1. dnbpaediatrics.blogspot.in
Abdominal pain in pediatrics
Dr Ajay Agade
Dr Sushmita Ghosh
Dr Vijayalaxmi
Moderator Dr Subodh
saha
Department of Pediatrics,
Jawaharlal Nehru Hospital & Research Centre
3. What is Pain
An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described
in terms of such damage
ref: international
assoc. for study of pain
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6. DIFFERENCES b/w infant &
adult nociception
Infant Adult
1. Afferent fibers Nonmyelinated C both A∂ & C fibers
fibers
2. Receptor field large & diffuse small
3. Inhibitory pathways less developed well developed
4. Substance P Higher concentration lower concentration
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7. TYPES OF ABDOMINAL PAIN
Visceral Pain - Dull
poorly localised,
usually periumbilical
Parietal pain - sharp,
intense,
discrete
Referred pain - same features as parietal
pain
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9. Pathophysiology visceral pain
Tension, stretching, and ischemia stimulate visceral pain
fiber.
Tissue congestion and inflammation tend to sensitize
nerve endings and lower the threshold for stimuli.
Because visceral pain fibers are bilateral and
unmyelinated and enter the spinal cord at multiple
levels, visceral pain usually is dull, poorly localized, and
felt in the midline.
10. Pathophysiology parietal pain
Noxious stimulation of the parietal peritoneum
Ischemia, inflammation, or stretching of the parietal peritoneum
Myelinated afferent fibers to specific dorsal root ganglia on the
same side and at the same dermatomal level
Sharp, intense, discrete, and localized,
Coughing or movement can aggravate it.
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11. Pathophysiology referred pain
Many of the characteristics of parietal pain
Remote areas supplied by the same dermatome as the
diseased organ
Shared central pathways for afferent
neurons from different sites dnbpaediatrics.blogspot.in
12. Site of pain
Foregut structures epigastrium
(oesophagus & stomach)
Midgut structures periumbilical
(small intestine)
Hind gut structure lower abdomen
(large intestine & rectum)
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28. Chronic abdominal pain
Chronic and recurrent abdominal pain are common in children
chronic abdominal pain is defined as pain that has been present for
at least three months
** Recurrent abdominal pain is defined as three or more
episodes of pain that are severe enough to limit a child's activity or
school attendance over the course of at least three months
* Chronic and recurrent pain occurs in 9 to 15 percent of all
children
* In boys, pain is most common between ages 5 and 6 years ** Girls
have pain most commonly between 5 and 6 years and 9 and 10 years
29. Functional abdominal pain
Abdominal pain that cannot be explained by structural,
physiological or pathological abnormality.
School-aged child or adolescent
At least 12 weeks of :
a-Continuous or nearly continuous abdominal pain and
b- No or only occasional relation of pain with
physiologic events (eg, eating, menses, defecation)
c- Some loss of daily functioning ,and
d- The pain is not malingering
e- The patient has insufficient criteria for other
functional gastrointestinal disorders
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30. NONSURGICAL CAUSES OF ABDOMINAL PAIN
Pyelonephritis
UTI
Abdominal migrain
Abdominal epilepsy
Functional abdominal pain
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32. Indications for Surgical
Consultation in Children
Severe or increasing abdominal pain
progressive signs of deterioration
Bile stained or feculent vomitus
Involuntary abdominal guarding/rigidity
Rebound abdominal tenderness
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33. Indications for Surgical
Consultation in Children
Marked abdominal distension with diffuse tympany.
Signs of acute fluid or blood loss
Significant abdominal trauma
Suspected surgical cause for the pain
Abdominal pain without an obvious etiology
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34. INTUSSUSCEPTION
90% < 2 years of age
More common in males
Associated with URI
Diarrhoea
rotavirus vaccine
hematoma(HSP)
Hemangioma
lymphoma
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35. symptoms
• Pain abdomen of sudden onset
• Vomiting
• Sausage shaped mass
• Normal in between pain
• Blood stained finger on PR examination
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43. Functional abdominal pain includes
several different types of chronic
abdominal pain
recurrent abdominal pain
three or more bouts of abdominal pain (belly ache) in
children 4-16 years old over a three-month period severe
enough to interfere with his/her activities.
located around the umbilicus
functional dyspepsia,
upper abdominal pain
nausea, vomiting,
irritable bowel syndrome (IBS).
pain relieved by motion
change in stool frequency
change in stool consistency
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44. Implications
Interference with school attendance
Depression
Anxiety
Emotional disturbances
Diagnosis
Normal physical examination
Absence of abnormal pathological tests
Absence of red flag signs
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45. Diagnosis
Normal physical examination
Absence of abnormal pathological tests
Absence of red flag signs
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46. Absence of red flag signs
Fever
Fever
Wt. loss
Poor growth
Joint pain
Mouth ulcer
Unusual rashes
Loss of appetite
Hemetemesis
Melena
Night time awakening due to pain or diarrhea
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47. Goals of management
Provide quality life through
Support
Education
Medication
Better coping skills
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49. physician
NORMAL LIFE
school parents
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50. Colic
Excessive paroxysmal crying
Most often in evening hours
Healthy baby
Difficult to console
Equal frequency in male & female
Wessels criteria
Cry lasting > 3 hrs
Occuring > 3 days
for > 3 weeks
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51. Etiology Increased level of motilin
lactalbumin
5 HIAA
Psychological stress
Drugs during pregnancy
Frequency
10 to 30 % Infants worldwide
Sex : Equal frequency
Age : 2 wks to 4 months
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52. History
Diagnosis of exclusion
Evening hours
Peaks at 6 weeks
High pitched cry
Exclude other causes : hair in eye
strangulated hernia
otitis
sepsis
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53. Physical examination
Shows normal weight gain
Differential diagnosis
-Overfeeding
-Underfeeding
-Milk Allergy
-Early introduction of foods
-GERD
-No burping after feeds
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54. dnbpaediatrics.blogspot.in
MANAGEMENT
SIMETHICONE
Reduces the surface tension of bubbles
over intestinal surface.
Anticholinergic drugs
dicyclomine/ dicycloverine
relax muscles in the wall of the gut
Dietary management
Elimination of cows milk
eggs
wheat
nut products
Car ride simulators
Reduced stimulation
Focussed parent counselling
Abdominal pain is a common presenting symptomin children. A substantial percent of unscheduledpaediatric office visits and paediatric emergency roomvisits are due to abdominal pain.... Scholer et alinvestigated the prevalence presenting complaints in children found that more than 63 childrens reported some kind of abd pain.....
Individual children differ greatly in their perception of & tolerance for abdominal pian ..this is one of the sevral reason why pediatric abd pain is Is difficult to deal with..A child with functional abdominal pain may be as uncomfortable as one with an organic cause… will be touching upon the following topics
Nociception differs from other sensation in that it sounds a warning that sumthing is wrong & it preempts other signals
Many of us think why treat pain if its causeless harmless ,I think q can be better answered by those who suffered from some or other kind of pain may it be severe abd pain of appendicitis or simple headache basically pain turns out to be a comlex. Any pain wen prolong results in alteration of physilogy ranging from hyperacidity to sleep disturbance the importance of pain is so much recognised that separate pain clinics are now well eastablished.
Pain can be explained on basis of 4 physilogical phenomenonTransduction is a process by which noxious stimuli are translated into electric signals at sensory n endings..performed Primary afferent fibers -synapse in the dorsal horn of spinal cordSecond order neuron in the lamina of the dorsal horn, ascending neurons projecting to brain stem,thalamus n thalamocortical projections. Transmission is a propagation of impulse through sensory n system by first aferentfibres which synapse in dorsal nerve & second order neurons in matrix of dorsal horne
a normal belief that newborns & children have less pain to noxous stimuli is very unphysilogical …..a newborn strts developing skin receptors and sensory nerve as early as 20 weeks ..while the inhibitory mechanism strt developing very slowly after 34 weeks…therefore pediatric pain of any quality & quantity may it b abdo pain or other shud never be overlooked
Clinically, abdominal pain falls into three categories: visceral (splanchnic) pain, parietal (somatic) pain, and referred pain…let us see the characteristics of eachThe difference in characteristics are because of different pathways n innervations at sensory end
Visceral pain occurs when noxious stimuli affect a viscus, such as the stomach or intestines. Tension, stretching, and ischemia stimulate visceral pain fiber .
Parietal pain arises from noxious stimulation of the parietal peritoneum . Pain resulting from ischemia, inflammation, or stretching of the parietal peritoneum is transmitted through myelinated afferent fibers to specific dorsal root ganglia on the same side and at the same dermatomal level as the origin of the pain. Parietal pain usually is sharp, intense, discrete, andlocalized, and coughing or movement can aggravate it.
Referred pain has many of the characteristics of parietal pain but is felt in remote areas supplied by the same dermatome as the diseased organ . It results from shared central pathways for afferent neurons from different sites . A classic example is a patient withpneumonia who presents with abdominal pain because the T9 dermatome distribution is shared by the lung and
Let us go through the causes o abd painsysem wise…in gi system in order of prevalnece
In a children with features suggestive of failure to thrive , recurrent abd pain following cause can be suspected
Drugs and toxins which can cause abd pain are erythro
Pneumonia @ diaphragmatic hernia are the pulm causes abd pain n operate through mech of reffered
The infant younger than 2 years old with abdominal pain is the most difficult to evaluate because the child cannot describe or localize the complaint
Similar to the infant ,the child who is 2 to 5 years of age usually has an organic cause of abdominal pain*The most common causes of abdominal pain are inflammatory process ,such as GE,and UTI
The preadolescent child add another dimension to the spectrum of abdominal pain- that of non organic or psychogenic illness The leading organic causes of abdominal pain still are inflammatory and include GE ,appendicitis and UTI
Some children have symptoms that do not fit the definition of organic disorders, functional dyspepsia, or IBS, and are thus described as having functional abdominal pain