CASE PRESENTATION

Acute Abdomen

Created by :
Devina 07120110064

Preceptor :
Dr. Ulynar Marpaung, Sp.A

Faculty of Medicine
University of Pelita Harapan

Department of Pediatric
Bhayangkara Hospital Tk. 1 Raden Said Sukanto
Kramat Jati, East Jakarta
(Periode March 30th 2015 June 6th 2015)

I.

Patient Identity
Name: An. Dh
Date, Birth Place: Jakarta, 30th November 2012
Age: 2 year 4 month
Gender: Female
Religion: Moslem
Address: East Jakarta
Medical Record Number: 75-33-xx

II.

Parents Identity
Father
Name: Mr. G
Age: 28 years old
Religion: Moslem
Education: High School
Occupation: Labor
Mother
Name: Mrs. M
Age: 26 years old
Religion: Moslem
Education: High School
Occupation: Housewife

III.

Anamnesis
Date of Admission at Hospital: 1st April 2015
Date of Anamnesis & Examination: 2nd April 2015 16th April 2015
Methods: Alloanamnesis
Place: Room no. 5, Anggrek 2 Ward, RS POLRI R Said Sukanto

IV.

Chief Complaint
Vomiting > 5 times a day, filled with fluid and food waste since 1 day before the
admission.

V.

Present Illness History

A 1 year and 4 months old girl with body weight 15 kg, came to RS POLRI R Said
Sukanto ER at 2nd April 2015, with a chief complain of vomiting. Patient vomit
more than 5 times a day, filled with fluid and waste food. The patient complained of
nausea, bloating, and abdominal pain since 1 day before the admission. Patient also
has fever lasts from 3 days, non-continuously, with the highest temperature 40 oC at

night. She has brought to the health center for treatment 2 days ago. The doctor gave
her paracetamol and domperidone but no sign of improvement.
VI.

Past illness History

Enteritis.

VII.

Allergic History
The patient didnt have any history of allergy.

VIII. Mothers Pregnancy History

Antenatal Care: Mother checked her pregnancy routine at clinics every 3 months.
Giving birth spontaneously at 38 weeks, without any complication.
IX.

Birth History
Labor
: Hospital
Birth attendants
: Obstetrician
Mode of delivery
: Spontaneous
Gestation
: 38 weeks
Fetal membrane
: Clear
Infant state
: Healthy
Birth weight
: 2800 grams
Body length
: 47 cm
According to the mother, the baby started to cry and the baby's skin is red. No
congenital defects.

X.

Post-natal History
Examination: By doctor
Infant State: Healthy

XI.

History of Development
Psychomotor development
Smile
: 2 months
Slant

: 4 months

Prone
: 4 months
Sitting
: 6 months
Crawling : 8 months
Standing : 8 months
Walking : 12 months
Conclusion: normal motor development status
XII.

History of Eating
Mothers breast milk exclusively from age 0-6 months.

XIII. Immunization History

Completed Hepatitis B, BCG, Polio, and DTP vaccination.

XIV. Family History
All of the family members are in a healthy state
XV.

History of Hereditary Disease

The patients father doesnt have Hypertension nor Diabetes Mellitus
The patients mother doesnt have Hypertension nor Diabetes Mellitus

XVI. Mode of Reproduction

Number of children

Age

Gender

6 years old

Male

1 years and 4 months old

Female (Patient)

XVII. Physical Examination

General Appearance
: Looks mildly ill
Consciousness
: Compos Mentis
Vital Signs
Pulse
: 120 beats / minute, strong, full, regular
The rate of breathing
: 48 times / minute
Body Temperature: 38.5 C
XVIII. Nutritional Status
ANTHROPOMETRIC DATA
Body weight
: 6.5 kg
Body length
: 63 cm
WFA (Weight for Age):
15/13.4 x 100 % = 111 %
HFA (Height for Age):
95/90 x 100 % = 105 %
WFH (Weight for Height):
15/14 x 100 % = 107 %
XIX. Systemic Physical Examination

XX.

Lab Results on April 1st 2015

XXI. Plain Abdomen X-Ray

XXII. Resume
A 1 year and 4 months old girl, came to POLRI Hospital ER at 1 st April 2015, with a
chief complain of vomiting. Patient vomit more than 5 times a day, filled with fluid
and waste food. The patient complained of nausea, bloating, and abdominal pain
since 1 day before the admission. Patient also has fever lasts from 3 days, noncontinuously, with the highest temperature 40oC at night.
On physical examination, she had no bowel sound on auscultation. There is
distention and tenderness on palpation. She also has a high temperature that reach
38.5oC.

On lab results, there is slight anemia and leukocytosis.

XXIII. Working Diagnosis
Ileus Paralytic
Reasons :
a. Fever
b. Nausea
c. Vomiting
d. No bowel sound on abdomen auscultation
e. Distention and tenderness on abdomen palpation
XXIV. Differential Diagnosis
Ileus Obstruction
Appendicitis
XXV. Management
Cefotaxime 2 x 750 mg
Paracetamol 5ml 3 x 1
Ambroxol syrup 3 x 1 cth
Domperidone 3 x 1 (0,2-0,4 mg/kgBW/day)
Rontgen BNO Abdomen
Nothing per oral
Add NGT

XXVI. Prognosis
Quo ad vitam

: Dubia ad bonam

Quo ad functionam

: Dubia ad bonam

Quo ad sanationam

: Dubia ad bonam

XXVII.

Follow Up

April 2nd 2015 (Lab results)

Hematology :
Hemoglobin
11
Leukocyte
13.200
Hematocrit
30
Thrombocyte
226.000
Basophil
Eosinophil
1
Rod
1

(12-14) g/dl
(5.000-10.000) u/l
(37-43) %
(150.000-400.000) /ul
(0-1) %
(1-3) %
(2-6) %

Segment
Lymphocyte
Monocyte
LED
Erythrocyte

83
12
3
60
3,79

(50-70) %
(20-40) %
(2-8) %
(<20) mm/hour
(4-5) million/ul

April 6th 2015

General conditions: Very ill (7th day of hospitalization)
Consciousness: Apatis
S : Fever (+), Nausea (-), Vomiting (-), Diarrhea (+) 3x/day
O : Vital Signs :
Temperature : 38.5oC
`

Heart Rate

: 120x/min

Respiratory Rate

: 24x/min

Physical Examination :
Abdomen

: Minimal bowel sound, distention (+), tenderness (+)

A : Susp. Ileus Paralytic

P:
Injection Meropenem 2 x 500 mg
Consult with Pediatric Surgeon
April 6th (Lab Results)
Haematology :
Hemoglobin

10

(12-14) g/dl

Leukocyte

26.300

(5.000-10.000) u/l

Hematocrit
Thrombocyte

29
295.000

(37-43) %
(150.000-400.000) /ul

April 7th 2015

General conditions

: Very ill (8th day of hospitalization)

Consciousness

: Apatis

 S : Fever (+), Nausea (-), Vomiting (-), Diarrhea (+) 1x/day, Bloating (+)
O : Vital Signs :
Temperature

: 39.1oC

Heart Rate

: 116x/min

Respiratory Rate

: 40x/min

Physical Examination :
Abdomen

Bowel sound (+) minimal, distention (+), tenderness (+),

defense muscular (+)

A : Appendicitis Perforation
P:
Injection Meropenem 2 x 500 mg
Aminofusin 125cc
Amikin 2 x 75mg
Operation Laparotomy Appendectomy
April 10th 2015
General conditions: Mildly ill (11th day of hospitalization)
Consciousness: Compos Mentis
S : Fever (-), Nausea (-), Vomiting (-), Flatus (+), Defecate (-)
O : Vital Signs :
Temperature

: 36.1oC

Heart Rate

: 120x/min

Respiratory Rate

: 30x/min

Physical Examination :
Abdomen :
Inspection

- Distention (+) minimal

Auscultation - Minimal bowel movements

Palpation

- Tenderness (-)

Percussion

- Tympani (+)

A : Post operation H-2 Appendix Perforation

P:

IVFD Ka En 3B
Inj. Meropenem 2 x 500mg
Inj. Metronidazole 3 x 150mg
Inj. Rantin 2 x 1/2 ampul
Inj. Kalnex 3 x 100mg
Inj. Amikin 2 x 100mg
Inj. Novalgin 3 x 150mg
Inj. Alinamin F 2 x 1/2 ampul
April 13th 2015
General conditions

: Mildly ill (11th day of hospitalization)

Consciousness

: Compos Mentis

S : Fever (-), Nausea (-), Vomiting (-), Flatus (+), Defecate (-)
O : Vital Signs :
Temperature

: 36.8oC

Heart Rate

: 108 x/min

Respiratory Rate

: 32 x/min

Physical Examination :
Abdomen :
Inspection

- Distention (+) minimal

Auscultation - Minimal bowel movements

Palpation

- Tenderness (-)

Percussion

- Tympani (+)

A : Appendix Perforation post Laparotomy H-6

P : Continue therapy
April 15th 2015
Haematology :
Hemoglobin

14.4

(12-14) g/dl

Leukocyte

15.500

(5.000-10.000) u/l

 Hematocrit

44

(37-43) %

Thrombocyte

430.000

(150.000-400.000) /ul

April 16th 2015

General conditions

: Healthy (14th day of hospitalization)

Consciousness

: Compos Mentis

S : Fever (-), Nausea (-), Vomiting (-), Flatus (+), Defecate (+)
O : Vital Signs :
Temperature

: 36.8oC

Heart Rate

: 108 x/min

Respiratory Rate

: 32 x/min

Physical Examination :
Abdomen :
Inspection

- Distention (-)

Auscultation - Bowel movements (+)

Palpation

- Tenderness (-)

Percussion

- Tympani (+)

A : Appendix Perforation post Laparotomy H-9

P : Discharge from hospital

XXVIII. Literature Review

Definition
Among children, abdominal pain is a frequent, nonspecific symptom that is
typically associated with self-limited, minor conditions such as gastroenteritis and
other viral illnesses. The challenge for the clinician is to identify patients with
abdominal pain who may have the following:
a. Serious, potentially life-threatening conditions, such as appendicitis or bowel
obstruction (as can occur from volvulus, intussusception, or adhesions)

b. Infections that require specific treatment (such as streptococcal pharyngitis,

urinary tract infection, or pneumonia)
c. Unusual manifestations of less common diseases (such as Hirschsprung's disease
or primary bacterial peritonitis with nephrotic syndrome)
Etiology

Pathogenesis
Abdominal pain may be classified as visceral, somatoparietal, and referred pain
according to the nature of the pain receptors involved. Interestingly, most abdominal
pain is associated with visceral pain receptors.
Visceral pain receptors are located on the serosal surface, in the mesentery,
within the intestinal muscle, and the mucosa of hollow organs. These pain receptors
respond to mechanical and chemical stimuli, such as stretching, tension, and ischemia.
Because visceral pain fibers are unmyelinated C-fibers, and enter the spinal cord
bilaterally at several levels, visceral pain is usually dull, poorly localized, and perceived
in the midline.
In addition, there are three broad pain areas with anatomic associations. Pain
emanating from foregut structures (e.g., lower esophagus, stomach) is felt in the
epigastric area, pain from midgut structures (e.g., small intestine) is felt in the

periumbilical area, and pain from hindgut structures (e.g., colon) is felt in the lower
abdomen.
Somatoparietal pain receptors are located in the parietal peritoneum, the muscle,
and the skin. Pain resulting from inflammation, stretching, or tearing of the parietal
peritoneum is transmitted through myelinated A- fibers to specific dorsal root ganglia.
Somatoparietal pain is characterized by sharp, more intense, and more localized
sensation. Movement may aggravate the pain; thus, the child will stay still.
Referred pain is well localized but felt in distant areas of the same cutaneous
dermatome as the affected organ. It results from shared spinal cord level for afferent
neurons from different sites. For example, inflammatory conditions that affect the
diaphragm can be perceived as pain in the shoulder or lower neck area
Acute Appendicitis
Acute appendicitis is the most common surgical cause of acute abdominal pain in
children. Typically, children with appendicitis present with visceral, vague, poorly
localized, periumbilical pain. Within 6 to 48 hours, the pain becomes parietal as the
overlying peritoneum becomes inflamed.
The pain manifests itself as a well-localized pain in the right lower quadrant.
However, some of these characteristic manifestations are frequently absent, particularly
in younger children. Therefore, physicians should consider the diagnosis of appendicitis
in all cases of previously healthy children who have a history of abdominal pain and
vomiting, with or without fever or focal abdominal tenderness.
Clinical Evaluation :
Important details of the history include symptom onset pattern, progression,
location, intensity, characters, precipitating and relieving factors of abdominal pain, and
associated symptoms. Age of the patient is a key factor in the evaluation of acute
abdominal pain as listed in the table below.

Physical Examination
General Appearance
Children with peritoneal irritation remain still or resist movement, while
patients with visceral pain change position frequently, often writhing with
discomfort.
Vital signs
Vital signs are useful in assessing hypovolemia and provide useful clues
for diagnosis. Fever indicates an underlying infection or inflammation including
acute gastroenteritis, pneumonia, pyelonephritis, or intra-abdominal abscess.
Tachypnea may indicate pneumonia. Tachycardia and hypotension suggest
hypovolemia or third-space volume loss.

Abdominal examination
The evaluating physician should gently palpate the abdomen moving
toward the area of maximal tenderness. The physician has to make efforts to
determine the degree of abdominal tenderness, location, rebound tenderness,
rigidity, distension, masses, or organomegaly. A rectal examination provides
useful information about sphincter tone, presence of masses, stool nature,
hematochezia, or melena.
Management

Treatment should be directed at the underlying cause of abdominal pain. Urgent

intervention and management is required for children who are prostrated and sickappearing, have signs of bowel obstruction and evidence of peritoneal irritation.
Initial resuscitation measures include correction of hypoxemia, replacement of
intravascular volume loss, and correction of metabolic abnormalities.
Gastric decompression using nasogastric tube may be necessary if there is bowel
obstruction.
Empirical intravenous antibiotics are often indicated when there is clinical suspicion
of a serious intra-abdominal infection.
Moreover, adequate analgesics should be provided to patients with severe pain,
preferably prior to surgical evaluation.
Conclusion
Acute abdominal pain is one of the most common complaints in childhood, and one
that frequently requires rapid diagnosis and treatment in the emergency department.
Although acute abdominal pain is typically self-limiting and benign, there are
potentially life-threatening conditions that require urgent management, such as
appendicitis, intussusception, or bowel obstruction.
Meticulous history taking and repeated physical examinations are essential to
determine the cause of acute abdominal pain and to identify children with surgical
conditions.
REFERENCES

1. D'Agostino J. Common abdominal emergencies in children. Emerg Med Clin North Am.
2002;20:139153. [PubMed]
2. Grant HW, Parker MC, Wilson MS, Menzies D, Sunderland G, Thompson JN, et al.
Adhesions after abdominal surgery in children. J Pediatr Surg. 2008;43:152156. [PubMed]
3. Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal
pain. Pediatrics. 1996;98:680685. [PubMed]
4. Ross A, LeLeiko NS. Acute abdominal pain. Pediatr Rev. 2010;31:135144. [PubMed]
5. Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003;67:2321
2326. [PubMed]
6. Reynolds SL, Jaffe DM. Diagnosing abdominal pain in a pediatric emergency department.
Pediatr Emerg Care. 1992;8:126128. [PubMed]

7. Carty HM. Paediatric emergencies: non-traumatic abdominal emergencies. Eur Radiol.

2002;12:28352848. [PubMed]
8. Kwok MY, Kim MK, Gorelick MH. Evidence-based approach to the diagnosis of appendicitis
in children. Pediatr Emerg Care. 2004;20:690698. [PubMed]
9. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have
appendicitis? JAMA. 2007;298:438451. [PMC free article] [PubMed]
10. Mason JD. The evaluation of acute abdominal pain in children. Emerg Med Clin North Am.
1996;14:629643. [PubMed]
11. Loening-Baucke V, Swidsinski A. Constipation as cause of acute abdominal pain in children.
J Pediatr. 2007;151:666669. [PubMed]
12. Vignault F, Filiatrault D, Brandt ML, Garel L, Grignon A, Ouimet A. Acute appendicitis in
children: evaluation with US. Radiology. 1990;176:501504. [PubMed]
13. Kristinsson G, Wall SP, Crain EF. The digital rectal examination in pediatric trauma: a pilot
study. J Emerg Med. 2007;32:5962. [PubMed]
14. Kwan KY, Nager AL. Diagnosing pediatric appendicitis: usefulness of laboratory markers.
Am J Emerg Med. 2010;28:10091015. [PubMed]
15. Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic accuracy of surgeon-performed
focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005;36:970975.
[PubMed]
16. Reich JD, Brogdon B, Ray WE, Eckert J, Gorell H. Use of CT scan in the diagnosis of
pediatric acute appendicitis. Pediatr Emerg Care. 2000;16:241243. [PubMed]
17. Saito JM. Beyond appendicitis: evaluation and surgical treatment of pediatric acute
abdominal pain. Curr Opin Pediatr. 2012;24:357364. [PubMed]
18. Nissman SA, Kaplan LJ, Mann BD. Critically reappraising the literature-driven practice of
analgesia administration for acute abdominal pain in the emergency room prior to surgical
evaluation. Am J Surg. 2003;185:291296. [PubMed]