Abdominal pain is a very common condition in children. A child with abdominal pain requires a good history, physical examination, laboratory examination in addition to radiological examination, depending on the type of pain. The main focus will be on the causes of abdominal pain that will require urgent surgical intervention.
A- REASONS REQUESTING EMERGENCY SURGERY (LIFE THROUGH):
Abdominal Trauma: Childhood falling from height during play, motorized Injuries to the intra-abdominal organs caused by situations such as vehicle accidents, falling off a bicycle may cause acute abdominal pain. A good story should reveal whether the child had abdominal trauma or not. The child should be kept under observation by performing examinations. If there is intra-abdominal organ injury and bleeding in the abdomen, emergency surgical intervention may be required if blood comes out in the aspiration made with an injector inserted into the abdominal cavity.
Appendicitis: It is more common in children over the age of two. The pain that starts around the navel may be accompanied by vomiting. The pain is then localized to the right lower quadrant of the abdomen. In the examination, especially abdominal tenderness and subfebrile fever are observed.
In diagnosis; Ultrasound, white blood cell elevation, subfebrile fever are important. Antibiotics used unconsciously may delay the diagnosis by masking the clinical picture. Due to the sudden onset of pain, the child pulls his legs towards his abdomen.
The child with suspected appendicitis should be first observed, and appendectomy should be performed surgically when the diagnosis is confirmed.
In cases passed in the diagnosis, the appendix is perforated (exploded) and the inflammation covers the entire abdomen and the pain encompasses the entire abdomen.
Invagination (intestinal knot): It is the entry of an intestinal section in the upper part into the intestine in the lower part following it, like a sailor’s binoculars. This situation mostly occurs when the last part of the small intestine enters the large intestine. Less often, the small intestine enters itself again, the thick It can also occur in the form of intestinal penetration. It is often seen in babies aged 4-10 months. However, it can also be seen rarely in children in younger and older age groups.
In 92-98% of patients, the cause of invagination cannot be found and it is evaluated as idiopathic. A focus that initiates the event can be detected in 2-8% of patients. This focus, polyp, Meccan diverticulum, hemangioma (blood vessel clump) There may be tumors, intra-abdominal fibrous bands (adhesion) due to previous surgery. The majority of patients with a focus as the cause of invagination are patients over the age of 3 years.
The course of the disease is usually typical. The previously healthy baby wakes up with abdominal pain. He pulls his feet to his stomach and cries. Initially, he vomits with the consistency of stomach contents as a reflex. repetitions, the patient sweats, becomes pale. Vomiting is bile and the intestinal content takes its consistency. The classic picture is completed with bloody mucus defecation, which is defined as strawberry jelly.
On abdominal examination, distension (swelling) may be seen in the abdomen. The abdomen is soft and the invagination mass is palpable.
Diagnosis is easy as the history and findings are typical. In rectal examination, blood smears in the form of strawberry jelly on the finger.
In diagnosis; The presence of gas-liquid levels in the intestines in the standing direct abdominal X-ray shows intestinal obstruction. In the ultrasonography, nested bowel loops are seen. When there is doubt in the diagnosis, the last method to be applied is the barium colon X-ray.
In the treatment of invagination; Reduction (opening the knot) or surgical treatment is performed under fluoroscopy with air or barium (rectal route). The treatment to be applied is selected according to the characteristics of the patient. ) reduction should be tried. Before the reduction attempt, the patient should be prepared for surgery. In case of complications that may develop during reduction (such as bowel perforation) or failure of reduction, surgical treatment should be started quickly. In hydrostatic reduction, the pressure should not exceed 100-120 mm Hg. In cases where reduction occurs in hydrostatic reduction, thin air passage to the intestine can be seen under fluoroscopy. Following the reduction, the patient should be kept under observation, and it should be ensured that he or she is passing gas and stool. If there are toxic findings (such as toxic findings), the risk of pressure reduction should not be taken. In such cases, manual reduction is tried by opening the abdomen. In cases where the reduction occurs in this way, if there is necrosis (tissue death) in the intestine, the relevant intestinal part is removed and the continuity of the intestine is ensured by performing an end-to-end anastomosis.
Invagination should be treated within the first 6 hours following its occurrence. Cases that are not treated on time can quickly become fatal. At the slightest suspicion, the patient should be evaluated by a pediatric surgeon.
B- DISEASES THAT MAY REQUIRE EMERGENCY SURGERY DURING THE PROGRESS:
In some of this group of diseases, acute abdomen findings and abdominal symptoms as a complication related to the same disease during the course of a previously diagnosed disease While pain may occur, the diagnosis of the main disease can only be made with the emergence of complications.
Malrotation and Midgut Volvulus: During embryological development, the intestines make a counterclockwise 270°C turn around the self-feeding superior mesenteric artery. It may rotate around the veins and cause both nutritional deterioration and intestinal obstruction. This occurs in 50% of children in the newborn period (within the first month). In older children, the diagnosis is usually made during surgery. It can be diagnosed preoperatively, after radiological studies reveal that malrotation and related volvulus (intestinal knotting), cecum (initial part of the large intestine and duodenum) are not in the normal localization. Surgical intervention is required only when a complication such as volvulus develops.
Incarcerated inguinal hernia (inguinal hernia): Inguinal hernia can sometimes manifest itself with strangulation (such as the organs entering the hernia sac, intestine or ovary in girls). choking may occur acutely, such as vomiting and pain. In early interventions, strangulated bowel loop can be reduced by manual intervention. In late cases, intervention as a remedy and control of whether intestinal necrosis (death) has developed in patients in whom more than 6 hours have passed since drowning is required. If necrosis has developed, that part of the intestine is removed, if necrosis has not developed, hernia repair is performed.
Necrotizing Enterocolitis of the Newborn:
It is more common in newborns, especially in premature ones. Necrosis and inflammation in the small and large intestines can be seen in reactions. Abdominal distention (swelling), with vomiting In case of free air in the abdominal cavity due to intestinal necrosis (tissue death), emergency surgical intervention is required. During the medical treatment of the disease, strictures may occur in certain parts of the intestine. In such cases, surgical intervention may be required.
Hirschsprung Disease (Congenital Aganglionic Megacolon:
It is characterized by the congenital absence of ganglion cells (nerve cells) in the region close to the last parts of the large intestine in these patients. It causes the loss of the character of pushing the poop forward and providing normal defecation in the abdominal region. Such newborns may have trouble pooping. Intestinal perforation may occur due to the increased pressure in the large intestine. Free air is seen in the stomach. These patients in whom acute abdomen develops require urgent surgical intervention
Duplication: They are anomalies in cystic or tubular structure in any part of the intestine from the mouth to the anus and localization to it in a cystic or tubular structure. These symptoms include mass compression, volvulus (intestinal twisting knot), puncture, bleeding or previous They appear as the focal point in the invagination we mentioned. Ultrasonography and scintigraphy are useful if it includes gastric mucosa. In case of acute abdomen development, emergency surgery may be required. The diagnosis is usually made during the operation performed during the complications.
Meccal Diverticulum: It is an embryonic remnant that opens into the intestine in the form of a diverticulum in the last 20 cm of the small intestine. Although it is found in 2% of people, only 4-34% of them give symptoms due to complications. 45% of patients are under the age of two.
Meccal diverticulum may cause complications such as rectal bleeding, intestinal obstruction, perforation.
They may have gastric mucosa and pancreatic tissue ectopically in Meccal’s diverticulum. In such cases, they may cause sour cherry-colored abon (excessive) rectal bleeding. The bleeding lowers the blood values of the child considerably. Diverticulum is suspected. The cause of bleeding depends on the ulcer formed by the gastric mucosa tissue in the diverticula. Scintigraphy confirms the diagnosis in such cases. The diverticulum is removed by surgical intervention by correcting the blood values.
Meccal’s diverticulum may cause a picture like appendicitis in some cases.
Meccal’s diverticulum can also be encountered as a focus of invagination and as a cause of volvulus (intestinal knotting).
Exploded ovarian cyst: A ruptured ovarian cyst may mimic acute appendicitis or intra-abdominal inflammation by causing severe abdominal pain and tenderness. They rarely present with life-threatening bleeding into the abdominal cavity. Ultrasound helps in diagnosis. .Surgical intervention is rarely required due to excessive intra-abdominal bleeding.
Primary Peritonitis: This disease is the inflammation of the abdominal cavity that does not originate from the intra-abdominal organs. Bacteria use the blood route to reach the abdominal cavity, and the genital tract in girls.
It is difficult to distinguish the disease from appendicitis. Although the onset is short-lived in this disease, the general condition of the patient is worse, fever and white blood cell value are higher than appendicitis. There is widespread tenderness in all parts of the abdomen. Widespread inflammatory fluid can be seen in the abdomen on ultrasound.
The onset and progression of the disease do not resemble acute appendicitis. In this case, mostly streptococci or gonococci are seen in the microscopic examination of the material to be taken with an injector from the abdomen, making the diagnosis easier. In addition to the above microorganisms, gram negative ones such as E. coli can also be encountered. Primary peritonitis It responds to antibiotic treatment within 12-24 hours. However, it is difficult to diagnose primary peritonitis definitively before surgery, and most of the patients are operated on with the suspicion of ruptured appendicitis.
Table.1- Diseases that may require emergency surgical intervention during their course
1- Choledochal cyst
2-Masenteric cyst
3-Urachal remnants
4-Cystic Fibrosis
5-Peptic ulcer
6-Gallbladder diseases
7-Pancreatitis
8-Ascariasis
9-Amebiasis
10-Typhoid
11-Foreign body Swallowing
12-Tumors
13-Polyps
14-Kron’s disease
15-Ulcerative Colitis
16-Henok-Chenlayn Purpura
17-Hemolytic-uremic Syndrome
18-Familial Mediterranean Fever
19-Hamophilia
20-Pyogenic liver and intra-abdominal abscesses
21-Tuberculosis Peritonitis
22-Gastrointestinal hemangiomas
