Documente Academic
Documente Profesional
Documente Cultură
Aswitha Boediarso
Abdominal pain :
- further investigation
Viscera abdomen Others organ outside of abdomen Lesion of Medulla Spinalis Metabolic disturbance Psychosomatic
Pathogenesis
1.
Vascular disorders
2.
Inflammation
Pain if the inflammation process are in peritoneum parietalis somatic inervation Local pain or general pain. Type of pain : stabile, increase with movement of inflammatory peritoneum
3.
4.
Fore gut pain in upper abdomen Mid gut pain in middle abdomen Hind gut pain in lower abdomen Muscle spasm colic which difficult to investigate the localization, not influenced with cough or abdominal pressure Peritoneal irritation pain in the field of irritation, stable, influenced by cough and abdominal pressure
Referred pain
Disorders of extra abdominal organ (i.e. thorax) sensory inervation (N. Vagus) abdominal pain
e.
f. g. h. i. j.
Gastroenteritis Appendicitis Mesenteric lymphadenitis Meckels diverticulum Ileitis regional Colitis ulserativa Diabetic acidosis Pneumonia Torsion of ovarian cord Constipation
k. l. m. n.
o.
p. q. r. s.
t.
Pyelonephritis Colic Ureter Lead intoxication Torsion of spermatic cord Abdominal epilepsy Sickle cell crisis Mononucleosis Porphiria Cholecystitis and cholelytiasis Pancreatitis
Cause of acute abdominal pain by age groups, that requirring surgical intervention (Walker-Smith et al, 1983)
Infant / age < 2 years old Abdomen : Perforation of gastric ulcers Bowel obstruction : - intusussception - volvulus and malrotation Appendicitis and enterocolitis necroticans Extra abdomen : Inguinal hernia with strangulation and incarceration
b.
c.
d. e.
Obstruction Bowel obstruction caused by fibrosis, volvulus, malrotation Perforation caused by bowel obstruction Inflammation (appendicitis, primary peritonitis, peritonitis caused by Meckels diverticle perforation, perforation of duodenal ulcer, perforation caused by typhoid fever, Meckels diverticulitis, cholecystitis with or without gall stone, toxic mega colon with perforation) Trauma (rupture of spleen, urinary bladder, another visceral organs, hematoma sub serosa) Bleeding (bleeding intra ovarian cyst) In tropic area (perforation associated with ascariasis, strongiloidiasis, jejunitis necrotican in New Guinea, perforation of abscess amoeba)
Extra abdomen: a. Torsion of testis b. Inguinal hernia with strangulation and incarceration
Cause of non surgical abdominal pain (Walker and Smith, 1983) Infant / age < 2 years old Abdomen : - Intestinal infection
Infant / age > 2 years old Abdomen : a. Intestinal - Infection (Salmonella, Shigella, Campylobacter, Yersinia enterocolitica) - Food intoxication (Toxin of Staphylococcus, etc) - Purpura Henoch Schonlein (purpura anaphylactoid) - Crohns disease - Colitis ulcerative - Colitis amoeba - Fecal impaction - Sickle cell anemia - Ileus meconeum - Adenitis mesenterica
b. Liver and billiary tree - Hepatitis - Cholelytiasis c. Pancreas - Pancreatitis d. Kidney - Urinary tract infection - Stone - Nephritis
e. Metabolic - Phorphiria - Hiperlipidemia - Diabetic keto acidosis - Familial Mediterranean fever f. Gynecologic - Salphyngitis
2 years 5 years Obstipation Volvulus Hepatitis Urinary tract infection - Ascariasis - Appendicitis - Pancreatitis -
> 5 years
Appendicitis Gastritis Ovarian torsion Menstrual cycle Cholecystitis Functional abdominal pain - Urinary tract stone - Varicocele testis
0 - 3 months : vomiting 3 months 2 years : vomiting, pitching/crying, trauma(-) 2 5 years : can tell the pain, localization not true > 5 years : can tell the type and localization of the pain
Diagnostic approach
1. 2. 3.
Anamnesis
Age Pain (localization , type, time, frequency, other symptom) Defecation pattern Urination pattern Menstrual cycle Skeletal muscle disorders Growth and development disorders Psychosocial aspect Trauma History of family disease
Physical examination
1. 2.
Physical examination
Especially in abdomen - Inspection: Asymmetry, meteorismus, bowel contour - Palpation: Stretching, pain, tumor - Percussion: Fluid? - Auscultation: Bowel sound - Rectal touchier Extra abdomen examination - Pneumonia/Acute respiratory infection - Hernia
Routine ( urine, blood, feces) Culture 3 positions of abdominal plan photo Thorax photo (severe disease) Barium meal/follow through Barium enema Intravenous pyelography Ultrasound Endoscopies
Therapy
Abdominal pain that require surgical intervention Symptoms - Severe pain, stable, onset 3-4 hours - Vomiting : green or fecal - Increase temperature
Obstruction
- Invagination, bolus ascariasis, volvulus/rotation of gaster
Inflammation
- Acute appendicitis, acute cholecystitis, peritonitis
Physical examination
Abdominal emergency
Further investigation
Abdominal plain photo Barium meal/follow through Barium enema Intravenous pyelography if suspected urinary tract disorders Ultrasound Endoscopy
Therapy
Exploration/operation laparotomy
Prevalence
Age 3 14 years old mostly 5 10 years old 5% of pediatric outpatient Organic cause 5-10%
Etiology
17 cases 47% spasmophylia 11.8% gastritis 5.9% colitis 29.4% worms infection 11,8% psychological/psychiatric disorders
Classical (2 groups)
Organic Functional
2.
Barr
Organic Disfunctional
Psychogenic
3.
Life style
Drugs
Anti convulsion Antibiotic Brochodilator
Urinary tract
Hidronephrosis Pyelonephritis Stone Renal neoplasm Ovarian cyst Dismenorrhea Endometriosisi Testis torsion Testis neoplasm
Metabolic
Hypoglycemia Phorphiria Lead intoxication Hyperlipidemia Angioneurotic edema
Symptoms suggested organic disorders Persistent fever Growth and development disturbance Weight loss Anemia Hematemesis Melena Hematochezia Pain away from midline Perianal disease
Diagnostic approach
1.
2.
3.
Careful anamnesis, Physical examination, and further investigation High cost examination and commonly was not positive Endoscopy greater probability to find the etiology
Anamnesis
Age Pain (localization , type, time, frequency, other symptom) Defecation pattern Urination pattern Menstrual cycle Skeletal muscle disorders Growth and development disorders Psychosocial aspect Trauma History of family disease
Laboratory and further investigation Routine ( urine, blood, feces) Ureum, creatinine Culture 3 positions of abdominal plan photo Thorax photo (severe disease) Barium meal/follow through Barium enema Intravenous pyelography Ultrasound Endoscopy
Therapy