Adhesive small bowel obstruction occurs in 2-15% of children following a laparotomy. Seventy five percent of such patients present with adhesive obstruction between 2 weeks and 3 months after their operation. Eighty percent will occur within 2 years of operation. The disorder is treated with nasogastric decompression.

Postoperative intussusception occurs most commonly after major abdominal operations. Usually it is seen around age 26 months, but any age child may be affected. Postoperative intussusception presents with emesis, increased nasogastric drainage, abdominal distention, and irritability. Severe colicky pain and bloody stools are unusual. Ninety percent of the patients present within 2 weeks following surgery. Postoperative intussusception is managed with repeat laparotomy.
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Meckel Diverticulum

Meckel diverticulum are present in 2% of the population. It presents as a tender left lower quadrant mass, associated with blood in the stool. Occasionally, technetium nuclear scans are positive for Meckel’s in the symptomatic patient.

Vague abdominal pain with hemoccult positive stools suggests a Meckel Diverticulum. Bleeding is seen in 35-40% of childhood cases. RLQ pain, suggestive of appendicitis, is the usual complaint of children with bleeding.

Meckel diverticulum may cause intestinal obstruction or diverticulitis, which cannot be distinguished from appendicitis.

Pancreatitis
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Pancreatitis is a rare cause of abdominal pain in children. Trauma is the most frequent cause of this disorder in children.

Symptoms include mid-epigastric abdominal pain, nausea and vomiting, jaundice, and acholic stools.

Signs include epigastric tenderness, abdominal distention, decreased bowel sounds, and an epigastric mass may be detected.

An elevated serum amylase or serum lipase level is diagnostic.
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Abdominal x-ray may show an epigastric sentinel loop or pancreatic calcifications. US is very sensitive and shows an enlarged, hypoechoic pancreas. A pseudocyst or an enlarged pancreatic duct may also be seen.
Abdominal Pain

In males with lower abdominal pain, the scrotum and its contents must be examined. Testicular torsion is a surgical emergency and must be treated within 6 hours of the onset of the pain to save the testicle.
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Testicular torsion may present as lower abdominal pain, which may be associated with recent trauma or cold The gonad is tender and elevated in the scrotum, with a transverse orientation. Although testicular torsion may occur at any age, it usually occurs in adolescent males at puberty or shortly afterwards. It may occur in neonates. If the scrotum is empty, then torsion of a testicle located in the groin or in the abdomen should be ruled out. Torsion of undescended testicles occurs more frequent than in normally descended ones.

Torsion of an appendix testis may cause testicular pain, which occasionally be visualized as a “blue dot” beneath the scrotal surface on the testicle, associated with point tenderness. This disorder requires only analgesics and bedrest.
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Laboratory Studies.

Ultrasound can sometimes help to localize an intraabdominal torsion. Doppler US may distinguish torsion (testes without blood flow) from epididymitis (where blood flow is normal or increased).

Gonadal Pain in Females

The leading causes of gonadal pain in females are ovarian cysts and torsion of uterine adnexal structures. Ovarian tumors are often associated with precocious puberty or virilization.

Ovarian cysts are responsible for 25% of childhood ovarian tumors. They are most common in adolescents. Bleeding into the cyst or cystic rupture causes pain, which usually subsides within 12-24 hours.

An ultrasound, performed after a cyst ruptures, may show pelvic fluid and the cyst.
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Surgery is required if bleeding is uncontrolled. Growing cysts >5 cm should be considered for surgical enucleation.

Torsion of Uterine Adnexal Structures

Torsion is associated with unilateral, sudden, severe pain with nausea and vomiting. However, the patient may have subacute or chronic symptoms, with intermittent pain for days. The pain is usually diffuse and periumbilical in younger patients, but in older children and adolescents, the pain may radiate initially to the anterior thigh or ipsilateral groin. Torsion is more commonly right-sided.

Fever and leucocytosis are usually present. Physical exam may reveal muscle rigidity and fixation of the mass on pelvic examination.
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Ultrasound will identify the mass accurately.

Surgical exploration may sometimes salvage the ovary. Malignant neoplasms may cause torsion in 35% of cases.

Signs of ectopic pregnancy include abdominal pain in any location, vaginal bleeding, and/or amenorrhea. Nausea and vomiting, other symptoms of pregnancy, and lightheadedness may also be present.
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Abdominal, adnexal, and/or cervical tenderness are often found on pelvic examination, but occasionally abdominal tenderness is absent. The cervix may be soft (Godell’s sign) and bluish in color (Chadwick’s sign). The examination may reveal adnexal fullness and uterine enlargement. Some patients present with blood loss and hypotension or unexplained anemia. Ten percent will be in shock.

Evaluation includes a pregnancy test and ultrasound.

Treatment consists of removal of the ectopic pregnancy by laparoscopy or exploratory laparotomy.

Hydrops of the gallbladder is characterized by massive gallbladder distention in the absence of stones, infection, or congenital malformations. It usually is preceded by another systemic disease (viral syndrome), and it is often associated with dehydration (bile thickening) or lymphadenopathy (partial obstruction). The usual treatment is a cholecystectomy.

Acalculous cholecystitis accounts for about 10-30% of gallbladder disease in children. It may occur with severe illnesses, such as burns, sepsis, or trauma.

Cholelithiasis may be a concomitant of hemolytic diseases in children. Fifty percent of children with spherocytosis develop gallstones. Sickle cell anemia and Thalassemia are the next most common causes. In adolescent females cholelithiasis can be found in the absence of hemolytic disease. Risk factors include obesity and pregnancy. Pregnancy is associated with 50% of all adolescent cholelithiasis.

Ultrasonography delineates gallstones and is the study of choice to screen for gallbladder disease.

Radioisotopic scanning evaluates biliary and gallbladder function. Nonvisualization of the gallbladder with no progression of isotope indicates acute cholecystitis.
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Abdominal x-ray reveals a classic double bubble caused by duodenal obstruction, but this finding is nonspecific. Pneumatosis intestinalis or distal bowel obstruction may also be apparent.

Infants with rapid deterioration and obstructed loops of bowel require immediate surgery.

If the infant is not critically ill, an UGI series with water-soluble, non-ionic, isoosmolar contrast will confirm midgut volvulus. If malrotation or volvulus (suggested by a beak, spiral or corkscrew sign) is found, an immediate laparotomy is necessary.

Thirty to sixty percent of malrotations are associated with other anomalies, described below.

Diseases and Anomalies Associated with Malrotation:

Congenital Diaphragmatic Hernia Hirschsprung’s Disease

Gastroschisis Imperforate anus

Large omphaloceles Duodenal webs

Prune Belly Syndrome Mesenteric cysts

Duodenal Atresia Cardiac anomalies

Jejunal Atresia Orthopedic anomalies

Fever, vomiting, irritability, lethargy with right lower quadrant (RLQ) tenderness and guarding are diagnostic of appendicitis in the very young patient until proven otherwise.
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Masses may be felt on rectal exam in 2-7% of younger patients with appendicitis.

Children Older than 2 years old present with a perforated appendix about 30-60% of the time. This incidence declines as the age of the child increases.

Lower abdominal pain in the adolescent female may be caused by pelvic inflammatory disease (PID), ovarian cysts, ovarian torsion, ectopic pregnancy, or mittelschmerz (pain with ovulation).

A WBC >15,000 supports the need for surgery, but a normal WBC and differential does not exclude appendicitis.
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Intussusception
Intussusception is the most common cause of bowel obstruction between 2 months and 5 years of age. The most vulnerable age group is 4-10 months old, but children up to 7 years old may be at risk.

Intussusception is characterized by vomiting, colicky abdominal pain (85%) with drawing up of the legs, and currant jelly stools (60%). Fever is common. Lethargy, dehydration, obtundation and/or coma may occur in younger infants.

The abdomen may be soft and nontender between episodes of colicky pain, but eventually it becomes distended. A sausage-shaped mass in the right upper quadrant (RUQ) may be palpable.

Intussusception may sometimes be palpated during rectal examination, and three percent of intussusceptions may prolapse.

Ninety-five percent of intussusceptions are located at the ileocecal junction, 5% are found elsewhere in the GI tract.
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Abdominal X-ray

The leading edge of the intussusception is usually outlined with air, which will establish the diagnosis. Often there are radiographic signs of bowel obstruction.

When the plain abdominal x-ray is normal, intussusception cannot be excluded without a barium enema.
Treatment usually consists of radiologic reduction using air and fluoroscopy, which is effective in 80-90%. Radiographic reduction is contraindicated if the patient has evidence of peritoneal irritation or toxicity. Under these conditions, surgery must be considered.
Abdominal pain

Colic results from spasms of a hollow viscus organ secondary to an obstruction. It is characterized by severe, intermittent cramping, followed by intervals when the pain is present but less intense. When spasms are present, the patient will appear agitated and restless, pale and diaphoretic. Colic pain usually originates from the biliary tree, pancreatic duct, gastrointestinal tract, urinary system, or uterus and tubes.

Inflammatory pain is caused by peritoneal irritation, and the patient presents quietly without much motion and appears ill. The pain is initially less severe and is exacerbated by movement.

Vomiting
The timing of the onset of vomiting is important. Usually abdominal pain will precede vomiting.
The interval between abdominal pain and vomiting is shorter when associated with colic.
Delayed vomiting for many hours is often associated with distal bowel obstruction or ileus secondary to peritonitis.

Diarrhea

Mild diarrhea with the onset of abdominal pain suggests acute gastroenteritis or early appendicitis.
Delayed onset of diarrhea may indicate a perforated appendicitis, with the inflamed mass causing irritation of the sigmoid colon.
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Physical Examination

The abdomen should be observed, auscultated, and palpated for distention, localized tenderness, masses, and peritonitis. The groin must be examined to exclude an incarcerated hernia or ovary, or torsion of an ovary or testicle.

Rectal Examination

Gross blood in the stool suggests ectopic gastric mucosa, Meckel’s diverticula, or polyps.

Blood and mucus (currant jelly stool) suggests inflammatory bowel disease or intussusception.

Melena suggests upper gastrointestinal bleeding, necessitating gastric aspiration for blood.

Tests for occult blood in the stool should be performed.

Pelvic examinations are mandatory for postmenarchal and/or sexually active female patients. The rectal examination may also be used to evaluate the cervix, uterus, adnexa, and other pelvic masses.

Fever

Thoracic disease (eg, pneumonia) may be the cause of abdominal pain associated with fever.

Costovertebral angle tenderness with fever suggests pyelonephritis or a high retrocecal appendicitis.

Localization of Abdominal Pain

Generalized pain in the epigastrium usually comes from the stomach, duodenum, or the pancreas.
Pain in the midgut (small bowel and colon or spleen) usually localizes to the periumbilical region.
Inflammation (parietal pain) is usually well localized.
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Referred abdominal pain occurs when poorly localized visceral pain is felt at a distant location.

Pancreatitis, cholecystitis, liver abscess, or a bleeding spleen cause diaphragmatic irritation, which is referred to the ipsilateral neck and shoulders.
Intraabdominal fluid may produce shoulder pain on reclining.
Gallbladder pain may be felt in the lower back or infrascapular area.
Pancreatic pain often is referred to the posterior flank.
A migrating ureteral stone often is felt as pain radiating toward the ipsilateral groin.
Rectal or gynecological pain often is perceived as sacral pain.
Right lower lobe pneumonia may be perceived as right upper quadrant abdominal pain.

Abdominal distention is a common complaint, particularly among women, who often note that the problem becomes more pronounced during the latter part of the day. Patients and physicians usually ascribe the problem to excess gaseousness. The ingestion of food causes relaxation of the stomach and rectus muscles. Any weakening of the rectus muscles, therefore, leads to more-pronounced distention. Because the largest meal usually is taken in the evening, distention following this meal is more pronounced than observed after breakfast. Although gaseousness is not the dominant cause, excess gas ingestion or generation will add to the problem. The absence of significant associated complaints such as vomiting, diarrhea, fever, and severe pain is often helpful in determining whether the complaint is caused by muscle relaxation or gastrointestinal structural pathology. A long history of symptoms also supports a functional cause. Women who have had one or more pregnancies or individuals who have undergone abdominal surgeries or have debilitating diseases may lose rectus muscle tone and thus distend easily.
Physical Examination
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The most important clinical observation is whether the distention is present in the erect and recumbent positions. If the evaluation is in the late afternoon and the patient is able to show abdominal distention while standing erect, the patient should be asked to lie recumbent on the examining table. If the distention is no longer apparent to the physician and patient, the diagnosis has been established. Many patients unfortunately have been subjected to numerous endoscopic and radiographic procedures and treated with a variety of drugs for a problem that is primarily mechanical. If the distention persists while the patient is recumbent, an obstruction series should be obtained and appropriate studies directed to determine whether the disorder is related to abnormal motility (pseudo-obstruction) or to a partial bowel obstruction.
Management

Efforts can be directed toward reducing the swallowing of air, the use of carbonated beverages, and the ingestion of foods that generate colonic gas such as cabbage, broccoli, cauliflower, and baked beans. A larger lunch and smaller dinner may prove beneficial. Dietary manipulation unfortunately is less helpful for patients with distention than for individuals with belching or flatulence. If weakened rectus muscles are thought to be the cause, younger patients may benefit from exercises aimed at strengthening the muscles (rectus-tensing exercises that are variations of the standard sit-up), but this strategy is not likely to be effective in older individuals. An abdominal support garment can reduce the cosmetic problems associated with distention.
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