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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1380-1385

Surgical aspects of common acute abdominal problems in infants and children


1 Department of Pediatric Surgery Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Pediatric Surgery, Kafr El Sheikh General Hospital, Kafr El Sheikh, Egypt

Date of Submission17-Apr-2017
Date of Acceptance11-Jun-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Eslam M Abd El-Hafez
Kfr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_291_17

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  Abstract 


Objective
The aim of this study was to discuss and evaluate the best diagnostic tool (clinical, radiological, laboratory, or endoscopy) used to reach a final diagnosis and best intervention for most common presentation of surgical causes of common acute abdominal problems in infants and children.
Background
Acute abdominal pain is a group of acute life-threatening condition that requires emergency hospital admission and often emergency surgical intervention within 24 h of duration.
Patients and methods
Hundred children of both sexes aged between 1 day and 12 years who presented with surgical causes of common acute abdominal problems were divided into two groups. Group A included 83 patients who required surgical intervention. Group B included 12 patients who were managed conservatively.
Results
A total of 100 children attended with complaints of abdominal pain during the study. Thirty-six children had confirmed final diagnosis as appendicitis and eight had complicated appendix, and 20 were diagnosed radiologically (either on ultrasonography or computed tomography scan) as intussusception. The remaining 24 cases were diagnosed clinically. The majority of cases of intestinal obstruction were diagnosed radiologically. All diagnoses of Mickel's diverticulum, necrotizing enterocolitis, incarcerated inguinal hernia, and ovarian and testicular torsion were confirmed by means of radiological investigation. The remaining 12 patients who did not need surgical intervention were managed conservatively.
Conclusion
Radiological and minimally invasive techniques are becoming important in the diagnosis of surgical abdomen in children. Urgent surgical intervention remains the gold standard for most cases. Appendicitis is mainly clinical diagnosis.

Keywords: abdominal pain, children, diagnosis, infants, surgical


How to cite this article:
Sultan TA, Abd El-Aziz TF, Abd El-Hafez EM. Surgical aspects of common acute abdominal problems in infants and children. Menoufia Med J 2018;31:1380-5

How to cite this URL:
Sultan TA, Abd El-Aziz TF, Abd El-Hafez EM. Surgical aspects of common acute abdominal problems in infants and children. Menoufia Med J [serial online] 2018 [cited 2024 Mar 29];31:1380-5. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1380/252039




  Introduction Top


Acute abdominal pain is one of the common and frequent complaints in most children[1].

Acute abdominal pain is one of the common reasons for referral to the emergency room and for hospitalization to pediatric medical or surgical departments among children[2].

Acute abdominal pain is a group of acute life-threatening condition that often results in obstruction, hemorrhage, and/or perforation (such as that which occurs with intussusception, trauma, appendicitis, or volvulus) and requires emergency surgical intervention within 24 h of duration and often emergency hospital admission[3].

Appendectomy is the most common surgical emergency[4].

Abdominal visceral pain is poorly localized in general. Parietal peritoneum, once becomes irritated (when the serosal surface becomes inflamed), pain may become localized more in the right iliac fossa[5].

Diagnosis and management of the common causes of acute abdominal pain early is important to prevent potentially fatal conditions in these patients[6].

Therapeutic approach, which follows subsequent diagnosis to the problem of acute abdominal problems (AAP) in children, remains a challenge for the clinician[5].

Often, final diagnosis is supported by imaging techniques such as radiographs, ultrasonography (US), and computed tomography (CT) scan and laboratory investigations to confirm or complete our diagnosis. Therefore, it is not uncommon to have a lot of modality of investigations used to reach professional diagnosis[7].


  Patient and Methods Top


Written informed consent from each patient was taken. Ethics committee permission and ethical practices was obtained on the study. The study was conducted on 100 infants and children with common acute abdominal surgical problem.

Data collected from the patients were assessed.

  1. Inclusion criteria: both sexes, age between 0 and 14 years, and consent to participate
  2. Exclusion criteria: current medical illnesses, presence of congenital anomalies, any major psychiatric disorder, uncontrolled health condition, and adolescence.


The present study was conducted on 100 children of both sexes aged between 1 day and 12 years who presented with surgical causes of common acute abdominal problems during a period of 1 year from first of December 2015 to end of November 2016 after obtaining consent. On the basis of the final diagnostic decision, patients were classified into two groups: group A included 88 patients who required surgical intervention, and group B included 12 patients who were managed conservatively. Patients were excluded if they were transferred from other hospitals after receiving any medical treatment of performing any surgical procedures. Moreover, patients who presented with associated systemic diseases were excluded, as these comorbid diseases may affect the final outcome and trauma [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7].
Table 1: Associated symptoms

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Table 2: Significant difference among the studied groups as regards body temperature

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Table 3: Significant difference among the studied groups as regards abdominal signs in the form of the presence of guard and rigidity and rebound tenderness

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Table 4: Radiological investigation in both groups

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Table 5: Significant difference among studied groups as regards laboratory investigations needed

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Table 6: The percentile diagnosis of patients with surgical abdomen

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Table 7: The percentile diagnose of group B patients who did not need surgical intervention

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Statistical analysis

Data were collected in preorganized data sheet by the researcher from patients fulfilling inclusion and exclusion criteria.

We performed a retrospective study on a prospectively collected data.


  Results Top


A total of 100 patients were included in the study, which included 36 patients who were confirmed as having acute appendicitis clinically and by means of investigations. Moreover, eight patients presented with localized peritonitis in the right iliac fossa diagnosed as complicated appendicitis and one patient presented with picture of acute appendicitis diagnosed as having Mickel's diverticulum and the diagnosis was confirmed during surgery. Two patients had the same manifestations of acute appendicitis but were diagnosed as Mesenteric lymphadenitis. The diagnosis was confirmed by means of US in one patient as the enlarged mesenteric lymph nodes were detected, and the other patient was diagnosed using CT.

As regards our study, 12 patients in group B were considered as having less fever conditions, which were managed conservatively. They presented with abdominal pain, which may be central or periumbilical pain, right or left sided pain or shifting pain all over the abdomen. Pain is usually colicky in nature. It may be associated with diarrhea and vomiting in cases of gastroenteritis, abdominal distention, and urinary symptoms in cases of renal colic and pyelonephritis or constipation as in cases of nonspecific colicky pain. There were no signs of surgical abdomen in the form of guarding and rigidity or rebound tenderness. The diagnosis can be confirmed by means of laboratory or radiological investigation, as needed. Further, two patients in group A presented in the medical conditions category as having acute gastritis. The patient clinically presented with abdominal distention and vomiting. The diagnosis was confirmed clinically and managed medically.


  Discussion Top


In our study, the identification of the clinical symptoms and signs (attributes) to facilitate the diagnosis of the surgical aspects of common acute abdominal problems in infants and children is what we discuss.

This study explains that acute appendicitis can be diagnosed with clinical examination and history alone safely. Diagnosis of surgical abdomen is often supported by imaging and laboratory investigation.

There was no significant difference among the studied groups as regards the previous visit to the emergency room in the past 48 h. Our results are in agreement with Michalowski et al.[8]; however, they reported a significant difference among the studied groups as regards the previous visit to the E.R in the past 48 h. This may be due to educational level and variations in the culture.

In this study there was a significant difference among the groups as regards pain site, showing that the patient who does not need surgical intervention tends to be more vague and generalized on examination. However, patients with surgical abdomen tend to be more localized on examination. These results are in agreement with Michalowski and colleagues[8],[9]. However, our study is in disagreement with studies that reported that there is no significant difference as regards pain site between the two groups.

There was significant difference among the studied groups regarding abdominal pain character showing that colicky pain representing the majority of cases (62 patients) while showing that the majority of patients have dull aching pain (35 patients).

However, the study can explain that pain begins as dull aching poorly localized pain and progresses to a constant well-localized pain, which indicates a surgically correctable cause; a classic example is the pain of acute appendicitis in which pain initially begins as a poorly dull aching pain in the periumbilical region and progresses to severe pain in the right lower quadrant. Colicky pain is associated with numerous diseases of hollow viscera and is most commonly associated with nephrolithiasis, biliary diseases, and intestinal colic. These explanations and results also matched with Michalowski and colleagues[8],[9].

The study is in disagreement with studies that reported that there is no significant difference among the studied groups as regards abdominal pain character, and this may be attributed to the fact that children up to the teenage years have a poor sense of onset or location or the character of pain and to the inability of children in the chosen specimen to express the real nature of abdominal pain.

Our study on abdominal pain duration showed that there was no significant difference as regards abdominal pain duration in group A patients as 42.11% had abdominal pain duration more than 1 day, whereas 57.89% had abdominal pain duration up to 1 day. Our study also shows a significant difference as regards abdominal pain duration in group B patients as 79.03% had abdominal pain duration up to 1 day, whereas 20.97% had abdominal pain duration more than 1 day. These results are in agreement with Buchert[10].

In our study as regards pain scale, the pain was presented on a scale presented as score from 0 to 10 called the Wong Baker Faces Pain Rating Scale. It is considered an easily applicable scale and the most valuable for the evaluation of the degree of pain as it can be easily matched with the facial expression of the patient. Patients given score 0–3 were considered as having mild pain, whereas patients given score 4–6 were considered as having moderate pain, and patients given score 7–10 were considered as having severe pain.

The difference between the two groups as regards the severity of pain is significant. These results are in agreement with Michalowski and colleagues[8],[10],[11], who showed significant difference among studied groups as regards the severity of pain. However, our results are in disagreement with Ruddy[12], who says that there was no difference between the two groups as regards severity of pain, which can be attributed to early presentation without waiting for complications to occur with more severe pain.

There was no significant difference as regards the number of patients complaining of vomiting; Mason and colleagues[9],[13] reported the same results.

Our study was in disagreement with Ross and LeLeiko[11],[14], who reported that the result revealed that there was a significant difference among the studied groups in relation to number of patients complaining of vomiting; the percentage of patients in group A complaining of vomiting was higher than that in group B, and this result may be due to better hygienic habits and less liability for gastroenteritis, the common cause of vomiting among group B patients.

There was important difference among our studied groups in relation to bowel habits. In group A eight patients complained of absolute constipation and none of the patients complained of diarrhea. However, there were only two patients with complaints of absolute constipation among patients and 16 with complaints of diarrhea in group B; the remaining patients in group B had normal bowel habits. Our study results are in agreement with Michalowski et al.[8], who revealed important difference among the studied groups in relation to the bowel habits.

Our study showed that classic 'currant-jelly stool' is often seen in patients with intussusception. Failure to pass flatus or feces suggests intestinal obstruction; Mason and colleagues[9],[13] reported similar results.

Our study is in disagreement with (14) and Ross and LeLeiko[11]; the study revealed that there is no important difference among the studied groups as regards the bowel habits, which may be due to early presentation with less possibility of complications and better hygiene.

The body temperature in our study shows important difference among the studied groups. In group A, patients with normal body temperature represented 10.53%, patients with low-grade fever represented 34.21%, patients with moderate fever represented 7.89%, and patients with high fever represented 47.37%.

Our study is in agreement with Michalowski et al.[8], who revealed a significant difference among the studied groups as regards body temperature and reported that fever indicates an underlying infection or inflammation. Acute appendicitis is usually associated with low-grade fever; if higher, it indicates complications or suggests other causes of acute abdomen or complicated appendicitis.

However, as regards the abdominal signs, the presence of localized guard and rigidity represented 86.8% in group A and 8.1% in group B. However, patients with the rebound tenderness in our study showed a significant difference among the studied groups, representing 11.3% of patients in group B and 86.8% in group A. Therefore, there was a significant difference as regards abdominal sign in both groups.

As regards the presence of guarding and rigidity and rebound tenderness, these results are in agreement with Michalowski and colleagues[8],[11] and (14), who also reported a significant difference between the two groups as regards abdominal sign. Rebound tenderness can be associated with peritonitis, which can occur in diseases such as appendicitis. Rebound tenderness represents aggravation of the parietal peritoneum by moving or stretching. Guarding is a characteristic finding in the physical examination for an abruptly painful abdomen (an acute abdomen) with inflammation of the inner abdominal (peritoneal) surface due, for example, to appendicitis or diverticulitis. The tensed muscles of the abdominal wall automatically go into spasm to keep the tender underlying tissues from being disturbed. Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed.

The investigations needed for diagnosis of patients with surgical causes of common acute abdominal problems include the following: radiological investigations including plain radiographs, US, and CT; laboratory investigations including C-reactive protein, urine analysis, and total leukocytic count; and other investigations including sodium and potassium concentration in addition to prothrombin concentration and hemoglobin percentage.

The study is in agreement with Michalowski et al.[8], who revealed a significant difference among the studied groups as regards the investigations needed, either radiological or laboratory investigations. We conclude that radiology studies of the patient's abdomen can be helpful, but are not always useful or necessary. Advances in CT and US recently have greatly improved the accuracy of the preoperative diagnoses in these patients.

However, most patients with typical clinical findings of acute appendicitis undergo immediate surgery without preoperative imaging. As diagnosis is uncertain in up to one-third of patients because of atypical symptoms, many centers today request imaging for clinically equivocal patients.

However, our study results are in disagreement with that of[15], who showed that acute abdominal pain is the most common surgical cause of abdominal pain. However, it is in agreement with the finding that acute appendicitis is the most common surgical cause of acute abdominal pain among children.

The accuracy for the diagnosis by our study in general was 98% (98 out of 100 patients were correctly diagnosed), except for two cases that were misdiagnosed as acute appendicitis and were discovered intraoperatively as Mickel's diverticulum. We evaluate the usefulness of the present study for its calculated accuracy, false-negative and false-positive rates, and the specificity and sensitivity in the diagnosis of various types of acute abdominal pain in various age groups. Overall mortality was 1% (only one patient out of 100 patients as a result of complicated appendix died of septic shock). Therefore, the present study used for diagnosis of acute abdominal pain is preferable and effective in reducing maltreatment and misdiagnosis at emergency.


  Conclusion Top


As regards our study there was no significant difference as regards abdominal pain duration and number with respect to patients complaining of vomiting. However, we also showed a significant difference as regards abdominal pain site, severity, and the character of pain between the two groups. However, there was a significant difference regards the bowel habit, including normal bowel habits, absolute constipation, and diarrhea between the two groups.

There was a significant difference as regards abdominal sign in both groups, including the presence of guarding and rigidity and rebound tenderness between the two groups. However, as regards the body temperature we found a significant difference among the studied groups.

Our study showed a significant difference as regards both laboratory and radiological investigations needed for diagnosis between the two groups. The investigations needed for diagnosis of patients with acute abdominal pain were as follows: radiological investigations including plain radiographs, US, and CT; laboratory investigations including total leukocytic count, urine analysis, and C-reactive protein; and other investigations including hemoglobin percentage and prothrombin concentration, in addition to sodium and potassium concentration.

As regards the diagnosis, the most common diagnosis among group A patients was found to be acute appendicitis, representing 26 patients out of 38 (68.4%) patients, followed by complicated appendix representing 13.1%, fecal impaction representing 5.3%, adhesive intestinal obstruction representing 5.2%, Mickel's diverticulum representing 5.3%, and intussusception representing 2.6%. However, the most common diagnosis among group B patients was found to be nonspecific colicky pain representing 25 patients out of 62 (40.3%) patients, followed by gastroenteritis representing 25.8%, mesenteric lymphadenitis representing 11.2%, renal colic representing 6.4%, constipation representing 6.4%, dysmenorrhea representing 4.8%, and acute gastritis representing 4.8%.

As regards our study we tried to evaluate the usefulness for its calculated accuracy, false-negative and false-positive rates, and the specificity and sensitivity in the instant diagnosis of various types of acute abdominal pain in different age groups. The general accuracy for the diagnosis by our study was 99% (99 out of 100 patients were diagnosed correctly except for one case misdiagnosed as acute appendicitis and was diagnosed intraoperatively as Mickel's diverticulum).

Mortality rate as 1% (out of 100 patients only one patient died of septic shock as a result of complicated appendix).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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8.
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Buchert GS. Abdominal pain in children: an emergency practitioner's guide. Emerg Med Clin North Am 1999; 7:497–517.  Back to cited text no. 10
    
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Ross A, LeLeiko NS. Acute abdominal pain. Pediatr Rev 2010; 31:135–144.  Back to cited text no. 11
    
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Ruddy RM. Pain abdomen. In: Fleisher GR, Ludwig S. Textbook of pediatric emergency medicine. 4th ed. Philadelpia, PA: Lippincott Williams and Wilkins; 2000. pp. 421–428.  Back to cited text no. 12
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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