age groups (such as appendicitis) and others that are usually confined .... specific. Appendicitis can develop at the extremes of the age range and may.
ABC of General Surgery in Children
ACUTE ABDOMINAL PAIN IN CHILDREN Mark Davenport
Principles of diagnosis -*.....Ah Operation m(n=126 (35X)) 7
:
Observed (n=237 (65%)) m
with acute abdominal pain can be a disconcerting experience for most doctors, and there is often little in the way of aids or ~~investigations that can be used to arrive at a correct diagnosis. Certainly there are common conditions that cause problems in most age groups (such as appendicitis) and others that are usually confined a specific age group (such as intussusception). ~~~~~~~to
doctor, and, of those that do, most being seen and treated at home by a general practitioner. Of those that are taken to hospital, some recover without obvious sequelae despite the lack of a specific diagnosis. The Diagnostic breakdown of one year's admissions for abdominal pain in a district general hospital (after Jones').
label non-specific abdominal pain has been used for these cases, and this, in truth, will be the commonest "cause" of most acute abdominal pain that most clinicians will see.
Clinical approach An accurate history is vital, although in younger children it is usually Symptoms associated with| hearsay. Important points are the length of the current illness; previous with Symptoms associated surgically correctable causes of similar episodes; periodicity if it is a colicky pain; whether it is
acute abdominal pain * Vomiting of bile * Asymmetric pain * Local tenderness ______Peritonism ____________________
.........
constant, worsening, or getting better; and any related or aggravating factors. Gastrointestinal upset (such as vomiting) is common and can be a non-specific feature. The presence of bile in vomit is an important discriminant suggesting intestinal obstruction. Alternatively, substantial diarrhoea can accompany surgical pathology and should not be accepted simply as enteritis. Urinary symptoms such as dysuria and frequency can be difficult to establish in young children and again can also be entirely erroneous-both are common in a child with a
! pelvic appendicitis.
Examination The examiner needs to have a patient, gentle technique, not only with the child, but also with the parents. Pyrexia and tachycardia with a flushed appearance. suggest an infective cause, which may be entirely extra-abdominal (such as tonsillitis or otitis media), and time should be spent investigating other systems. The crux of the abdominal examination is patience; provoking crying reduces the value of the examination. Important points are whether the tenderness is local or general, whether it has always been in the same site, and whether it comes and goes. Non-specific abdominal pain is usually vague, central, and colicky. The pain of appendicitis is unilateral, well localised, and worsens. Localised tenderness and the signs of peritoneal inflammation (that is, muscle guarding and rigidity) cannot be ignored, but they can easily be mimicked by a quick, clumsy palpation by an inexperienced examiner. Dilated small bowel (ileum) c obstructive intussusception. 498
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examinations-Although this
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> 10 cells/mm' in boys and >50 cells/mm' in girls) or the presence of organisms. Even if a positive result is obtained an open mind should be maintained, particularly with older children (most urinary tract infections occur in preschool children). The abdominal signs should be re-evaluated after a period of treatment. Urinary tract infections may occur in an otherwise normal urogenital system, particularly in girls, but a search for an underlying congenital urological anomaly should be part of the overall management plan. Among the commonest anomalies identified are vesicoureteric reflux, duplex collecting systems, hydronephrosis, and ureteroceles. Although it has been calculated that only 8% of children with a urinary tract infection have a surgically correctable condition, these are important diagnoses to make. There is controversy on the most appropriate tests to choose, but an ultrasound scan of the kidney and bladder and a dimercaptosuccinic acid radionuclide scan seem sensible. BMJ VOLUME 312
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Causes of acute abdominal pain in children Common causes * Appenticitis * Non-specific abdominal pain Uncommon causes Meckel's diverticulitis, mesenteric adenitis, Crohn's disease, sickle cell crisis, gall stones, pancreatitis, tonsillitis, otitis media, acute hapatitis, acute porphyria, intestinal bands, malrotation, ureteric calculi, urinary tract infection, pneumonia, peptic ulcer disease, psychogenic, Henoch-Schonlein purpura, intussusception, yersinia infection, obstructed inguinal hernia, torsion of testicle, omental infarction, renal vein thrombosis, acute hydronephrosis, primary peritonitis, salpingitis, ovarian cyst, ectopic tubal pregnancy, pyelonephritis, trauma, infective gastroenteritis, food poisoning, child abuse, attention seeking behaviour, intestinal volvulus, choledochal cyst, cholangitis, foreign body, adhesions and small bowel obstruction, pica, ketoacidosis
Renal and ureteric calculi, though rare, are a potent cause of acute abdominal pain, with most being associated with chronic urinary infection. Children with neurogenic bladders (for instance, those with spina bifida) are prone to develop this problem. Upper abdominal pain Acute upper abdominal pain is much less common in children than in adults, but if it occurs in older children, and particularly if it is recurrent, thought should be given to gall stones (especially in children with chronic haemolysis, such as sickle cell anaemia), peptic ulcers, and pancreatitis (often associated with a choledochal cyst).
1 Jones PF. Active observation in management of acute abdominal pain in childhood. BMJ 1976;ii:551-3.
Professor Lewis Spitz, Institute of Child Health, London, provided the pictures of faecalith, gangrenous appendicitis, and Crohn's disease.
The ABC of Paediatric Surgery is edited by Mark Davenport, consultant paediatric surgeon, department of paediatric surgery, King's College Hospital, London.
Children on hunger strike: child abuse or legitimate protest? A Mok, E A S Nelson The issue of children on hunger strike (voluntary total fasting) has not been reported before. The World Medical Association Declaration of Tokyo 1975 and the Declaration of Malta 1991 (revised 1992) provide clinicians with guidelines for the management of adult patients on hunger strike1 2 but do not mention children. We report the management of 14 Vietnamese children, aged 1 to 12 years, who took part in a hunger strike at a refugee detention centre in Hong Kong. The influx of Vietnamese boat people to Hong Kong and other South East Asian countries began in the 1970s. Initially all were deemed to be political refugees who would be resettled in a third country. This policy was then revised and over 20 000 refugees were reclassified as "economic migrants" for repatriation to Vietnam. Some returned under a voluntary repatriation programme, but most resisted. Earlier attempts at forced repatriation were opposed by the United States Administration. A resumption of forced repatriation, together with a possible reversal of United States policy, was reported in the local media in September 1994.3 This resulted in the north section of the High Island Detention Centre (population 1500) embarking on a hunger strike. Everyone in this section, including children, fasted or were fasted, for up to five days. Only water was taken orally. Breast feeding was allowed, although mothers were expected to fast. Department ofPaediatrics, Chinese University of Hong Kong, 6/F Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong A Mok, medical officer E A S Nelson, lecturer in paediatrics
Correspondence to: Dr Nelson. BMJ 1996;312:501-4
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The hunger strike Sixty seven hunger strikers made 93 attendances to the camp sick bay during this period. Fifty seven of the attendees were children under the age of 15 years (fig 1). Attendees were assessed, given treatment for minor complaints, and offered food and oral rehydration fluid. Parents were advised of their responsibility to feed their children and of the clinical consequences of withholding food. Fourteen children were transferred from the camp sick bay to the Prince of Wales Hospital. No parents objected. The youngest "hunger striker" was less than
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9 8
Sick bay (n=57) M Hospital (n= 14)|
__
645 02 U-. .5
2 3 4
7 8 9 10 11 12 13 14 Age (years) Age distribution ofchildren on hunger strike 5 6
2 years old (fig 1). All children had some degree of ketonuria and two were hypoglycaemic. Normal ward diet was offered and no child refused food. In the absence of guidelines or previous experience, we considered that total fasting of the children was a form of child abuse and we did not discharge' the children until we were satisfied that they would be fed normally. Fortunately after five days, before major logistical problems developed, the hunger strike stopped. Parents were interviewed when their children were discharged. On direct questioning no parents admitted secretly feeding their children and some indicated that there had been coercion. The reasons they gave as to why they let their child fast included regretting it but thinking it was right; that it had been their child's own decision to fast; or that they had been forced by the leaders to fast their child. Some older children claimed that they had begun the hunger strike voluntarily because their parents and everyone else were fasting, and they believed that such action might have prevented them from being sent back to Vietnam. Parents were informed that we considered this an unacceptable form of political protest, and we emphasised the potential adverse effects on their children's health.
Discussion A hunger striker is defined as a "mentally competent person who has indicated that he has decided to refuse 501
