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Abdominal Pain

We are going to talk about three main diseases; appendicitis, intussusception and mid-gut volvulus abdominal pain, abdomenal pain, stomach pain, stomic pain. All of which may present as an acute abdomen and yet have very characteristic findings that will help you differentiate them.

What’s the cause of appendicitis? Many, and some would say all, are really caused by obstruction of the lumen of the appendix, an appendolith. This causes the intra-appendiceal pressure to rise, which causes mucosal ischemia, necrosis and ulceration, bacterial invasion from the lumen of the appendix into the wall, a lot of inflammatory changes.

What do you see clinically? Acute cramping. It’s acute, not sudden. It’s not an instantaneous onset but relatively acute. Crampy, oftentimes steady periumbilical pain initially. Anorexia is very common.

What are the physical findings? The patients oftentimes do things to decrease stimulation to the peritoneum. They may be lying on the examining table with their knees drawn up to soften the stomach. Pulmonary exam; you want to be sure and do … a right lower lobe pneumonia may give you referred abdominal findings. Palpation; initially the tenderness will be periumbilical. It will move down towards the right lower quadrant to McBurney’s point.

What’s the clinical progression of appendicitis? Well, people are always concerned about late diagnosis and that the appendix may in fact rupture. In 95% of patients less than two-years-of-age they actually present after their appendix has ruptured. So they are going to have more signs of diffuse peritonitis rather than classic appendiceal signs.

Therapy; if they are hemodynamically unstable, they are not taken to the operating room until they are stabilized with medical management. They need antibiotics, either Cefoxitin or triple antibiotics are oftentimes used. And the therapy is surgical with an appendectomy.

Okay, intussusception. Much different disease. We are going to talk about the epidemiology, the pathophysiology, the clinical presentation, what diagnostic tests if any are going to be helpful, and what the therapy is.

The incidence of intussusception, one to four per thousand live births are going to have an intussusception. The age is very characteristic. Three months to three years. Very much different than the age of children who get either appendicitis or a mid-gut volvulus.

Okay, the other big acute abdomen in childhood is a mid-gut volvulus. This is truly a surgical emergency. Patients are typically less than a month of age. Males greater than females. This is really a congenital malrotation of the GI tract.

So this is an upper GI with … you can see the stomach filling, the so-called corkscrew sign here. You see that the small bowel is pushed off to the right side of the intestine, not much over here on the left side. If you have a mid-gut volvulus and necrotic bowel, this is what it is going to look like. Dark ischemic-appearing bowel. The surgical approach to this varies