have obstructing fibrous bands (Ladd's bands) that can cause proximal intestinal obstruction. Unfortunately, complete volvulus can lead to bowel necrosis in 1 to 2 hours,15 and
Clinical Presentation
Midgut volvulus has a sudden onset of vomiting, abdominal pain, and feeding intolerance in the otherwise healthy young infant. Bilious emesis, the hallmark, is present in 77% to 100% of cases.44, 56 Symptoms are more vague in the older child and malrotation without volvulus can occur even in adulthood. The older child can display symptoms of chronic, intermittent vomiting, crampy abdominal pain, failure to thrive, constipation, bloody diarrhea, and hematemesis.30 The frequency of volvulus
MECKEL'S DIVERTICULUM
Meckel's diverticulum, a vestige of the omphalomesenteric duct, occurs in 2% of the population. Two percent of patients with a Meckel's diverticulum manifest symptoms. The diverticulum is usually 2 feet proximal to the terminal ileum. Forty-five percent of symptomatic patients are younger than 2 years old.2 This finding is known as “Meckel's rule of twos.”
INCARCERATED INGUINAL HERNIA
Inguinal hernia repair is the most common surgical procedure in children. One to two percent of children have an inguinal hernia (approaching 30% in premature infants) and 10% of inguinal hernias eventually are complicated by incarceration.33 Seventy percent of incarcerations occur in infants younger than 1 year of age,57 with the greatest risk occurring during the first 6 months of life.49 If left undiagnosed and untreated, incarcerated inguinal hernias can have serious and even
SUMMARY
Because young children often present to EDs with abdominal complaints, emergency physicians must have a high index of suspicion for the common abdominal emergencies that have serious sequelae. At the same time, they must realize that less serious causes of abdominal symptoms (e.g., constipation or gastroenteritis) are also seen. A gentle yet thorough and complete history and physical examination are the most important diagnostic tools for the emergency physician. Repeated examinations and
References (60)
- et al.
Clinical validity of ultrasound in children with suspected appendicitis
Ann Emerg Med
(1993) - et al.
The treatment of complicated appendicitis in children using peritoneal drainage: Results from a public hospital
J Pediatr Surg
(1993) Nontraumatic surgical emergencies in children
Emerg Med Clin North Am
(1991)- et al.
Acute appendicitis in preschool age children
Am J Surg
(1980) - et al.
Importance of diarrhea as a presenting symptom of appendicitis in very young children
Am J Surg
(1997) - et al.
The approach to common abdominal diagnoses in infants and children
Pediatr Clin North Am
(1998) - et al.
Selective use of ultrasonography for acute appendicitis in children
Am J Surg
(1999) Intussusception and the diagnostic value of testing stool for occult blood
Am J Emerg Med
(1991)The evaluation of acute abdominal pain in children
Emerg Med Clin North Am
(1996)- et al.
Intussusception: Barium or air?
J Pediatr Surg
(1991)
Pediatric appendectomy
J Pediatr Surg
The approach to common abdominal diagnoses in infants and children, Part II
Pediatr Clin North Am
Acute appendicitis in children: Emergency department diagnosis and management
Ann Emerg Med
Clinical features of misdiagnosed appendicitis in children
Ann Emerg Med
The treatment of pain in the emergency department
Pediatr Clin North Am
Measuring pain quality: Validity and reliability of children's and adolescents' pain language
Pain
Ultrasound investigation of pyloric stenosis
Radiogr Today
Meckel's diverticulum
Appendicitis in the first three years of life
Aust NZJ Surg
Infantile hypertrophic pyloric stenosis
Intussusception in infants and children: Diagnosis and therapy
Radiology
Sonographic diagnosis of hypertrophic pyloric stenosis
AJR Am J Radiol
The clinical features of children with malrotation of the intestine
Pediatr Emerg Care
Meckel's diverticulum in the pediatric surgical population
Conn Med
Intussusception: Evolution of current management
J Pediatr Gastroenterol Nutr
Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults
AJR Am J Radiol
Gastrointestinal bleeding
Progress of acute appendicitis: A study in children
Br J Surg
Neurophysiology of pain and pain modulation
Am J Med
Appendicitis
Cited by (56)
Non-traumatic abdominal surgical emergencies in children in Dapaong (TOGO)
2023, International Journal of Surgery OpenPerforation of ileum by unnoticed toothpick ingestion presenting as acute appendicitis: A case report
2023, International Journal of Surgery Case ReportsCitation Excerpt :A self-limiting benign condition, such as gastroenteritis, causes most cases of acute abdominal pain. Still, it can also result from more severe and life-threatening conditions, such as appendicitis and intussusception [2]. The most frequent pediatric surgical emergency is appendicitis [3].
Abdominal pain
2022, Journal de Pediatrie et de PuericultureLaboratory Tests in the Patient with Abdominal Pain
2021, Emergency Medicine Clinics of North AmericaCitation Excerpt :The water volume and electrolyte depletion can be quite profound with certain types of parasitic infection, such as Cryptosporidium, Cystoisospora, and Giardia species, especially in immunocompromised individuals.16 In pediatric patients with abrupt illnesses including malrotation or midgut volvulus, this test serves little diagnostic utility; however, it may show significant electrolyte derangement and evidence of failure to thrive in the setting of repeated vomiting in chronic intermittent malrotation without volvulus, which can be seen in older children and even adults.10 Although corrected surgically, pyloric stenosis often requires significant medical resuscitation because of the profound electrolyte abnormalities and volume depletion associated with the repeated vomiting characteristic of this condition.
Priorities in Evaluation of the Acute Abdomen
2018, Abernathy's Surgical Secrets: Seventh EditionMesenteric cystic lymphangioma causing jejunal obstruction
2017, Journal of Pediatric Surgery Case ReportsCitation Excerpt :Surgery prevails as both diagnostic and therapeutic. Cases of small bowel obstruction in the pediatric patient rarely present with cystic lymphangiomas and instead present with several other documented conditions such as intussusception, incarcerated hernias, acute midgut volvulus, adhesions and duplication cysts [8,9]. Yet, cystic lymphangiomas are not commonly considered as a cause for episodes of small bowel obstruction and malrotation [10].