I-Definition
Abdominal pain is a clinical symptom that develops due to reasons involving intraperitoneal or other systems. Acute abdomen is a clinical picture consisting of inflammatory signs and symptoms that occur in the intraperitoneal area and require surgery.
II-Etiology
Acute abdominal pain in children should prompt emergency physicians. It is a conundrum that challenges pediatric surgeons when making a diagnosis. Because only 1-5% of abdominal pain in children requires surgery. Acute appendicitis is one of the most common diseases requiring surgery. In addition, intussusception, Meckel's diverticulitis, volvulus, and ovarian cyst torsion and rupture in girls are diseases that require surgery. Diseases such as peptic ulcer, inflammatory bowel diseases, pancreatitis, cholecystitis and primary peritonitis may also require surgery in the later stages of the disease. Apart from these, the main causes of abdominal pain include gastroenteritis, urinary tract infections, parasitosis, food poisoning, mesenteric lymphadenitis, lower lobe pneumonia, which do not require surgery, as well as metabolic diseases such as diabetic ketoacidosis, acute adrenal insufficiency, acute porphyria, sickle cell anemia, acute leukemia, HenochSchölein. Hematological diseases such as purpura, hemolytic uremic syndrome, and neurological diseases such as abdominal epilepsy and abdominal migraine can also be mentioned. Constipation, one of the causes of acute and chronic abdominal pain in children, should be kept in mind in the differential diagnosis.
In summary, the causes of abdominal pain are gastrointestinal, genitourinary, hepatobiliary, pulmonary systems. may be of interest. It may also be due to hematological, metabolic, neurological causes and poisons-drugs. Infantile colic, functional and psychogenic abdominal pain in children are among the etiological factors that should be considered after other causes are excluded. Etiological factors according to systems are summarized in Table 1. The etiology of abdominal pain varies depending on childhood. These differences are shown in Table 2.
III-Pathophysiology
Abdominal pain can be classified as visceral, somatoparietal and referred pain. Visceral receptors are located in the mucosa, muscle layer, serosa and mesentery of the hollow organ. These receptors, stretch, They respond with pain to chemical and mechanical stimuli such as ischemia. Visceral pain is a dull pain in the midline that is not well localized. Since the abdominal quadrants in children are small, pain can be experienced in the epigastric region (originating from the foregut such as the lower esophagus and stomach), periumbilical (originating from the midgut such as the small intestine) and in the lower abdominal region (last intestine such as the large intestine). source) is felt.
Somatoparietal receptors are localized in the parietal peritoneum, muscle and skin. Pain occurs as a result of inflammation, stretching and tearing of the parietal peritoneum. Pain may be sharper, more intense and localized. The pain increases with movement, so the child lies down with his feet pulled to his stomach. In referred pain, pain may be felt in the same dermatome region as the affected organ.
IV-Diagnosis
Anemnesis, physical examination, laboratory and imaging methods are used in diagnosis. In the anamnesis, the patient's age, the form and duration of the pain, its localization, and the patient's history should be questioned. Diseases such as organ torsion, perforation and intussusception should be considered in cases of sudden and severe pain, and diseases such as appendicitis, cholecystitis and pancreatitis should be considered in cases of slow-onset pain. The characteristics of the diseases will be explained under a separate heading.
V-Treatment Approach
Conservative approach, medical treatment and follow-up are sufficient to solve the problem in abdominal pain, except for patients requiring surgical treatment. . In fact, most of the time, in cases of undiagnosed abdominal pain, it is decided whether surgery is required by taking a conservative approach and monitoring whether the condition progresses or not. This approach is even more important in pediatric patients. During follow-up, surgical indications are determined according to the clinical, laboratory and radiological findings of diseases requiring surgery. The approaches to be applied in diseases that require surgery will be explained under disease headings.
A- DISEASES THAT REQUIRE SURGERY
a-Acute Appendicitis
Acute appendicitis is one of the most common diseases that require urgent surgical intervention in children. While it is most common between the ages of 6-12, its frequency drops below 1% after the age of 15. Appendix Vermiformis, 5-30 cm in length, less than 6 mm in diameter, and its blood supply is 200' around the area from the ileocolic artery. It is a lymphoid organ with nearly 1,000 lymph follicles, and anatomically, 95% is intraperitoneal and 5% is retroperitoneal and retrocecal. Since the appendix vermiformis is long in length, small in diameter, and has a thin wall, perforation may develop in a shorter time in children.
ai-Pathophysiology
Petrified stool (Fecalith), Parasite (Entanmoeba strongyloides, Enterobius vermicularis, Schistosoma, Ascaris), Foreign body (fruit seeds, metal objects, etc.) Submucosal lymphoid hyperplasia (most common cause in children), Due to reasons such as carcinoid tumors
As a result of lumen obstruction;
Bloodflow in the Appendiceal Wall Decreases
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Stasis
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Bacterial Proliferation
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Inflammation
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Chemotactic Cell Release, Necrosis
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Perforation
aii-Diagnosis
History Diagnosis can be made by physical examination, laboratory and ultrasonography. In cases of perforated and blastron appendicitis that are difficult to diagnose, spiral CT can be performed in obese patients.
aiii- Clinical picture; Initially, due to the increase in intraluminal pressure, visceral pain occurs that cannot be localized around the umbilicus, and in the abdomen. The pain settles towards the Mc Burney point within 8-12 hours as the inflammation affects the parietal peritoneum. Loss of appetite (60%) is an important finding; acute appendicitis is less likely in a patient with a desire to eat. Vomiting (80%) usually occurs shortly after the onset of pain. In gastroenteritis, first vomiting occurs and then pain and diarrhea begin.
The child with acute appendicitis is distressed. To reduce abdominal pain, lie down with your legs pulled towards your stomach. The probability of a child jumping up and down on the examination table to have appendicitis is almost non-existent. There is often fever. In retrocecal appendicitis, low-volume diarrhea due to irritation of the sigmoid colon and dysuria due to damage to the ureter may occur. This may make it difficult for the physician to rule out gastroenteritis and urinary infection in the differential diagnosis.
aiv- In Physical Examination; The physical examination, which is performed by distracting the child and drawing his attention elsewhere, starts from the lower left quadrant. Your wife There may also be distension. Typical finding; Sensitivity at the Mc Burney point on palpation (there may be no sensitivity in the retrocecals). Direct and indirect rebound (+), tenderness on the right side during palpation of the left lower quadrant (Rovsing's sign) may be present. Cough Test; Pain in the right lower quadrant when the patient coughs, Heel test; Findings that support the diagnosis include pain in the right lower quadrant when the patient stands up on his toes and quickly lands on his heels. In retrocolic or retrocecal cases, psoas test (straight upward elevation of the right leg) and obturator test (internal rotation of the right thigh) can be performed, but these tests are not of much value in children. On rectal examination, fullness and sensitivity in the pelvis may be observed. One or more of these findings being positive is important in diagnosis.
av- Laboratory Findings:
Leukocyte count is the most frequently used laboratory method in acute appendicitis. While leukocytosis is observed in 70-80% of acute appendicitis, white blood cells may remain within normal limits in 20% of cases. The sensitivity of leukocytosis in the diagnosis of acute appendicitis is reported to be 70-80% and the specificity is 60-68%. However, in cases of abdominal pain lasting longer than 24 hours, the specificity of the white blood cell count for acute appendicitis reaches 90%. As classical information;
Leukocytosis: Non-perforated 11,000-20,000 mm3
Perforated: > 20,000 mm3
Leukocytosis exceeding 20,000 in acute appendicitis can only be seen in patients with perforation and peritonitis. In patients whose clinical picture has just begun, high leukocytosis directs the diagnosis to infectious causes such as acute tonsillitis, bronchopneumonia and pneumonia. C-Reactive Protein (CRP) increases significantly, especially when perforated appendicitis and intra-abdominal abscess due to appendicitis develop. CRP levels are considered the most sensitive test in abdominal pain lasting longer than 24-48 hours.
Neutrophil/Lymphocyte ratio is also one of the tests used in diagnosis. It has been reported that a Neutrophil/Lymphocyte ratio of 3.5 and above is more sensitive than leukocytosis in diagnosis, but has less specificity.
Procalcitonin (PCT) is an important parameter in the early diagnosis of systemic infection and inflammation. High PCT Its level is proportional to the severity of the infection. It is reported that PCT is more useful than CRP in the diagnosis of acute appendicitis, its sensitivity reaches 95% and its specificity reaches 100%. However, there are also articles reporting that there is no significant difference between the PCT levels of patients with acute appendicitis and healthy people. In the light of these studies, there is no clarity regarding the diagnosis of acute appendicitis with PCT.
In recent years, calprotectin and leucine-rich alpha glycoprote (LRG) in serum and urine have been used to diagnose appendicitis. ), studies have been conducted to help diagnose appendicitis with markers such as interleukin-6, which induces CRP production, Serum Amyloid A (SAA), leukocyte gene expression, cytokines, Granulocyte Colony Stimulating Factor (GCSF), Tc99m Citrate Scintigraphy, Tc99m Hexamethylpropylene amine oxime scintigraphy. . However, they do not have routine application. Anamnesis, clinical findings, physical examination and simple laboratory tests are still extremely important in the diagnosis of appendicitis. For this reason, many scoring systems have been developed based on criteria based on anamnesis, clinical and physical examination and laboratory findings. In addition to these, imaging methods can also be extremely helpful in diagnosis.
It is reported that urine analysis is also valuable in acute appendicitis. Especially in perforated appendicitis, an increase in ketone bodies, nitrate, pH, density, leukocytes and erythrocytes has been detected in the urine. Alkaline urine pH and increase in 5-Hydroxy Indole Acetic Acid (5-HIAA) in urine are parameters that indicate inflammation. 5-HIAA comes from serotonin-releasing cells in the appendix and is found high in the urine in the early stages of inflammation. Its level decreases as appendiceal necrosis progresses.
As a result, none of the laboratory tests alone can diagnose acute appendicitis, but in practice; It is seen that leukocytosis, CRP (+), no neutrophil dominance (≥75%) in the peripheral blood smear, and a Neutrophil/Lymphocyte ratio of 3.5 or above strengthen the diagnosis.
avi- Imaging Methods Standing Direct Abdominal Radiograph:
Fecalith, tiny air-fluid level in the right lower quadrant (abnormal gas pattern), preperitoneal fat shadow and psoas shadow obscuration may be seen.
Ultrasonography: Diagnostic value % extremely over 90
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