Common abdominal emergencies in children

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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

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