acute abdomen in children

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Acute Abdomen In Children Prof.G.Raghavendra Prasad Pediatric Surgeon , Hyderabad

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What is acute abdomen ? Acute abdominal pain Often requiring surgical considerations And If not addressed may result in Dangerous complications

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A practical approach Does It differ from adults ? Is Diagnosis different from adults ?is the treatment different from adults ? Are the results same ? Special aspects of acute abdomen in children Common aspects of both What is new ? Take home message

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Child is not a miniature adult

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Anatomical Physiological Psychological Emotional Stress response Child vs. Adult

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Pediatrics is an age dependent science

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Age specific conditions Age directed approach Age dependent prognosis Age dominated scenario Pediatric A cute Abdomen

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Acute abdomen Symptomatic approach G I symptoms common But universal

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GIT is the face of many systems

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One symptom : Many systems One system : Many symptoms

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Bilious vomiting Is Intestinal obstruction Unless proved otherwise

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Acute Abdomen in children

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Padiatrics Obstruction Peritonitis Bleeding Vague Vomiting Pain Constipation distension Neonate Infant <5Years >5Years 4

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Vomiting Content Type Fever Blood Bile Other X Neonate: Swallowed maternal blood, Stress later, NNEC , HDN, Coagullopathy,gangrene Infant Stress,Gastritis,Ac Du, Dengue fever, Gangrene of gut, Older Child Gastritis, AcDu,Portal hypertension,Gangrene,coagulopathy ,

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Bilious Vomit =

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Vomiting related to Fever------ Fever first and vomiting and pain next : mostly infective or inflammatory

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NNEC in NB NSJejunoileitis in infants Enteric fever in children Infected cysts Urachal, omphalomesenteric,Lymphatic, appendicitis, Acute gastrtis Examples

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Diagnosis is clinical Investigations : Only supportive and to exclude others When in doubt remove may still be an acceptable policy Acute appendicitis Triad is an exception

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Disproportionate vomiting Pancreatitis Poisoning CNS Lesions

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Distension Born with distension: HD, Masses, Ascites, Painful distension: Peritonitis,Infected ascitis, Infected cysts, Complicated Int.obstruction

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Distension first vomiting later Lower GI Obstruction Infected ascites Infected cysts

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Constipation since birth is Hirschsprung’s disease Constipation

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Be ware

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GI Bleeding Upper or Lower Massive or Mild Well or Ill child Age Constitutional symptoms Painful or painless

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GI Bleeding 1 st day: Swallowed maternal blood 2-3 rd Day: HDN, Coagulopathy 1 st week: NNEC, Stress, delayed HDN, Gangrene Drugs Portal hypertension HDN, Trauma, fissure in Ano, Dysentery, Meckels, massive upper GI, Inflammatory bowel disease, Gangrene, Enteric Fever, TB, dysentery, Intususception Upper lower Acute abdomen

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First symptom Relation of Symptoms Well child or sick child Extra abdominal signs

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Overlap Is Characteristic Of Pediatric Acute abdomen Lesions overlap

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Neonatal : NNEC/ Atresias / HD Infantile : Intussusception / NSJI /Acute appendicitis Older Children : RW/ Bezoars / Tumours /Pancreatitis/ Ac. Appendicitis Adolescents : Hematometrocolpos / Ovary / gonad related/ Overlap with adults Pediatric Acute abdomen is age specific

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Quadrant / Regions Diagnostic Based Approach may not be reliable Diagnostic Approach

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Medico-surgical overlap is Characteristic Of Pediatric acute abdomen

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NNEC Starts as medical condition And Becomes a surgical emergency

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Medico surgical mimicry Malrotation with volvulus: Stress Bleed , IHPS : IEMs Pneumonia : Ileus DK : Acute abdomen Sickle cell crisis : acute appendicitis HUS : Acute abdomen

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Diagnosis

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Age Is A Great Clue

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Newborn : Atresias , ARMS, Infant : Intussusception Older child : Acute Appendicitis Adolescent : Hematometrocolpos

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Laboratory & Acute abdomen Only supportive Suggests complications, Local & Systemic TLC & DLC Micro ESR Platelets Shift to Left ICAM / PCAM

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Imaging & Acute Abdomen The Diagnostic Tool Plain Radiograph Supine & Erect Decubitus Prone Cross Table Lateral CT Scan

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Plain Radiograph yields Many Clues

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Abdominal Gas Pattern Fluid Levels Fixed Loop Pneumatosis Intestinalis Free Air Calcification Mass Effect Shadow in a shadow

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Double Bubble Triple Bubble Multiple asymmetric levels Gas in Rectum Scanty Air Neuhauser’s sign Mueller's sign Gasless Abdomen Floating Bowels C L A S S I C S

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CT Abdomen The Emerging Gold Standard

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Management

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Universal Principles Early Diagnosis Early & Effective Transport & Resuscitation Concomitant Resuscitation & Treatment Take care of the “5” Enemies of NB & Infants Removal of Septic Supportive Care decides outcome Long-term anatomic and functional considerations Child rarely forgets & Forgives but loves the saviour

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“5” Enemies

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Laparoscopy & Pediatric Acute Abdomen

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Neonates & Small Infants : Limited Role Older & Adolescents: Very effective And may avoid unnecessary explorations and avoids surprise encounters Appendectomy, & Cystectomy Drainage Laparoscopy &Acute Abdomen

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Results – Different from Adults ? Y E s Wound Healing Recurrence Psychological Long-term functional

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Common Conditions Obstruction : Site Dependent Hernia Adhesions HD Round Worm Peritonitis : Toxemia Organ F ailure Morbidity & Mortality

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Causes & Cases

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A case of IHPS

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Palpate from left to right

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Pyloric Olive

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Pyloric "Olive" is most diagnostic

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Pyoloromyotomy

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Cases of NNEC

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NNEC

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Meckel,s Diverticulum

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A case of Duodenal atresia

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A case of Meconium Ileus

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Round worm obstruction

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Malrotation with volvulus

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CONCERN FOR INCONSISTENT CLINICAL OPINIONS

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Pediatric a cute Abdomen Rounding up

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Intussusception Vs Dysentery Newborn Infant Child Mediacl Vs Surgical Difficulty & Delay Non Homogenous Appendicitis Vs NSAP Conservative VS Surgical Problem of Enteric and Kochs

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Infant Child New Born Predictable Prognostic Therapeutic Index Of Suspicion Diagnostic X -ray Study Newer modalities Repeat Examination High Resolution Ultrasound Thorough Evaluation

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Involve Surgeon early in NNEC Paracentesis detects early Perforation Medical Surgical Overlap Time is precious Air Enema Avoid Dehydration, Acidosis , Hypoxia In Sickle Cell Syndrome Ultrasound detects appendicitis NSAP can be working diagnosis Repeat Reevaluation is the key word Infant Child New Born

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Take Home----- Delay is Dangerous Diagnosis & Treatment need to be simultaneous Do not forget “5”Enemies Supportive care decides Long Term sequele Infertility Adhesions Scar Psychological

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Where are we now !!!

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CONCERN FOR INCONSISTENT CLINICAL OPINIONS HD or Habitual constipation IHPS or IEM / Ac GE Intussusception or Dysentery Appendicitis or Mes . adenitis

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Under the tight grip of Technology

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Doubting patients Daunting Relatives Eveready Consumer Forum Where Is it going ?

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Defensive Practice Too many investigations Too much of caution Too apprehensive Doctors Dwindling patients faith Vicious Cycle goes on & on

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grprasad22@gmail.com A raghvendra Prasd presentation

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