CLINICAL PRESENTATIONS: THE ACUTE ABDOMEN
Acute abdominal pain is one of the most frequent presentations of children visiting emergency departments or outpatient clinics. The differential diagnosis is extensive (Table 40-1). The clinical and radiographic findings are often nonspecific. Appendicitis, gastroenteritis, constipation, trauma, pneumonia, sepsis, toxic ingestion, and hemolytic uremic syndrome are among the conditions that can produce acute abdominal pain in children of all ages. The possibility of Hirschsprung disease, intussusception, and volvulus must be considered in infants with clinical indications of acute abdominal pathology. Intussusception can also occur in preschool children. In older children, testicular torsion and inflammatory bowel disease enter the differential diagnosis. The possibility of tuboovarian disease or ectopic pregnancy needs to be considered in adolescent girls.
Table 40–1.Differential Diagnosis of Acute Abdominal Pain |Favorite Table|Download (.pdf) Table 40–1. Differential Diagnosis of Acute Abdominal Pain
|Inflammatory conditions ||Appendicitis |
|Mesenteric adenitis |
|Crohn disease |
|Henoch–Schönlein purpura |
|Hemolytic uremic syndrome |
|Acute pancreatitis |
|Epiploic appendagitis |
|Ischemia ||Midgut volvulus |
|Segmental omental infarction |
|Splenic infarction |
|Acute bowel obstruction ||Volvulus |
|Postsurgical adhesions |
|Incarcerated hernia |
|Reproductive organs ||Hemorrhagic ovarian cyst |
|Pelvic inflammatory disease |
Blunt abdominal trauma and penetrating injuries of the abdomen most often lead to solid organ injuries. The spectrum of traumatic pathology includes intraparenchymal contusion, intraparenchymal hematoma, subcapsular hematoma, laceration, fracture, and vascular pedicle injury. CT is generally the imaging modality of choice for evaluating these patients. It provides high sensitivity for the detection of solid organ injuries, characterizes the injury, and determines the severity of hemoperitoneum. Please refer to Chapters 41, 42, 43 and 51 for detailed descriptions of solid organ injuries.1
Bowel and mesenteric injuries due to abdominal trauma are uncommon, but are potentially life-threatening. Traumatic intestinal lesions include perforation, either intraperitoneal or retroperitoneal, and intramural hematoma. There is often concomitant injury of the mesentery. The diagnosis of GI injury based on the clinical findings alone is often difficult. Substantial hemorrhage is uncommon with these injuries; the intestine is the least common source of hemoperitoneum in patients suffering blunt abdominal trauma. Obstructive symptoms can occur in patients with an intramural hematoma. Patients with trauma-related perforation of the bowel are susceptible to peritonitis, but the clinical manifestations of this complication are often delayed.
The duodenum is the most frequently injured portion of the intestine. This is due to the fixed retroperitoneal position of the duodenum directly over the spine. Because of fixation by the ligament of Treitz, the proximal portion of the jejunum is the next most common site of intestinal injury with blunt trauma in children. In both of these areas, the most common traumatic lesion is hemorrhage, usually intramural. The most common location of a bowel rupture in patients suffering blunt abdominal trauma is in the mid to distal portion of the small intestine. Penetrating injuries can involve ...