stomach ache

September 6 2022

Acute Abdominal Pain: Necrotizing Enterocolitis

PME-Admin article, medical abdominal pain, children, emergencies, NEC, necrotizing enterocolitis, pediatric, pediatrics, stomach ache

Acute Abdominal Pain: Necrotizing Enterocolitis — Santa J. Bartholomew M.D.

Acute Abdominal Pain in Children: Necrotizing Enterocolitis

NEC is one of the most common GI emergencies in the newborn infant. Characterized by ischemic necrosis of the intentinal mucosa and associated with severe inflammation of the bowel. As gas forms in the bowel from gas producing organisms and bacteria these organisms can leak through the wall of the gut into the bloodstream causing severe sepsis, loss of large portions of bowel and death if not diagnosed and treated early.

Preterm infants: Incidence 2-7.5%

More susceptible to GI injury because they lack GI defenses such as gastric acid, fully developed GI enzymes, normal mucous production because of incomplete maturity of villi, inadequate peristalsis and inadequate amounts of IgA.
- Acid and enzymes: eliminate most ingested pathogens and antigens from food
- Mucous inhibits the sticking of bacteria to the wall of the GI tract so it can cause inflammation.
- Active peristalsis prevents bacteria from forming complexes with antibodies from the infant that can be detrimental to the GI tract
- IgA reduces the risk of bacterial and viral antigens from penetrating the GI wall

Term Infants: Incidence 1-%

Typically, these infants are eating formula not breast mill
Have a preexisting condition or illness such as cyanotic heart disease or respiratory failure, perinatal asphyxia, sepsis of the newborn

This very quickly can become a fulminant process that requires one of more surgeries to remove dead bowel and risk the infant’s life and future ability to feed orally with all the consequent problems that go with the inability to eat by mouth.

Risk Indicators

Low gestational age
Low birth weight
Abnormal microbial colonization
Intestinal prematurity
Genetic predisposition

Other risk factors for NEC include

Maternal issues such as drug use, infections of the uterus and fluid surrounding the infant (chorioamnionitis), HIV positive status of mother.
Transition during delivery risk factors include: metabolic acidosis low flow or perfusion states where the infant does not get enough blood or oxygen during delivery such as tightly wrapped umbilical cord around neck, neonatal shock

Pathophysiology of NEC: Nutrients 2020, 12(2), 520

Diagnosis

Diagnosis is made by Bell’s Modified Staging Criteria which defines three classic stages of NEC

STAGE	SYSTEMIC SIGNS	ABDOMINAL SIGNS	RADIOGRAPHIC	TREATMENT
IA Suspected	Temperature instability, apnea, bradycardia. lethargy	Gastric retention, abdominal distention, emesis, heme-positive stool	Normal or Intestinal dilation, mild ileus	NPO, antibiotics x 3 days
IB Suspected	Same as above	Grossly bloddy stool	Same as above	Same as IA
IIA Definite, Mildly ill	Same as above	Same as above, plus absent bowel sounds with or without abdominal tenderness	Intestinal dilation, ileus, pneumatosis intestinalis	NPO, antibiotics x 7 to 10 days
IIB Definite, Moderately ill	Same as above, plus mild metabolic acidosis and thrombocytopenia	Same as above, plus absent bowel sounds, definite tenderness with or without cellulitis or right lower quadrant mass	Same as IIA, plus ascites	NPO, antibiotics x 14 days
IIIA Advanced, Severely ill, intact bowel	Same as IIB, plus hypotension, bradycardia, severe apnea, combined respiratory and metabolic acidosis, DIC and neutropenia	Same as above, plus signs of peritonitis, marked tenderness, and abdominal distention	Same as IIA, plus ascites	NPO, antibiotics x 14 days, fluid resuscitation, inotropic support, ventilator therapy, paracentesis
IIIB Advanced, Severely ill, perforated bowel	Same as IIIA	Same as IIIA	Same as above, plus pneumoperitoneum	Same as IIA, plus surgery

Diagnostic signs: generally non-specific: abdominal distension and feeding intolerance, redness of the abdomen and induration or hardness of the abdominal wall, apnea or respiratory failure in infant, temperature instability, shock.
Laboraotry signs: Low platelets and signs of disseminated intravascular coagulation (DIC), 20% have + blood cultures.
Radiographic signs: Abnormal gas pattern, pneumotosis intestinalis (gas bubbles that appear in the wall of the bowel), air in the abdomen- a large amount causes a “football sign” – a large amount of air in the midline over the liver.

Pneumatosis Intestinalis

Football Sign

Gas in the venous system on the liver

Treatment

Treatment depends on presenting stage in the infant and disease progression but in general includes broad spectrum antibiotics, no feeding the gut (bowel rest), support of blood pressure with fluids and medications if needed., Surgery may be required to remove portions of dead bowel that put the infant at risk for ongoing infection and death.

NEC Prevention

Despite modern medicines myriad of antibiotics and radiographic tools adequate treatment that leaves the infant unscathed is still elusive. Research focus has been shifted to how to prevent this from occurring.

There is early data that early exposure to mother’s colostrum (the first milk mother produces after infants’ birth) as high concentrations of immune mediators that provide protection from bacterial and stimulates the GI tract.
Use of mother’s breast milk or banked breast milk decreases the incidence of NEC in infants. Even small amounts (trophic feeds) of breast milk in the infant’s gut helps nourish the villi that produce mucous, helps prevent injury of the bowel mucosa (lining) and helps prevent the gut wall from leaking bacteria into the baby’s blood stream.
Environmental protection from stressors like cold stress and acidosis, excessive exposure to light and noise all provide decreased risk.
Skin to Skin Care (SSC) enhances stress resiliency in infants, improves resting vagal tone (fewer bradycardic events).
Use of probiotics in infants protects against inflammation and injury to the gut by proving “good bacteria”.

REFERENCES

Necrotizing enterocolitis: It’s not all in the gut. Alissa L Meister , Kim K Doheny, R Alberto Travagli. Experimental Biology and Medicine 2020; 245: 85–95.

Increased Fecal Calprotectin in Preterm Infants with Necrotizing Enterocolitis. Gokhan A, et.al. (Clin. Lab. 2012;58:1-4.

Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Ou J, Courtney C, Steinberg A.E., Tecos M.E., Warner B.W. Nutrients 2020, 12(2), 520

Meister, Alissa L, Doheny, Kim K, Travagli R Alberto. Minireview: Necrotizing Enterocolitis: Its not all the Gut. Exp Bio Med 2020;245:85-95

Gokhan Aydemir, et.al. Increased Fecal Calprotectin in Preterm Infants with NEC. Clin Lab 2013;58.

Up-to Date: 2022: NEC : parts 1-5

Necrotizing enterocolitis: a Mini-review. Sanchez J.B., Kadrofske M. Neurogastroenterology and Motility 2019:31:3.

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August 9 2022

Acute Abdominal Pain: Non-Surgical Emergencies

PME-Admin article, medical abdominal pain, children, colic, constipation, emergencies, intestinal parasites, non-surgical, pediatric, pediatrics, stomach ache, urinary tract infections

Acute Abdominal Pain: Non-Surgical Emergencies — Santa J. Bartholomew M.D.

Acute Abdominal Pain in Children: Non-Surgical Emergencies

In this second part of our series on Acute Abdominal Pain, we will explore non- surgical causes of abdominal pain that are common in children. Keep in mind that this series of articles is an overview of this topic on which textbooks have been written.

CAUSES FOR NON-SURGICAL ABDOMINAL PAIN

Acute abdominal accounts for approximately 9% of visits to physicians’ offices and although we never want to miss a surgical abdomen, they account for 2% of all visits to offices and the emergency department. In a previous article I have outlined the major causes of surgical abdomen including:

Appendicitis
Midgut Volvulus
Intussusception
Pyloric Stenosis
Incarcerated hernia
Hirschsprung’s syndrome
Meckel’s diverticulum
Testicular torsion
Ovarian torsion

Symptoms and signs that increase the risk of illness being surgical in nature are:

Fever
Vomiting bile (green vomit)
Absent bowel sounds
Tense or rigid abdomen
Exquisite tenderness when examiner releases hand from abdomen (rebound tenderness)

As in Part One, the age of the child can help with differential diagnosis as common causes of abdominal pain vary in different age groups.

source: https://www.aafp.org/pubs/afp/issues/2016/0515/p830.html

COLIC

Colicky babies usually cry inconsolably often bringing them to medical attention. There is a predictable diurnal pattern to their crying which usually occurs more in the evening hours. Prevalence of colic is 5-19% and it defined best by Wessel’s criteria of crying for at least 3 hours a day, at 3 days a week for at least three weeks.

The importance of diagnosing and treating colic is excessive inconsolable crying can be frustrating to some caregivers and be a trigger for shaken baby syndrome. It is estimated that approximately 1% of parents of a 1-month-old admit to shaking their child at least once to get the child to stop crying. 2.2% admit to having shaken, slapped or smothered their infant to stop crying. By 6 months of age 6% of parents have admitted to trying these shocking behaviors to get their child to stop crying.

It is estimated that approximately 2.2% of parents admit to having shaken, slapped or smothered their infant to stop crying.

Cow’s milk allergy may play a causative role in portion of formula fed infants there are also infants who experience idiopathic infant colic. There are also theories that infant colic may be akin to abdominal migraine. A highly genetic disorder but theses studies today are all retrospective case-control studies.

Clinical picture:

Inconsolable infant crying usually beginning about two weeks of life. More in the evening than daytime hours suggesting a role of the circadian rhythm in this process.

Treatment:

Parent education – this is not an illness that anyone causes, it generally ends by three months, how to manage frustration with infant, finding resources for parents when they become overwhelmed.
Decrease stimulation for the infant
Turn down loud TVs, music, and remove toys that make noise
Dim lights and have older siblings and animals who provide stimulation go to another part of the home
Avoid strong smells such as cooking, perfume, incense
Rock baby gently, no jiggling
As sleep seems to be helpful in terminating abdominal migraines anything that encourages sleep in the infant may also be useful.
Acetaminophen may be helpful when non-pharmacologic treatments fail but must be used as a last resort and prudently when dosing.

CONSTIPATION

Constipation is among one of the most common causes for visits to the emergency department. Constipation occurs in 30% of children, peak prevalence between ages 3-5 years old. Although it’s true that functional constipation is responsible for 95% of constipation in healthy children, it is important to evaluate each child for organic causes for constipation.

Constipation defined: fewer than 3 stools a week, fecal incontinence, large palpable stools in rectum or on abdominal examination, pain on stooling.

Other causes of acute abdominal pain

Gastrointestinal infections: can cause severe “crampy” abdominal pain and diffuse abdominal tenderness to examination before diarrhea begins.
- Causes: can be viral or bacterial.
- Treatment: is supportive in the cases of viral GI infections but may include antibiotics is stool cultures reveal a bacterial source.
Urinary Tract Infection: abdominal pain and fever are the classic presenting sign of UTI in children 2 to 5 years old. Infants may also stop feeding and have vomiting.
- Symptoms: foul smelling urine, non-specific signs like fever, irritability, nausea and vomiting
- Treatment: antibiotics

Evaluation and Diagnosis of Acute Abdominal Pain in Children

https://www.aafp.org/pubs/afp/issues/2016/0515/p830.html

July 26 2022

Acute Abdominal Pain: Surgical Emergencies

PME-Admin article, medical abdominal pain, children, pediatric, pediatrics, stomach ache, surgical emergencies

Acute Abdominal Pain: Surgical Emergencies — Santa J. Bartholomew M.D.

Acute Abdominal Pain in Children: Surgical Emergencies

Abdominal pain in children is a very frequent complaint. Physicians must determine from the myriad of these complaints which 2% of children have catastrophic abdominal issues. And because many of these complaints are mostly benign it is quite easy to be lulled into complacency and miss a child with catastrophic abdominal problems. Assessing abdominal pain requires exemplary clinical acumen and a constant index of suspicion for an acute serious problem causing the abdominal pain.

CAUSES FOR ABDOMINAL PAIN

Causes of abdominal pain differ by age group and is extensive. The table below shows the most common causes in each age group.

Pediatric Medical Experts Abdominal Pain Chart

Abdominal pain is perceived by two sets of pain receptors:

One set on the mucosal lining of the bowels, and
The other on the serosa or fibrous lining of the abdominal cavity.

Pain is usually poorly localized until the serosal surface becomes inflamed such as in appendicitis, then pain is easier to pinpoint to a specific area. Despite this inflammation however, children younger than 5 years old will have difficulty localizing pain.

Most abdominal pain is self-limiting and not life threatening: 48% of abdominal pain is constipation, 19% is left undiagnosed and only 2% of abdominal pain has a surgical cause. So diagnosis can be likened to a needle in a haystack but organized and methodical evaluation usually leads to appropriate diagnosis.

MAKING THE DIAGNOSIS

Detailed and careful history including not only the history of the present illness but past events and medical history; complete family history of abdominal diseases.
Thorough physical examination including digital rectal examination.
Focused laboratory examination based on differential diagnosis for the age group of child.
Focused radiographic examination based on differential diagnosis for the age group of child: ultrasound has gained great popularity as it does not require sedation in young children and does not expose children to large amounts of radiation. The usefulness of US in obese or very uncooperative children may make this modality difficult.
CT remains the gold standard imaging study for many abdominal processes such as appendicitis and volvulus.
MRI is becoming more popular but often requires sedation for younger children.

ABDOMINAL EMERGENCIES

MIDGUT VOLVULUS

Midgut volvulus is a twisting of the bowel that can cause lack of blood flow to the bowel from a few minutes after the twist. Bowel become quickly necrotic if not untwisted urgently. Children can lose part to all their bowel causing them to have short bowel syndrome and not be able to eat by moth for the remainder of their life.

One must have a high index of suspicion to make this diagnosis which is done by upper GI.

APPENDICITIS

Appendicitis is the most common surgical emergency in childhood although unusual in children under 5 years old. It is an inflammation of the distal end of the cecum and can progress from inflamed to perforated in under 12 hours causing severe sepsis and death if not treated quickly.

In 35% of cases a fecolith (hard piece of stool) is found to obstruct the lumen causing subsequent inflammation.
How does this happen? See Fig. 2
Recent development of scoring systems have largely superseded radiographic tests but US and CT are still useful in difficult diagnoses. See Fig. 1

Figure 1. Large thick-walled inflamed appendix by ultrasound

Figure 2

INTUSSUSCEPTION

Intussusception is an invagination of the proximal segment of bowel into the distal segment of bowel (See Fig. 3) as this happens the mesentery (which contains vasculature) is dragged with bowel causing it to become ischemic, swollen and possibly having the bowel perforate.

Children usually present with severe abdominal pain, sausage shaped mass in abdomen and currant jelly (reddish black) stools. See Fig. 4
Children are listless and septic appearing.
The lead point for the intussusception can be a variety of things: Meckel’s diverticulum, patches of lymph tissue known as Peyer patches, there is also an increased risk with rotavirus vaccination.
Ultrasound has been revolutionary in early diagnosis and usually these can be reduced in radiology without surgical intervention with the use of contrast enema’s.
- Chance of success with this method depends on the time the bowel has been intussuscepted, the age of child, and if there is a lead point.
- Unstable patients go directly into surgery for reduction otherwise stable children can undergo multiple attempts at reduction in radiology.
Perforation occurs in <1% of children.
Children are listless and septic appearing

Figure 3

Figure 4

Intussusception by regular x-ray

Intussusception by ultrasound

INCARCERATED HERNIA

Incarcerated hernia is when the bowel slips through an opening in the abdominal musculature into the scrotum or labia major and it cannot be gently pushed back into place. This causes the bowels blood flow to be compromised hence the bowel can die causing sepsis in the child.

Surgical reduction of the bowel or resection of the bowel and the repair of the abdominal wall defect prevent further episodes of damage.

Pediatric Medical Experts Incarcerated Inguinal Hernia

PYLORIC STENOSIS

Pyloric Stenosis is a hypertrophy of the muscle at the outlet of the stomach that causes narrowing of the outlet of the stomach into the small bowel that causes persistent vomiting in the infant and profound metabolic abnormalities in the blood in the first few weeks of life because formula cannot pass through to small bowel.

Usually diagnosed by Ultrasound or upper GI.
The cure for this is making an incision in the muscle and opening the outflow tract of the stomach.

Pediatric Medical Experts Pyloric Stenosis

MECKLE’S DIVERTICULUM

Meckel’s diverticulum is an out pocketing of the end of the small bowel that is a congenital abnormality found in about 2% of the population of which up to 60% of which contain gastric tissue.

Typically painless but can cause minimally painful rectal bleeding, abdominal distension and vomiting.
Can also ulcerate and perforate or present as the lead point for intussusception.

HIRSCHSPRUNG’S DISEASE

Hirschsprung’s Disease is characterized by lack of ganglion cells in the distal gut making movement of stool through the bowel very difficult.

It is the most common gut motility disease in children. Suspected in infants with difficulty stooling and abdominal x-rays with hugely enlarged colon.

Diagnosis is made by rectal biopsy.
Treatment begins with rectal washouts and dilations of the rectum and then is completed with an endorectal pull through procedure – which pulls bowel through and resects the affected portions leaving healthy bowel remaining.

TESTICULAR OR OVARIAN TORSION

Testicular

Testicular torsion occurs when a testicle rotates, twisting the that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Testicular torsion is most common between ages 12 and 18, but it can occur at any age, even before birth. 1

Age distribution is bimodal with a peak in the neonatal period and a peak in puberty.
Newborn testicular torsion can present as painless scrotal swelling and the salvage rate is very poor, approximately 9%. This is thought to be secondary to poor fixation of the neonatal tissues to one another. It is predominantly an extra-vaginal torsion – this accounts for 5% of all torsions.
Occurs more frequently in high birth weight infants.
Scrotal imaging can aide in diagnosis

Older Children and Adults Testicular Torsion

Testicular torsion or acute scrotum is heralded by a sudden unbearable unilateral scrotal pain in the scrotum.
Patients may have
- Fever
- Nausea
- Vomiting
- Generalized abdominal pain
Higher testicular position – indicative of a twisted and shortened spermatic cord.

Testicular Torsion Pediatric Medical Experts

Acute scrotal pain must be evaluated quickly as it is a surgical emergency to try to untwist and save the testicle. For this reason, any adolescent that complains of abdominal pain should always have a scrotal examination as part of their evaluation. Every 10 minutes of delay in releasing the torsion testicular survival is diminished by 5%.

Testicular examination can be summarized by the scoring system known as TWIST, short for Testicular Workup for Ischemia and Suspected Torsion.

Parameters include:

Swelling of the scrotum and testicles –
where normal landmarks (epididymis) may not be palpable due to swelling (2 pts )
Hard testicle (2 pts)
Absent cremasteric reflex (1 pt)
Nausea/vomiting (1 pt)
High raised testicle (1 pt)
Risk is assessed as
- low (0-2 pts)
- medium (3-4 pts)
- high (5-7 pts)

Ultrasound can be used to confirm diagnosis: typically reveals a whirlpool sign. See Fig. 5 It is possible to provide analgesia and try manually un-twisting, but more often these children are taken to the OR for decompression.

Figure 5. Testicular Torsion by Ultrasound

Ovarian

Ovarian torsion is a rare issue in pediatrics but must be included in any differential of abdominal pain in a female child or a child with an abdominal mass in the premenarchal or preteen years.

Clinical presentation is non-specific so diagnosis relies on a high index of suspicion. Most common symptoms are:

Lower abdominal pain,
Nausea, and
Vomiting.
Some children also report flank and back pain.

Figure 6. Ovarian Torsion by Ultrasound

Ultrasound is the most useful way of evaluating these children (See Fig. 6) to visualize the ovary and possible torsion of it. In cases of ovarian torsion it is common to find an ovarian cyst or benign teratoma. Ovarian pathology in torsion cases is found in 50% to 84% of cases.

Treatment is operative.