1. Acute abdomen inAcute abdomen in
pediatricpediatric
DR.MEDHAT M, IBRAHIMDR.MEDHAT M, IBRAHIM
CONSULTANTCONSULTANT
PEDIA,SURGERYPEDIA,SURGERY

2. Definition of the acuteDefinition of the acute
abdomenabdomen
 This is an abdominal condition whichThis is an abdominal condition which
interfere with the normal live and makeinterfere with the normal live and make
patient ask the medical advice with in fewpatient ask the medical advice with in few
hours.hours.
 Emergent abdominal condition is theEmergent abdominal condition is the
abdominal condition need for immediateabdominal condition need for immediate
interference with out any delay.interference with out any delay.

3. EtiologyEtiology
 InflammatoryInflammatory
 Traumatic ?Traumatic ?
 ObstructiveObstructive
 VascularVascular

4. Age related causeAge related cause
 Neonatal causesNeonatal causes ::
 Necrotizing enter colitisNecrotizing enter colitis
 Obstructive causesObstructive causes
 Mega colonMega colon
 Meconieum plugsMeconieum plugs
 Atresia and its typesAtresia and its types
 malrotatinmalrotatin
 Birth injuriesBirth injuries
 Infant causesInfant causes::
 GastroenteritisGastroenteritis
 NonspecificNonspecific
abdominal painabdominal pain
 Complicated herniaComplicated hernia
 IntussusceptionsIntussusceptions
 malrotationmalrotation
 Volvulus and vascularVolvulus and vascular
insufficienciesinsufficiencies

5. Age related causesAge related causes
 Child age acute abdomen:Child age acute abdomen:

6. Presentation of acute abdomenPresentation of acute abdomen
 Abdominal painAbdominal pain
 Abdominal massAbdominal mass
 Organ dysfunctionOrgan dysfunction
 BleedingBleeding

8. Upper G I T bleedingUpper G I T bleeding
Endoscopic images from children with (a) a normal
esophagus, (b) an esophagus with erosive reflux esophagitis, and
(c) an esophagus affected by eosinophilic esophagitis.
Eosinophilic
esophagitis, distinct from GERD, often appears as in this
image, with furrowing of the esophageal mucosa, and white

11. Abdominal tumors
Neuroblastoma lymphoma Willms tumors Rabdomyosarcoma

12. Abdominal tumors (renalAbdominal tumors (renal((

13. Intestinal lymphomaIntestinal lymphoma
 Tumor induce abdominal pain ,mass,andTumor induce abdominal pain ,mass,and
intestinal obstractionintestinal obstraction
 Obstractin is the indecation of surgeryObstractin is the indecation of surgery

14. Inflammatory causesInflammatory causes
 Primary bacterial peritonitisPrimary bacterial peritonitis
• spontaneous bacterial peritonitisspontaneous bacterial peritonitis
• spontaneous bacterial peritonitis in healthy patientsspontaneous bacterial peritonitis in healthy patients
 Secondary bacterial peritonitisSecondary bacterial peritonitis
• visceral perforation, inflammation, tumorvisceral perforation, inflammation, tumor
(pathology)(pathology)
 Tertiary bacterial peritonitisTertiary bacterial peritonitis
• most bad prognosis it is usually occur in ICUmost bad prognosis it is usually occur in ICU
patientspatients

15. Gut perforation secondaryGut perforation secondary
peritonitisperitonitis

16. Plain X-Ray in perforated gutPlain X-Ray in perforated gut

17. TraumaticTraumatic
 That abdominal condition is not includingThat abdominal condition is not including
the abdominal trauma which was need forthe abdominal trauma which was need for
specific different management.specific different management.
 Bleeding and Gut contents causedBleeding and Gut contents caused
peritonitis.peritonitis.

18. ObstructiveObstructive
 Hollow organ obstructive disordersHollow organ obstructive disorders
 Most common colon (spastic colon andMost common colon (spastic colon and
irritable bowel syndrome)irritable bowel syndrome)
 Obstructive type of acute appendicitisObstructive type of acute appendicitis
 Intestinal obstructionIntestinal obstruction
 Obstructive uropathyObstructive uropathy
 Bilary colicBilary colic

19. VascularVascular
 Acute ischemiaAcute ischemia
 Necrotizing enter colitis is the mostNecrotizing enter colitis is the most
common cause in neonatecommon cause in neonate
 The entropic drugs become the mostThe entropic drugs become the most
common cause in the childrencommon cause in the children
 Intussusceptions and VolvulusIntussusceptions and Volvulus
 Strangulated herniaStrangulated hernia

20. MalrotationMalrotation
 The commonest features of malrotation are:The commonest features of malrotation are:
 (1)the D-J flexure lies right of midline,(1)the D-J flexure lies right of midline,
 (2) the dorsal mesenteric attachment is narrow(2) the dorsal mesenteric attachment is narrow
 (3) peritoneal folds cross from colon and Caecum to(3) peritoneal folds cross from colon and Caecum to
duodenum, liver and gallbladder (Laddduodenum, liver and gallbladder (Ladd’’s bands), thuss bands), thus
possibly obstructing the duodenum. Whether Laddpossibly obstructing the duodenum. Whether Ladd’’ss
bands are substantial enough to cause mechanicalbands are substantial enough to cause mechanical
obstruction is debatable. The narrowed mesentericobstruction is debatable. The narrowed mesenteric
base can lead to midgut volvulus, bowel obstructionbase can lead to midgut volvulus, bowel obstruction
and mesenteric vessel occlusion.and mesenteric vessel occlusion.

21. Congenital band of Ladd'sCongenital band of Ladd's

22. MalrotationMalrotationMalrotationMalrotation

23. MalrotationMalrotation
Cork screw upperCork screw upper
jejunum,jejunum,
indicative ofindicative of
volvulus withvolvulus with
partial obstructionpartial obstruction

24. outcomeoutcome
The outcome of patients undergoingThe outcome of patients undergoing
LaddLadd’’s procedure for isolateds procedure for isolated
malrotation is very good and themalrotation is very good and the
majority make a full recovery. Themajority make a full recovery. The
commonest postoperativecommonest postoperative
complication is adhesioncomplication is adhesion
obstruction occurs in 45obstruction occurs in 45––65% of65% of
children with malrotation and stillchildren with malrotation and still
carries a mortality rate of 7carries a mortality rate of 7––15%;15%;
necrosis of more than 75% of thenecrosis of more than 75% of the
midgut short bowel syndromemidgut short bowel syndrome

25. Meconieum IleusMeconieum Ileus
symptoms include abdominalsymptoms include abdominal
distension (96%), biliousdistension (96%), bilious
vomiting (50%) and delayedvomiting (50%) and delayed
passage From a clinical point ofpassage From a clinical point of
view, it is possible to recognizeview, it is possible to recognize
two different conditions:two different conditions:
a simple, uncomplicated anda simple, uncomplicated and
non-surgical type, andnon-surgical type, and
a complicated, severe type, witha complicated, severe type, with
a mortality of at leasta mortality of at least
25% of all cases.25% of all cases.
In the first type (58%), signs andIn the first type (58%), signs and
symptoms of a distal ilealsymptoms of a distal ileal
obstruction are seen not laterobstruction are seen not later
than 48 h after birththan 48 h after birth

26. Meconium IleusMeconium Ileus
When meconium has a very highWhen meconium has a very high
protein content and is particularlyprotein content and is particularly
sticky, it can cause distal ilealsticky, it can cause distal ileal
obstruction.obstruction.
For practical purposes, meconium ileusFor practical purposes, meconium ileus
means cystic fibrosis and 10% to 20%means cystic fibrosis and 10% to 20%
of cystic fibrosis patients present inof cystic fibrosis patients present in
this way in the neonatal period.this way in the neonatal period.
As with ileal atresia, the neonateAs with ileal atresia, the neonate
presents with bilious vomiting andpresents with bilious vomiting and
abdominal distension, and failure toabdominal distension, and failure to

27. Gas in inspisated MeconieumGas in inspisated Meconieum
 Besides theBesides the
nonspecific signs ofnonspecific signs of
obstruction seen onobstruction seen on
plain film, the mostplain film, the most
characteristiccharacteristic
evidence is of aevidence is of a
FrothyFrothy bubbly patternbubbly pattern
of bowel gas in theof bowel gas in the
right lower quadrantright lower quadrant
which indicates gaswhich indicates gas
in inspesiatedin inspesiated
meconium.meconium.

28. Meconium ileusMeconium ileus

29. MECONIUM ILEUSMECONIUM ILEUS
A contrast enema with water-soluble and hyperorA contrast enema with water-soluble and hyperor
iso-osmolar contrast is the medical treatment ofiso-osmolar contrast is the medical treatment of
choice and mucosal safe, for uncomplicated cases. Achoice and mucosal safe, for uncomplicated cases. A
recent study that used various enema solutionsrecent study that used various enema solutions
administeredadministered
in a mouse model showed that surfactantin a mouse model showed that surfactant
and Gastrografin were the most efficacious for the inand Gastrografin were the most efficacious for the in
vivo relief of constipation in comparison withvivo relief of constipation in comparison with
perflubron,perflubron,
Tween-80, Golytely, DNase,Tween-80, Golytely, DNase, NN-acetylcysteine-acetylcysteine
and Viokase.and Viokase.

30. ATRESIAATRESIA
 Neonatal obstructive pathology due to lossNeonatal obstructive pathology due to loss
of the gut lumen continuity.of the gut lumen continuity.
 Intra-uterin vascular insult is the cause.Intra-uterin vascular insult is the cause.
 Ante natal ultra sound is diagnostic.Ante natal ultra sound is diagnostic.
 There is several types, the contrast studyThere is several types, the contrast study
post natal is corner stone of the diagnosis.post natal is corner stone of the diagnosis.
 Prognosis is variable depending onPrognosis is variable depending on
several factors as the neonate generalseveral factors as the neonate general
assessment +and type of atresia.assessment +and type of atresia.

31. Dr Magda Shady Clinic
Dr. Magda Shady Clinic
Dr Magda Shady Clinic
Collapsed lower bowelCollapsed lower bowel
Dr Magda Shady Clinic
LaddLadd’’s band at DJJ.s band at DJJ.

32. Presentation of intussusceptionsPresentation of intussusceptions''
Typical symptoms pattern. In an early
state initial vomiting – found
in 80%.
lethargy are caused by tearing of the
mesentery;
obstruction, as well as no abdominal
distension.
Colicky, intermittent abdominal pain.
initially around every 20 min – but
with increasing frequencies. on
examination?? palpable abdominal
mass

33. U.S-IntussusceptionsU.S-Intussusceptions

34. IntussusceptionIntussusception

35. IntussusceptionsIntussusceptions

36. ManagementManagement
 HydrostaticHydrostatic
reduction underreduction under
radiological guideradiological guide
is the modern wayis the modern way
for ttt.for ttt.
 Open manualOpen manual
reduction after it isreduction after it is
failure or if it is notfailure or if it is not
available.available.

37. N.E.CN.E.C
--1-31-3cases per 1000 livecases per 1000 live
birthbirth,,
-Mortality 10% to 70%.-Mortality 10% to 70%.
--it is the disease ofit is the disease of
prematurityprematurity..
--infant below 1500gminfant below 1500gm
have high significanthave high significant
mortalitymortality..
--Bell staging system ofBell staging system of
N.E.C. to 3 stagesN.E.C. to 3 stages..
--peritoneal lavage in aperitoneal lavage in a
new method for tttnew method for ttt..

38.  PNEUMATOSISPNEUMATOSIS
INTESTINALISINTESTINALIS..
 THERE ARE ALSOTHERE ARE ALSO
SUBTLE AIRSUBTLE AIR
DENSITIES OVERDENSITIES OVER
THE LIVER. THISTHE LIVER. THIS
SUGGESTS THATSUGGESTS THAT
THERE IS AIR INTHERE IS AIR IN
THE PORTALTHE PORTAL
CIRCULATIONCIRCULATION
(INTRAPORTAL AIR).(INTRAPORTAL AIR).
 BOTH FINDINGSBOTH FINDINGS
INDICATEINDICATE
NECROTIZINGNECROTIZING
ENTEROCOLITISENTEROCOLITIS ..

39.  PNEUMATOSISPNEUMATOSIS
INTESTINALIS.INTESTINALIS.
 NOTE THE AIRNOTE THE AIR
IN THE BOWELIN THE BOWEL
WALL.WALL.
 DOUBLEDOUBLE
LINEDLINED
APPEARANCEAPPEARANCE
(ie.,(ie.,
RAILROADRAILROAD
TRACKSTRACKS
WITHOUTWITHOUT
TIESTIES).).

40. Hypertrophic pyloric stenosisHypertrophic pyloric stenosis
 The ultrasound isThe ultrasound is
diagnostic , contrastdiagnostic , contrast
study is performedstudy is performed
only in d doubtful.only in d doubtful.
 Correction of theCorrection of the
electrolytes and pH,electrolytes and pH,
and hydration isand hydration is
mandatory beforemandatory before
OR.OR.

41. Hypertrophic pyloric stenosisHypertrophic pyloric stenosis
 Common in male 4-1.Common in male 4-1.
 First born at 2w-7w.First born at 2w-7w.
 Projectile non bileProjectile non bile
stain ,increase instain ,increase in
severity and frequencyseverity and frequency
with time.with time.
 Constant hunger justConstant hunger just
after the vomiting.after the vomiting.
 Hypo cl alkalosis .Hypo cl alkalosis .
 Olive mass at the rtOlive mass at the rt
hypo chondriam.hypo chondriam.

42. Barium studyBarium study

43. Acute appendicitisAcute appendicitis

44. Acute app,Acute app,
Gradual onset generalizedGradual onset generalized
abdominal pain , whichabdominal pain , which
become localized to rt iliacbecome localized to rt iliac
foss. associated withfoss. associated with
nausea and vomiting.nausea and vomiting.
--the use of medication--the use of medication
change this picture.change this picture.
--the advance in the--the advance in the
radiological diagnosisradiological diagnosis
make it is diagnosis by U.Smake it is diagnosis by U.S
and C.T more accurate .and C.T more accurate .
--laparoscopic or open--laparoscopic or open
appendectomy is the ttt.appendectomy is the ttt.

45. AppendicitisAppendicitis
 an appendix with a diameteran appendix with a diameter ofof more than 6 mm .more than 6 mm .
periappendiceal inflammation, conventionalperiappendiceal inflammation, conventional CTCT
criteria have efficacy in differentiatingcriteria have efficacy in differentiating appendicitisappendicitis
from a normal appendix. However, the newfrom a normal appendix. However, the new CTCT
criterion based on a maximum depthcriterion based on a maximum depth ofof thethe
intraluminal appendiceal fluidintraluminal appendiceal fluid ofof more than 2.6 mm ismore than 2.6 mm is
helpful in this differentiation.helpful in this differentiation.

46. Acute pancreatiatsAcute pancreatiats
 Pancreatitis is uncommon duringPancreatitis is uncommon during
childhood.childhood.
 It should be considered in every child withIt should be considered in every child with
unexplained acute abdominal pain.unexplained acute abdominal pain.
 The prognosis is generally good.The prognosis is generally good.
 C.T scan and serum amylase +abdominalC.T scan and serum amylase +abdominal
pain is the golden stone for diagnosis .pain is the golden stone for diagnosis .
 Management will directed to the cause.Management will directed to the cause.

47. Distribution of clinical
presentation
 Symptoms /Signs (%)
 Abdominal pain 11 (91.7%)
 Upper (41.7%)
 Central (33.3%)
 Lower
 Generalised (16.7%)
 Vomiting (58.3%)
 Fever (16.7%)
 Abdominal tenderness (100%)
 Upper (75.0%)
 Central (8.3%)
 Lower (8.3%)
 Generalised (16.7%)
 Abdominal distension (8.3%)
 Abdominal mass (16.7%

48. Complicated herniaComplicated hernia
 The inguinal hernia isThe inguinal hernia is
the most commonthe most common
obstructive pathologyobstructive pathology
in infants and childrenin infants and children
in pre-school age.in pre-school age.
 Groin swellingGroin swelling
+abdominal pain ++abdominal pain +
vomiting arevomiting are
diagnosticdiagnostic

49. Scrotal causesScrotal causes
 Testicular torsion ,Testicular torsion ,
and a testicularand a testicular
appendicealappendiceal
torsion are antorsion are an
important causesimportant causes
of abdominal painof abdominal pain
in children.in children.
 Clinical +u.sClinical +u.s
=diagnosis.=diagnosis.

50. --ACUTE ABDOMINAL PAIN.ACUTE ABDOMINAL PAIN.
-COMPLEX ADENEXIAL MASS-COMPLEX ADENEXIAL MASS
(U.S).(U.S).
-ELEVATED W.B.C-ELEVATED W.B.C
Ovarian torsion orOvarian torsion or
tumortumor

51. Hydro-pyo-metrocolopsHydro-pyo-metrocolops

52. Incidence of the NSAP ,to acuteIncidence of the NSAP ,to acute
appendicitis and intestinal ;obstructionappendicitis and intestinal ;obstruction

53. Red Flags of recurrent abdominalRed Flags of recurrent abdominal
pain syndromepain syndrome

54. InvestigationsInvestigations
 What is the general condition of theWhat is the general condition of the
patient? (Essential investigation for allpatient? (Essential investigation for all
acute abdomens).acute abdomens).
 What is the primary cause of the acuteWhat is the primary cause of the acute
abdomen? (specific investigation).abdomen? (specific investigation).

55. EssentialEssential
 Haemoglobin,WCC,PCVHaemoglobin,WCC,PCV
 Urea and electrolytes, amylase.Urea and electrolytes, amylase.
 Chest X-ray, supine and erect abdominalChest X-ray, supine and erect abdominal
X-rayX-ray
 Blood CulturesBlood Cultures
 Group and save cross matchGroup and save cross match

56. SpecificSpecific
 Abdominal ultrasoundAbdominal ultrasound
 Abdominal CTAbdominal CT
 Peritoneal lavagePeritoneal lavage
 Mesenteric angiographyMesenteric angiography
 Laparoscopic laparotomyLaparoscopic laparotomy

57. Logarithm for work upLogarithm for work up

58. Complex anomaliesComplex anomalies

59. Thank you