Pediatric emergency medicine trisk 1036 1036
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (102.36 KB, 1 trang )
CHAPTER 53 ■ PAIN: ABDOMEN
VINCENZO MANIACI, MARK I. NEUMAN
INTRODUCTION
Abdominal pain is a common complaint of children who seek care in the ED.
Although most children with acute abdominal pain have self-limiting conditions,
the presence of pain may herald a serious medical or surgical emergency. The
diverse etiologies include acute surgical diseases (e.g., appendicitis,
intussusception, strangulated hernia, trauma to solid or hollow organ), intraabdominal nonsurgical ailments (e.g., gastroenteritis, urinary tract infection
[UTI], gastric ulcer disease, gastroesophageal reflux disease), extra-abdominal
conditions (e.g., pneumonia, pharyngitis, contusions of the abdominal
musculature or soft tissue), systemic illnesses (e.g., “viral syndrome,” leukemia,
diabetic ketoacidosis, vaso-occlusive crisis from sickle cell anemia), and,
commonly, functional abdominal pain. Making a timely diagnosis of an acute
abdomen, such as appendicitis or volvulus, early enough to reduce the rate of
complications, particularly in infants and young children, often proves
challenging.
PATHOPHYSIOLOGY
Abdominal pain can be stimulated by at least three neural pathways: visceral,
somatic, and referred. Visceral pain generally is a dull, aching sensation caused
by distention of a viscus that stimulates nerves locally and initiates an impulse
that travels through autonomic afferent fibers to the spinal tract and central
nervous system. The nerve fibers from different abdominal organs overlap and
are bilateral, accounting for the lack of specificity to the discomfort. Children
perceive the sensation of visceral pain generally in one of three areas: the
epigastric, periumbilical, or suprapubic region. Somatic pain usually is well
localized and intense (often sharp) in character. It is carried by somatic nerves in
the parietal peritoneum, muscle, or skin unilaterally to the spinal cord level from
T6 to L1. An intra-abdominal process will manifest somatic pain if the affected
viscus introduces an inflammatory process that touches the innervated organ.
Referred pain is felt at a location distant from the diseased organ and can be either
a sharp, localized sensation or a vague ache. Afferent nerves from different sites,
such as the parietal pleura of the lung and the abdominal wall, share pathways
centrally. All three types of pain may be modified by the child’s level of
