1. ACUTE ABDOMEN
Acute abdomen by term definition is used to describe the abdominal
condition of rapid onset severe enough to warrant patients admission to
hospital. The cause of this will sometime be life threatening condition that
will require surgical inten… immediately or soon after rescucitation.
The cause of these can be grouped into:
1 Inflammatory conditions
2 Performation of hollow viscus
3 Hemorrhage
4 Medical conditions
DIAGNOSIS
Diagnosis is made from history physical findings and a few but careful
chosen laboratory investigations.
HISTORY
A carefully taken history is the key to a diagnosis of the cause of acute
abdomen in children.
Reliance is made on history from:
1. Parents for the infants
2. Older child with parental input
3. Old child’s own history
PAIN
Acute abdomen is heralded by abdominal pains. As relates to acute
abdomen specific aspects of the pain are important in leading to diagnosis.
A.
a. SITE OF PAIN
(i). Visceral pain (colic obstruction) is vague and is referred to the region
of sometime segments of the viscus involved:
1 Epigastric for foregut
2 Umbilicus for midgut
3 Hypogastric for hindgut
This is unreliable in young children. Older children can localize pain more
accurately. It is important to ask the child to point to indicate the site of
pain.
(ii). Sometime pain is a result of direct stimulation of the peritoneum and
peritonitis and is referred directly to the site of origin of pain. It is
2. sharp will described and is associated with tenderness.
b. SHIFT OF PAIN
Pain shift when perforation of the involved organ occurs and there is direct
stimulation of the parietal peritoneum. E.g. the pain of acute appendicitis is
initially epigastric. (Visceral pain) which later shifts to the right iliac fosa
when peritonitis sets on.
c. RADIATION OF PAIN
Parietal pain sometimes in felt elsewhere. This is not common in children
d. DURATION OF PAIN
Establish the duration of the present pain and whether it’s a continuation of
episodes of pain experienced in the past to establish whether this is an acute
or chronic problem.
e. PROGRESS OF PAIN
The pain that is getting better may resolve but the pain that is getting worse
may require surgical intervention.
f. NATURE OF THE PAIN
Progress and cresendo pain is important surgical pain as this is typical
intermittent pain of intestinal, biliary or renal condition.
f. SEVERITY OF THE PAIN
The severity and uniqueness of the pain is determined by asking whether a
similar pain has been experienced before and whether this is the worst pain
ever felt.
g. AGGREVATING FACTORS
Establishing the aggrevating factors is central to making a diagnosis and the
effect of abdominal movements is of particular important.
RELIEVING FACTORS
Ask for the factors that make the pain less.
3. B. VOMITING
The onset of vomiting and its relationship to the abdominal pain are
important and relevant. Its qualities and frequency color and type reflect the
level and duration of the intestinal unrest.
1 Food in early cases in the early composition of the vomitus
2 Blood stained to bile staining later in the history
3 Bile stained or feacal is indication lf intestinal obstruction
unless other causes can be found.
C. BOWEL HABBIT
Is there a genuine change in the bowel habit? Establish what is
normal in the patient before concluding there is change in pattern.
4 Constipation after previous abnormal surgery should alert the
possibility of adhesion causing intestinal obstruction
5 Diarrhea in many surgical conditions is slightly loose and
associated with other features. Loose stool is associated with
appendicitis, intusscusception.
6 Blood in stools is not common. Passage of bricks red stool
without abdominal pain is indication of Meckele diverticulum.
Bloody mucosal stool in a sick child is indication of pathology
of upper gastrointestinal blood for varices or peptic ulceration
present as rectal bleeding.
MICTURATION
Symptoms of abnormal micturation may accompany surgical diseases.
Micturating pain occur with pelvic appendicitis. Dribbling of some occur
with constipation.
MENSTRUATION
7 Complete menstrual history in teenage girls
8 Sudden mid cycle pain is indicated if ruptured follicle.
9 Amenorrhea with sudden abdominal pain may indicate ectopic
pregnancy.
PHYSICAL EXAMINATION
Physical examination is the second part in process making a diagnosis in
acute abdomen. It should yield new information that reinforces impressions
made from the history.
The physician should use his eyes, ears and his hands and he will achieve
this by inspection, ascultation palpation, percussion and ascultation.
4. OBSERVE
(i). Inactive of the child is most likely not having a significant surgical
problem.
A quiet, silent on lying with no movement is not likely having a
surgical problem
Restricted abdominal thoracic movements and its indicative of acute
abdomen or pneumonia.
Jaundice - chills
Temperature and pulse
State mucous membrane
Paltor
PALPATION
Warm hands are essential for a good examination
Avoid touching sore areas as pointed out by the patients abdominal wall.
Look at the child’s face while palpating the abdomen.
Look for;
1. Guarding. Stiffening of the muscularal wall of the abdominal wall
is indicative of local peritoneal initiation.
2. Feel for continuation of respiratory movement these are absent
with in the peritonitis.
3. Rigidity. This is muscular stiffening its indicative of peritonitis.
4. Masses felt on deep palpation may be abscess or intussusception.
5. Emptiness with right iliac fosa indicative of intuscuception.
RECTAL EXAMINATION
This can be informative and important to reach a diagnosis.
Intuscuception: blood mucoid stool or mass is palpable
Appendicitis: tenderness or mass if a bowel present.
10 Examine all hernial orifices for obvious hernia, which may be
obstructed.
Ascultations
In intestinal obstructions, the bowel sounds are high pitched
11 In peritonitis the bowel sounds are reduced or absent.
12 In gastroenteritis, the bowel sounds are rushing
5. INVESTIGATIONS
Diagnosis of the cause of acute abdomen in a child is often that 75% of the
case make by history and physical examination in more than 75% cases.
A few focused laboratory and imaging evaluation is carried out not so much
as to arrive at a diagnosis but as aid with plan of management.
Laboratory evaluation
Complete blood count, a shift to the left is sometimes relevant.
Serum chemistry
Electrolytes
Blood, urea nitrogen
Blood gas.
All are none specifications for diagnosis and useful in management of
patients with dehydration, acid basis and electrolyte imbalance and may
indicate the presence of bacterial infection.
URINE
Urinalysis: of low diagnostic value but can confirm the presence of urinary
tract infections or suspicion of a ureter stone.
Pregnancy test
Rule out ectopic pregnancy.
Imaging
i. Plain x-rays
Useful in intestinal obstruction
Useful in appendicolith
Useful in urinary stone.
Useful in perforation infection.
ii. Ultrasonography
Can visualize change in outline of solid organs.
Can visualize vascular supply to organs
Used more often in many cases of acute abdomen
iii. Upper and lower intestinal Contrast Studies
These are often used for different diagnosis in children as in
malformation or intuscuseption. Contrast used is either barren,
watersoluble gastrograffin or air.
iv. Computerised tormography
v. Magnetic resonance imaging are of no immediate use in acute
abdomen.
6. Other measures.
Laparotomy
Increasingly diagnostic laparotomy is being used in the absent of acute
abdomen. In particular patients suspected of appendicitis and management
of lower abdominal pains in young females.
Laparotomy
Laparotomy remains the mainstay of treatment in acute abdomen.
Exploratory laparotomy requires an incision that will expose the whole part
of the abdominal cavity to the surgeon. This is a transverse abdominal
incision in children and infants. In old children, a midline incision may be
enough. Systemic exploration of the abdominal cavity is carried out unless
the cause is immediately obvious.
TABLE 1. PROMPT SURGICAL INTERVENTION REQUIRED
Vascular compromise
Malrotation with Volvulus
Other intestinal torsion (eg, lymphangioma, colon)
Irreducible incarcerated hernias
Non-reduced intruscuception
Late adhesive bowel obstruction
Solid organ torsion (eg, gonad, spleen)
Perforated viscus
Acute appendicitis
Necrotizing enterocolitis
Idiopathic or drug-induced lesions (eg, steroids)
Peptic ulcer disease
Meckel’s diverticulum
Trauma
Foreign bodies
Acute hemorrhage
Trauma to solid viscus (unstable patient)
Trauma to major vessels
Meckel’s diverticulum
Ectopic pregnancy
TABLE 2. RELATIVE SURGICAL URGENCY REQUIRED
Intestinal obstruction
Congenital lesions (eg, atresia, bands, megacolon)
Adhesive bowel obstruction (early stages)
Postoperative intussuception
Inflammatory bowel disease
Tumor (eg, lymphoma)
8. Constipation
Aerophagia
Swallowed foreign bodies
Systemic and metabolic diseases
Henoch-Scoenlein purpura
Diabetes
Porhyria
Uremia
Hyperlipidemai
Addisonian crisis
Circulatory diseases
Cardiac failure
Microemboli
Intoxication
Lead
Thallium
Fungi
Certain insect and snake bites
Miscelaneous
Pneumoperitoneum secondary to mediastinal emphysema
Paralytic ileus
Labor (pregnancy)
Muscle strain (exercise, coughing)
Idiopatic conditions
Table 5. Differential Diagnosis Between Intestinal Strangulation and Obstruction
Strangulation Obstruction
Sudden onset Gradual onset, often accompanied by
Severe pain prodrome and/or associated disease
Early onset of emesis (usually colorless, process
Formy, “nagging,” not followed by relief) Oveflow emesis (bilious,fouls smelling
Shock floccular, perceived as providing relief)0
Blood and mucus in stool No flatus or stool abdominal distension
May be absent with high obstruction)
Aspiration pneumonia
Danger of adynamic ileus, dehydration,
Heat loss, aspiration.
Urgent prompt action required Adequate preparation required
Table 6. Factors That Influence the Timing of Operation
The patient
Heemodynamic, ventilatory, electrolyte status, associated conditions and risk
factors, medication, allergies pain.
The surgeon
Experience, availability of help, stress, other commitments, sleep deprivation
9. The environment
The operating team, availability, hour of day
Anaesthesia: experience, availability
Support services: blood banks, pathology, radiology
Other: Intensive care unit and expert postoperative nursing availability, child’s
family, medico-legal issues.
10. The environment
The operating team, availability, hour of day
Anaesthesia: experience, availability
Support services: blood banks, pathology, radiology
Other: Intensive care unit and expert postoperative nursing availability, child’s
family, medico-legal issues.
