Acute abdominal pain in children

Constipation and nonspecific abdominal pain in teenage girls referred for emergency surgical consultation

OBJECTIVE

The aim of this study was to describe the discharge diagnoses of children receiving surgical consultation for acute abdominal pain according to age and sex.

METHODS

Retrospective chart review.

RESULTS

Nine hundred forty-one children were included. Appendicitis was confirmed in 31% of young boys (<12 years), 42% of teenage boys (≥12 years), 38% of young girls, and only 18% of teenage girls. A large number of teenage girls were diagnosed as having constipation and nonspecific abdominal pain. Gynecological diagnoses were relatively rare (9% of teenage girls). Teenage girls often required multiple visits to the emergency department. In addition, they frequently received consultation from other medical specialists: 30% versus 20% of young girls and 12% of boys. Teenage girls had the highest rate of (retrospectively) unnecessary surgery: 36% versus 10% of young girls (P < 0.01) and 11% of boys (P < 0.01).

CONCLUSIONS

Most children receiving surgical consultation for acute abdominal pain do not have diseases requiring surgery. In teenage girls, especially, the proportion with appendicitis is low. Constipation and nonspecific abdominal pain are the main discharge diagnoses in this group. Physicians should have a high index of suspicion of constipation when examining teenage girls with acute abdominal pain.

Clinically monitored delay-A valid option in cases with doubtful diagnosis of acute appendicitis

AIM

To evaluate the effect of delayed surgery after a period of observation in patients with doubtful diagnosis of acute appendicitis in the form of improvement in negative appendectomy rates and the incidence of complications.

MATERIALS AND METHODS

One hundred twelve patients operated with the diagnosis of acute appendicitis between May 2008 to June 2009 were included in this retrospective study. They were divided into two groups based on timing of surgery after admission. These two groups were studied in respect to age, sex, Alvarado score at presentation, ultrasound findings, operative findings, histopathology and postoperative complications. Proportions of negative appendectomies, and complicated appendicitis were analysed statistically.

RESULTS

Group wise age and sex distribution was comparable. The mean Alvarado score in the group 1 was 7.9 (range, 6-10) where as in those operated later than 12 hours (group 2), it was 4.5 (range, 3-8). Normal appendectomies were significantly (p < 0.05) less in group 2 (1 out of 40) as compared to group 1 (4 out of 72). The number of complicated appendicitis were higher in group 1 (14/72) as compared to group 2 (4/40) but not significantly (p > 0.06). The number of postoperative complications was also high in group 1 (11 vs 2 in group 2).

CONCLUSION

It is better to wait in cases with doubtful initial diagnosis of appendicitis on admission in order to decrease negative appendectomy rates. These patients need to be continuously monitored clinically to prevent complications.

Abdominal pain and emergency department evaluation

By approaching the abdominal pain patient in a systematic fashion, the physician can improve his or her performance in evaluating the patient in a safe and efficient manner without extensive or redundant tests.

Delay of surgery in acute appendicitis

BACKGROUND AND OBJECTIVES

It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis.

PATIENTS AND METHODS

We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications.

RESULTS

Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS).

CONCLUSION

Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeon's decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.

A papular eruption and acute abdominal pain associated with coxsackie A-14 virus

A 14-year-old girl who was admitted to hospital with acute abdominal pain developed an erythematous papular eruption which persisted for 4 weeks. Examination of a stool specimen yielded evidence of a coxsackie A-14 virus.

Active observation in acute abdominal pain

Only a minority of patients admitted with acute abdominal pain require urgent operation, but the identification of those who need an operation may be difficult. Many surgeons adopt a radical approach and operate when the diagnosis is doubtful, which often leads to 20 percent rate of negative findings on laparotomy. In this study, 220 patients of all ages admitted with acute abdominal pain were studied prospectively, and when the diagnosis on admission was uncertain, a policy of active observation was employed. In all, 39 percent of the patients underwent operation and only 5 percent had negative findings on laparotomy. No patient suffered as a result of this policy, which is recommended as a safe and effective approach to the management of acute abdominal pain.

Audit of abdominal pain in general practice

An audit of 150 consecutive cases of abdominal pain presenting to an urban teaching practice between October 1983 and May 1984 was performed. The median duration of pain prior to presentation was two days. Females predominated in all age groups.Eighty-nine per cent of these patients were managed entirely in the practice and of these, 52 per cent were managed with reassurance and advice alone, while 48 per cent also received a prescription. Only 15 per cent of patients were investigated in any way by the practice. Of the 17 patients (11 per cent) referred, nine were referred as emergencies and eight were admitted that day. However, there were only three true surgical emergencies in the entire series (one appendicitis, one intussusception and one fulminating pancreatitis).

Hospital Admissions for Abdominal Pain in Childhood

From January to March 1980, a consecutive sample of 50 children admitted to hospital with acute abdominal pain provisionally diagnosed as appendicitis but who recovered spontaneously without a specific physical diagnosis was studied. The instruments used were a standardized parental interview and Rutter A(2) and B(2) questionnaires which are designed as screening devices to explore levels of emotional adjustment in children. A comparison was made with 43 children (controls) matched for sex and age from the same schools. Forty children suffering from acute appendicitis were studied in the same way. A significantly increased number of children in the nonspecific group obtained abnormal scores on the Rutter Scales compared with the control group ( P < 0.025). An unexpectedly large number (31%) of boys suffering from acute appendicitis obtained abnormal scores on the Rutter Scales. Postal follow up three months following discharge from hospital indicated that 8 (16%) of the nonspecific group were incapacitated to the extent of missing school. During the study, 15 children had a normal appendix removed at operation. Seven of them showed a significant degree of maladjustment.