Tummy pain is only part of the range of surgical presentations and patients will often present with penile or scrotal problems.

PAP1– Abdominal Pain

EM Curriculum: (click to view)

BACKGROUND

There is some overlap between the presentation of an acute abdomen in children and adults, especially with appendicitis. However finding the correct cause of abdominal pain is often more of an art than a science.

There is also more to surgery than "tummy pain" and patients will often present with penile or scrotal problems.

There is some overlap between the presentation of an acute abdomen in children and adults. Appendicitis is the most common cause of an acute abdomen in children over 1 year old [1], however there are many other causes. Other surgical conditions (intussusception and malrotations) have been covered in earlier sessions, but you also need to consider hernias and other surgical causes.

CT3 Surgery (icon).png

Finding the correct diagnosis is often tricky and sometimes more of an art than a science (again especially with appendicitis). There is considerable debate surrounding the use of investigations and diagnostic tools in establishing a diagnosis., however clinical judgement and time are sometimes the most important steps.

Furthermore the patient may not even have a surgical cause for their pain and a diagnosis of functional abdominal pain may be considered. Whilst this diagnosis lacks any significant pathology it can cause problems with time off school and other knock on effects.

References:

  1. Tseng YC1, Lee MS, Chang YJ, Wu HP. Acute abdomen in paediatric patients admitted to the paediatric emergency department. Pediatr Neonatol. 2008 Aug; 49(4):126-34. doi: 10.1016/S1875-9572(08)60027-3.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Recall the advantages and disadvantages of investigations for appendicitis in children and apply this to your clinical practice.

  • List the causes of scrotal pain and be able to construct a management plan for patients presenting with this.

  • Consider surgical causes for vomiting and recognise pyloric stenosis, including the metabolic picture.

LEARNING OUTCOMES FROM FACE-TO-FACE TEACHING

  • Construct a differential diagnosis for an acute abdomen in a child.

  • Consider functional abdominal pain and whether this is a suitable ED diagnosis.

  • Discuss the psychosocial aspects of paediatric abdominal pain.


TASKS

Complete the following before the face to face session:

TASK 1: Problems "Down Below"

Duration: 60 mins

Read the following articles: (warning: they contain some graphic pictures, beware if using public computers). The links to the individual artilcles are below, or link to the main Don't Forget the Bubbles page via the picture. Between the three articles they cover a range of conditions that can present to the ED.

Bonus: Penile Zipper Entrapment

A useful summary which includes techniques for extraction. 

Task 2: Appendicitis tests in children

Duration: 55 mins

Appendicitis tests in children: via: empem.org or iTunes.

A podcast discussing the role of tests in the diagnosis of appendicitis, covers a review article: http://www.ncbi.nlm.nih.gov/pubmed/17652298. Includes discussion of the clinical features of appendicitis and their significance. It also considers the role of the wcc, esr and scoring systems as well as imaging. There is some discussion of the limitations of the literature and the benefits of "Rule In Vs Rule Out".

Special note: lookout for discussion of an article by Acheson & Banerjee!

Task 3: Splat! A vomiting infant.

Duration: 45 mins

From Life in the Fast Lane, work through this case of a vomiting six week old. It is a fairly classic presentation and shouldn't be too challenging to get the diagnosis, beware that the answer is given away in the tab of your browser so if you want to be truly spoiler free don't look there! (that being said, the diagnosis is made at Q3).


EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to chest pain.


CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

Another concerned parent brings you their child out of hours. Little Jimmy is 6 years old and has not opened his bowels for two weeks now.
A 5 day old baby has been brought into the department as parents reported one episode of vomiting bile.

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

The Royal College of Surgeons

A quick guide for the media, including a helpful section on "What do Paediatric Surgeons Do?". As a quick read it gives an idea of the role of paediatric surgeons and why they are only in limited centres. It also names some of the common operations performed.

Nice Guideline on Constipation in Children and Young People

It is worth reading the summary of the guidance (this link) rather than the whole thing, as it is a presentation we see in the ED. Also it might just contain the answers to one of the wiki cases.

Don't Forget the Bubbles: Post circumcision bleeding 

As if the tasks weren't enough, but this website really is useful! A case of a post circumcision bleed in a 9 day old boy. This is a potential consequence of any circumcision, but it is also how some illegal practice has come to light. If you suspect a patient you have seen has undergone illegal circumcision you should complete an A-form and consider discussion with the senior ED physician.

Don't Forget the Bubbles: Vomiting from noodles, or are we missing something?

Another great page from the DFTB team, this time discussing intestinal obstruction.


COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: