Pediatr Neonatol 2008;49(4):126−134

O R IGINAL ART ICL E

Acute Abdomen in Pediatric Patients Admitted to

the Pediatric Emergency Department
Yu-Ching Tseng1,2, Ming-Sheng Lee2, Yu-Jun Chang3, Han-Ping Wu4,5*
1
Division of Pediatric Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
2
Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
3
Laboratory of Epidemiology and Biostatistics, Changhua Christian Hospital, Changhua, Taiwan
4
Department of Pediatrics, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung, Taiwan
5
Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan

Received: Dec 14, 2007 Background: Acute abdomen in children is a serious condition frequently encoun-
Revised: May 9, 2008 tered in the pediatric emergency department (ED). This study aimed to analyze the
Accepted: Aug 28, 2008 clinical spectrum of acute abdomen, and to investigate the prevalence of various
etiologies in different age groups of children admitted to the pediatric ED.
KEY WORDS: Methods: From 2005 to 2007, we retrospectively recruited 3980 consecutive pediat-
abdominal pain; ric patients who presented to the pediatric ED suffering from acute abdominal pain.
abdomen, acute;
Of these patients, 400 were identified as having acute abdomen. These patients were
then divided into traumatic and non-traumatic groups, and also divided into four
child;
age groups: infant, preschool-age, school-age and adolescent. Differences between
emergency service,
the traumatic and non-traumatic groups in the prevalence, clinical presentations,
hospital laboratory and imaging findings, and hospital courses were analyzed statistically.
Results: In the non-traumatic group (n = 335), the most common etiology in infants
was incarcerated inguinal hernia (14/31, 45.1%), followed by intussusception (13/31,
41.9%), while acute appendicitis was the major cause in children older than 1 year
(68.7%). In the traumatic group (n = 65), the major cause of acute abdomen was
traffic accidents (76.9%). The liver was the most frequently injured organ, followed
by the spleen. The mortality rate was highest in patients with multiorgan injury.
In both groups, bowel loop dilation and local ileus were the two most common find-
ings demonstrated by plain film X-rays. Children in the traumatic group who under-
went abdominal computed tomography (CT) scans all showed positive findings for
their diagnoses. Patients with bowel perforation or obstruction had the longest dura-
tions of hospitalization in the non-traumatic group, while those with multiorgan
injury had the longest duration in the traumatic group.
Conclusion: The etiology of acute abdomen varied depending on the age of the
patient. Acute appendicitis was the most common cause of acute abdomen in chil-
dren older than 1 year of age, followed by traumatic injury. Abdominal CT scanning
was a useful diagnostic imaging modality in patients with both traumatic and non-
traumatic abdominal pain.

*Corresponding author. Department of Pediatrics, Buddhist Tzu Chi General Hospital, Taichung Branch, No. 66, Section 1,
Fongsing Road, Tanzih Township, Taichung County 42743, Taiwan.
E-mail: arthur1226@gmail.com

©2008 Taiwan Pediatric Association

Acute abdomen in children and adolescents 127

1. Introduction 2.2. Methods

Acute abdominal pain is one of the most common Demographic information on the patients was ob-
problems in children admitted to the pediatric tained from hospital chart records. The patients’
emergency department (ED), and often presents a ages, genders, chief complaints, and clinical symp-
diagnostic dilemma for primary clinicians. Acute toms and signs were recorded on our data sheet.
abdominal pain in patients presenting to the ED is We also noted the etiologies of acute abdomen, hos-
often diagnosed as a disorder that does not require pital duration, laboratory test results (white blood
surgical intervention, such as acute gastroenteri- cell [WBC] count, C-reactive protein [CRP], total
tis, functional digestive disorders or constipation. neutrophil count, and manual band count), imaging
However, abdominal emergencies requiring surgery findings (abdominal radiography, computed tomog-
must be picked up by primary pediatric physicians raphy [CT] and ultrasonography), the time of admis-
in the pediatric ED because of their potentially sion, and their condition at discharge. In the traumatic
life-threatening risks. The symptoms and signs that group, the location of the trauma, and additional
suggest acute abdomen include rebounding pain, laboratory test results, including hemoglobin (Hb),
involuntary guarding or rigidity, abdominal distention amylase, lipase, and aspartate aminotransferase/
and diffuse tenderness.1 However, acute abdomen alanine aminotransferase, as well as the type of
may not be easily diagnosed in young children based trauma, were also recorded.
on these clinical presentations because of their poor All patients in our study were divided into four
ability to express themselves. Abdominal surgical age groups: infant (1 month−1 year), preschool-age
emergencies can also be induced by trauma. Internal (2−6 years), school-age (7−12 years) and adoles-
organ involvement resulting from traumatic insults cent (13−18 years). The etiologies of acute abdomen
in children can differ markedly from those in adults. in the non-traumatic group were divided into six
Moreover, acute abdomen in children of different major categories: (1) acute appendicitis, (2) hollow
ages may have different etiologies and clinical organ perforation, (3) incarcerated inguinal hernia,
courses, and may produce different laboratory test (4) intussusception, (5) intestinal obstruction other
results and imaging findings. Different etiologies than due to the diseases described above, and
of acute abdomen can show different distributions (6) ovarian torsion. In the traumatic group, the loca-
in different months, but the reasons for this remain tions of the injuries were divided into six catego-
unclear. In the present study, we analyzed the etiol- ries: (1) liver, (2) spleen, (3) kidney, (4) pancreas,
ogies, laboratory test results, imaging findings and (5) intestine/colon, and (6) multiple organs (more
clinical courses of pediatric patients with acute than one organ involved).
abdomen. We also analyzed the prevalence of vari-
ous etiologies of acute abdomen in different age 2.3. Statistical analysis
groups and in different months, in children admitted
to the pediatric ED. Differences in the prevalence, clinical symptoms and
signs, laboratory test results, imaging findings, hos-
pital courses and the lengths of hospitalization be-
2. Patients and Methods tween the traumatic and the non-traumatic groups
were analyzed by Fisher’s exact test and the Kruskal
2.1. Patient population Wallis test. A p value of < 0.05 was considered
significant.
From July 2005 to June 2007, we retrospectively
recruited 3980 consecutive patients aged younger
than 18 years who presented to the ED at the 3. Results
Changhua Christian Hospital, Taiwan, with acute
abdominal pain. Among the 3980 patients, 400 chil- Acute abdomen had a non-traumatic etiology in
dren were identified as having been diagnosed with 335 of the 400 patients, and was due to trauma in
acute abdomen. These 400 patients were divided 65 patients. There were 270 boys and 130 girls who
into two groups: a non-traumatic group and a trau- ranged in age from 1 month to 18 years (mean age,
matic group. The non-traumatic group comprised 10.6 ± 5.7 years). The case distributions in all patients
patients with acute abdomen unrelated to trauma and in the traumatic group are shown in Figure 1.
but requiring surgical intervention. The traumatic The demographics, clinical presentations, laboratory
group comprised patients who presented to the test results, imaging findings and hospital courses
ED with acute abdominal pain caused by traumatic in children with acute abdomen are presented in
injury. Table 1.
128 Y.C. Tseng et al

A B

Perforation 3.5% Liver

Hernia, 22%
Appendicitis incarcerated
Multiple organs
64.0% 7.5%
44%
Intussusception
6.3% Spleen
18%
Intestinal
Trauma obstruction
16.3% 1.3%
Kidney 5%
Torsion 1.3%
Pancreas 3%
Intestine &
colon 8%

Figure 1 Case distribution of patients with (A) acute abdomen, and (B) distribution of the different locations of
organ injuries involved in the traumatic group.

50 Appendicitis (n = 256)
40 Perforation (n = 14)
Percentage

30 Hernia, incarcerated (n = 30)

20 Intussusception (n = 25)

10 Intestinal obstruction (n = 5)
Torsion (n = 5)
0
1 2 3 4 5 6 7 8 9 10 11 12 Trauma (n = 65)
Month

Figure 2 Case distribution based on different months in our study period.

3.1. Demographics type intussusception and in all cases of ileo-ileo-

colic and ileo-cecal-colic type intussusception.
The most common etiology of acute abdomen in Intestinal obstruction was noted in five patients in
infants was incarcerated inguinal hernia (14/31, the non-traumatic group. The etiologies were intra-
45.1%), followed by intussusception (13/31, 41.9%). abdominal abscess (n = 2), foreign body ingestion
These etiologies were uncommon in school-age and (olive) (n = 1), patent omphalomesenteric duct with
adolescent children. In contrast, acute appendicitis malrotation (n = 1) and adhesion ileus (n = 1); per-
was the major cause of surgical abdomen in chil- forated appendicitis was excluded in the causes
dren older than 1 year in the non-traumatic group of intra-abdominal abscesses. The first case of
(68.7%). Based on the pathology reports of resected intra-abdominal abscess was caused by perforation
appendices from appendectomies, 15.6% (40/256) following acute gastroenteritis, and the abscess
of patients with appendicitis presented with early culture showed Bacteroides ovatus and Escherichia
appendicitis, 64.1% (164/256) with suppurative or coli coinfection. The culture results from the other
gangrenous changes, and 20.3% (52/256) with per- case of intra-abdominal abscess revealed Entero-
forated appendicitis. All cases of ovarian torsion, bacter cloacae, E. coli, and methicillin-resistant
which is a gynecological abdominal emergency, were Staphylococcus aureus. In the case of foreign body
diagnosed in children of more than 12 years of age. ingestion, the location of the olive obstruction was
In addition, 21 cases of incarcerated inguinal hernia 50 cm away from the ileocecal valve. The case of
were right-sided (70%), seven cases were left-sided adhesion ileus was due to a previous surgical com-
(23.4%), and two cases involved both sides (6.6%). plication (laparoscopic appendectomy), and was
Incarcerated inguinal hernias were most prevalent unresponsive to decompression treatment. Figure
in preschool-aged children (50%) and infants (46.7%), 2 shows the monthly distribution of non-traumatic
and least prevalent in adolescents (3.3%). cases. Analysis of the monthly distribution of cases
During the study period, 95 pediatric patients revealed that the peak of appendicitis occurred
were diagnosed with intussusception, including 91 in September, while the peak of intussusception
cases with ileo-colic type, three with ileo-ileo-colic occurred in February.
type and one with ileo-cecal-colic type. Surgical Most patients in the traumatic group were ado-
reductions were performed in 21 cases of ileo-colic lescents (n = 41, 63.1%). The characteristics of the
Table 1 Demographic data, clinical presentations, laboratory test results, imaging findings, and hospital courses in patients with acute abdomen*

Hernia, Intestinal
Appendicitis Perforation Intussusception Torsion Trauma p
incarcerated obstruction

Age < 0.001

Infant 1 (0.4) 1 (7.1) 14 (46.7) 13 (52.0) 2 (40.0) 0 0
Preschool-age 28 (10.9) 6 (42.9) 15 (50.0) 11 (44.0) 2 (40.0) 0 12 (18.5)
School-age 113 (44.1) 2 (14.3) 0 1 (4.0) 1 (20.0) 0 12 (18.5)
Adolescent 114 (44.5) 5 (35.7) 1 (3.3) 0 0 5 (100) 41 (63.1)
Gender 0.001
Male 165 (64.5) 13 (92.9) 25 (83.3) 17 (68) 5 (100.0) 0 45 (69.2)
Female 91 (35.5) 1 (7.1) 5 (16.7) 8 (32) 0 5 (100) 20 (30.8)
Clinical symptoms and signs
Fever 147 (57.4) 8 (57.1) 0 6 (24) 2 (40) 0 0 0.126
Vomiting 167 (65.2) 9 (64.3) 1 (3.3) 8 (32) 4 (80) 2 (40) 1 (1.5) 0.668
Diarrhea 56 (21.8) 9 (64.3) 0 2 (8) 3 (60) 0 0 0.001
Abdominal fullness 5 (1.9) 5 (35.7) 1 (3.3) 1 (4) 1 (20) 0 2 (3.0) 1.000
RLQ tenderness 253 (98.8) 1 (7.1) 0 0 0 3 (60) 0 < 0.001
Diffuse 3 (1.2) 13 (92.9) 0 1 (4) 3 (60) 0
Acute abdomen in children and adolescents

Intermittent pain 0 0 0 22 (88) 0 2 (40) 0

Rebounding pain 246 (96) 14 (100) 0 0 2 (40) 1 (20) 0.001
Muscle guarding 9 (3.5) 4 (28.5) 0 0 0 0 0 0.195
Imaging studies
Abdominal X-ray 243 (94.9) 14 (100) 13 (43.3) 20 (80) 5 (100) 1 (20) 12 (18.5) < 0.001
Negative finding 101 (41.6) 1 (7.1) 8 (62.5) 5 (25) 0 1 (100) 8 (66.7) < 0.001
Bowel dilatation 55 (22.6) 0 3 (23.1) 7 (35) 0 0 1 (8.3)
Local ileus 31 (12.8) 1 (7.1) 1 (7.7) 4 (20) 3 (60) 0 2 (16.7)
Air-fluid level 1 (0.4) 0 1 (7.7) 0 1 (20) 0 0
Fecalith 54 (22.2) 1 (7.1) 0 0 0 0 0
Free air 1 (0.4) 11 (78.6) 0 0 1 (20) 0 1 (8.3)
Crescent sign 0 0 0 4 (20) 0 0 0
Ultrasonography 56 (21.9) 3 (21.4) 0 25 3 (60) 4 (80) 40 (61.5) < 0.001
Accurate diagnosis 41 (73.2) 2 (66.7) − 25 (100) 2 (66.7) 4 (100) 31 (77.5) 0.021
Abdominal CT 61 (23.8) 4 (28.6) 0 2 (8) 3 (60) 0 64 (98.5) < 0.001
Accurate diagnosis 60 (98.4) 4 (100) − 2 (100) 3 (100) − 64 (100) 0.522
Laboratory tests
WBC (×103/mm3) 15.2 ± 5.0 15.0 ± 8 .3 12.5 ± 4.0 12.5 ± 4.2 16.8 ± 10.2 10.3 ± 3.9 14.5 ± 6.3 0.005
Neutrophil count (%) 81.0 ± 12.1 75.4 ± 12.7 42.3 ± 27.2 65.7 ± 15.7 63.9 ± 24.1 72.8 ± 15.7 75.0 ± 15.4 < 0.001
Band count (%) 8.5 ± 10.0 12.6 ± 12.2 3.0 ± 1.4 5.0 ± 7.5 8.5 ± 6.4 − 11.6 ± 11.8 0.241
CRP (mg/dL) 7.81 ± 8.63 16.61 ± 14.21 0.16 ± 0.18 1.99 ± 2.87 8.85 ± 14.28 3.66 ± 6.27 6.34 ± 4.33 0.001
ICU admission 4 (1.6) 2 (14.3) 0 0 0 0 43 (66.2) 0.000
ICU admission days 3.5 ± 1.9 4.5 ± 0.7 − − − − 5.4 ± 6.3 0.791
Hospitalization days 4.9 ± 3.3 12.2 ± 4.6 1.8 ± 1.1 5.5 ± 1.9 12.4 ± 7.2 2.2 ± 1.1 12.4 ± 11.6 0.000
Mortality 0 0 0 0 0 0 3 (4.6)

*Data are presented as n (%) or mean ± standard deviation. RLQ = right lower quadrant; CT = computed tomography; WBC = white blood cell count; CRP = C-reactive protein; ICU = intensive
129

care unit.
130 Y.C. Tseng et al

injuries and the organs involved are presented in 3.4. Hospital course and outcome
Table 2. Traumatic injuries involved more than one
organ in 44% of these patients. The liver was the organ In the non-traumatic group, patients with bowel
most frequently involved in abdominal trauma (21.5%), perforation and obstruction had the longest dura-
followed by spleen laceration (18.5%). The most com- tions of hospitalization, while those with incar-
mon cause of injury was traffic accidents (76.9%), cerated inguinal hernia had the shortest duration.
and the least common was child abuse (1.5%). Six patients in this group were admitted to the
pediatric intensive care unit (PICU) because of per-
3.2. Clinical presentations and laboratory forated appendicitis (n = 4) or intestinal perforation
tests (n = 2). The average length of stay in the PICU for
patients with perforated appendicitis was 4.9 ± 3.3
The clinical presentations and laboratory data are days, and that for patients with intestinal perfora-
shown in Table 1. Patients with appendicitis com- tion was 4.5 ± 0.7 days. There were no mortalities
monly presented with rebounding pain (n = 246, 96%), in this group. In the traumatic group, three pa-
vomiting (n = 167, 65.2%), fever (n = 147, 57.4%), and tients died; two of them had injuries involving
diarrhea (n = 56, 21.8%). All patients with intestinal multiple organs and one had intestinal perforation.
perforation presented with rebounding pain. In lab- Patients with multiple organ injuries and those
oratory tests, WBC counts, total neutrophil counts with liver lacerations had the longest durations of
and CRP levels showed significant differences among hospitalization, and patients with spleen lacera-
children with different etiologies of acute abdomen tions had the shortest duration of hospitalization
(p < 0.01). Mean WBC counts, neutrophil counts and and ICU stay.
CRP levels were all highly elevated in patients with
acute appendicitis and intestinal perforation. How-
ever, CRP levels and band forms in the differential 4. Discussion
counts were relatively low in patients with incar-
cerated hernia and intussusception. The character- Abdominal pain is one of the most common com-
istics of patients in the traumatic group are shown plaints in childhood.2 Although most of these com-
in Table 2. There were no significant difference in plaints arise from self-limiting conditions, abdominal
mean Hb values and WBC counts among the groups pain might herald a surgical or medical emergency.3,4
with different organ injuries. This retrospective study aimed to help primary
pediatricians to better understand the clinical spec-
3.3. Imaging studies trum of acute abdomen in children, including the
demographics, clinical presentations, laboratory test
In our study, plain radiographs were available for results, imaging findings, and clinical courses. This
77% (308/400) of the patients. Bowel loop dilation research also provides detailed information on the
and local ileus were the two most common find- epidemiologic variations of the disease in children
ings on plain radiographs in children with acute presenting to the pediatric ED.
abdomen. Fecaliths accounted for only 22.2% of In the non-traumatic group, intussusception and
patients with appendicitis. After excluding patients incarcerated inguinal hernia were the major causes
with perforations due to appendicitis, there were of acute abdomen in children ≤ 1 year old, and acute
14 patients with intestinal perforations. The locations appendicitis was the major etiology of surgical ab-
of the perforations included the gastrium (n = 4), the domen in children > 1 year old. According to other
small bowel (n = 1), the duodenum (n = 2) and the investigations, intussusception occurs frequently be-
cecum (n = 7). In 78.6% (11/14) of these patients, free tween the ages of 3 months and 5 years, with 60%
air was demonstrated on abdominal radiographs of cases occurring in the first year of life and a peak
(Figure 3A). In addition, abdominal CT scans were incidence at 6−11 months of age.5 A 9-year survey
taken in 33.5% (134/400) of the patients in our study. recorded the following anatomic sites of intussus-
Most of the traumatic patients (98%) received abdo- ception found during open reduction: 19 (82.5%) in
minal CT examinations, and the definitive diagnoses the ileo-colic area, three (13%) in the ileo-cecal
in all of these patients were based on the CT findings. region, and one (4.5%) was ileo-ileo-colic.6 In our
Moreover, 32% (131/400) of the patients underwent study, only 26.3% of patients with intussusception
ultrasound examinations. In our series, the patients required surgery. In addition, 21 cases with ileo-
with intussusception were all diagnosed using bed- colic type intussusception (23.1%), three ileo-ileo-
side abdominal sonogram (100%) (Figure 3B), and two colic type (100%), and one ileo-cecal-colic type
of them also underwent abdominal CT examinations underwent surgery (100%). Based on our analysis,
in order to exclude pathologic leading points, because we found that surgical reductions were needed in
of recurrent episodes. all cases of ileo-ileo-colic and ileo-cecal-colic type
Table 2 Characteristics of patients in the traumatic group*

Liver Spleen Kidney Pancreas Intestine, colon Multiple organs

p
(n = 14) (n = 12) (n = 3) (n = 2) (n = 5) (n = 29)

Age 0.039
Infant − − − − − −
Preschool-age 7 (50.0) 0 0 0 1 (20) 4 (13.8)
School-age 3 (21.4) 3 (25.0) 0 0 2 (40) 4 (13.8)
Adolescent 4 (28.6) 9 (75.0) 3 (100) 2 (100) 2 (40) 21 (72.4)
Gender 0.757
Male 8 (57.1) 9 (75) 3 (100) 2 (100) 4 (80) 19 (65.5)
Female 6 (42.9) 3 (25) 0 0 1 (20) 10 (34.5)
Imaging studies
Abdominal X-ray 2 (14.3) 2 (16.7) 1 (33.3) 0 2 (40) 5 (17.2) 0.704
Negative finding 1 (50) 1 (50) 1 (100) − 1 (50) 4 (80) 0.657
Bowel dilatation 1 (50) 0 0 − 0 0
Acute abdomen in children and adolescents

Local ileus 0 1 (50) 0 − 1 (50) 0

Free air 0 0 0 − 0 1 (20)
Ultrasonography 9 (64.3) 8 (66.7) 2 (66.7) 0 4 (80) 17 (58.6) 0.605
Accurate diagnosis 9 (100) 7 (87.5) 1 (50) − 1 (25) 13 (76.5) 0.030
Abdominal CT 14 (100) 12 (100) 3 (100) 2 (100) 4 (80) 29 (100) 0.154
Accurate diagnosis 14 (100) 12 (100) 3 (100) 2 (100) 4 (100) 29 (100)
Laboratory tests
WBC (×103/mm3) 12.5 ± 6.5 15.6 ± 9.5 12.7 ± 6.0 11.5 ± 3.8 17.1 ± 4.0 15.1 ± 5.3 0.416
Neutrophil count (%) 61.0 ± 19.4 76.6 ± 13.8 87.9 ± 5.9 49.0 ± 0 67.5 ± 23.3 79.1 ± 12.1 0.170
Band count (%) 10.3 ± 12.7 3.3 ± 2.5 3.0 ± 0 − 14.5 ± 16.3 14.3 ± 12.6 0.650
CRP (mg/dL) 9.40 ± 0 − − − − 3.28 ± 0 0.317
Hb (g/dL) 11.2 ± 3.1 11.7 ± 1.4 12.2 ± 2.2 13.0 ± 1.2 10.7 ± 4.8 11.8 ± 3.3 0.914
Amylase (U/L) 130.2 ± 183.9 41.2 ± 10.9 59.5 ± 33.2 322.0 ± 0 39.0 ± 0 201.8 ± 458.4 0.261
Lipase (U/L) 20.0 ± 5.5 28.8 ± 14.3 27.5 ± 10.6 − 31.0 ± 0 1307.0 ± 4158.5 0.811
AST (U/L) 1106.8 ± 691.2 29.0 ± 0 − − − 420.4 ± 407.5 0.121
ALT (U/L) 479.2 ± 424.2 82.5 ± 94.0 − 50.0 ± 0 18.0 ± 0 255.4 ± 300.0 0.266
Urgent surgery 2 (14.3) 4 (33.3) 0 0 4 (80.0) 13 (44.8) 0.055
ICU admission 10 (71.4) 10 (83.3) 1 (33.3) 1 (50) 2 (40) 19 (65.5) 0.375
ICU admission days 9.9 ± 10.4 2.6 ± 1.3 3.0 ± 0 6.0 ± 0 3.5 ± 3.5 4.9 ± 4.6 0.231
Hospitalization days 12.3 ± 12.5 8.2 ± 4.0 9.7 ± 1.2 9.5 ± 3.5 9.8 ± 10.0 15.2 ± 13.9 0.811
Mortality 0 0 0 0 1 2

*Data presented as n (%) or mean ± standard deviation. CT = computed tomography; WBC = white blood cell count; CRP = C-reactive protein; Hb = hemoglobin; AST = aspartate
aminotransferase; ALT = alanine aminotransferase; ICU = intensive care unit.
131
132 Y.C. Tseng et al

A B

C D

Figure 3 Imaging findings in patients with acute abdomen: (A) free air under both hemidiaphragms (arrow) on erect
abdominal radiograph; (B) ultrasonography shows intussusception: target sign (arrow); (C) axial abdominal computed
tomography shows twisted and engorged mesenteric vessels in a whirl pattern (arrow), which is diagnostic of bowel
volvulus; (D) blunt abdominal trauma with liver laceration (arrow).

intussusceptions, compared to 23.1% (21/91) of cases a perforation rate of about 30−65%.5 The lower
of ileo-colic type intussusception. Primary pediatri- perforation rate in our study might reflect the high
cians should therefore pay particular attention to level of availability of medical care in this residen-
patients who are diagnosed with ileo-ileo-colic type tial area in Taiwan, and the fact that most doctors
or ileo-cecal-colic type intussusception, because are alert to the implications of right lower quadrant
these patients are more likely to require surgical abdominal pain.
reduction. A study in North America showed that Past experience has revealed that the seasonal
60% of cases of incarcerated inguinal hernia occurred incidence of intussusception peaks in spring and
during the first year of life, with a male predomi- autumn,9 and that the correlation between intus-
nance (female/male: 1/6), and that it occurred susception and adenovirus infection is high. In this
more often on the right side (2:1).5 Another study study, we found that cases of intussusception re-
reported that nearly 50% of incarcerated inguinal quiring surgery peaked in February, but no obvious
hernias occurred before the age of 6 months.1 In our seasonal difference could be found. Our previous
study, however, 53% (16/30) of patients with incar- studies failed to reveal any monthly patterns of
cerated inguinal hernias were older than 1 year. This distribution of other diseases in the non-traumatic
may reflect a difference between our pediatric ED group; however, our survey suggests that more cases
and those in previous reports. The female:male ratio of appendicitis occurred in September, while more
in our study was 1:5, and the ratio of right-sided intestinal perforation occurred in June. Larger sam-
to left-sided hernias was almost 3:1 (21:7). Our ple sizes are needed to confirm any seasonal disease
findings revealed that the incidences of appendicitis patterns.
were similar in school-age children and adoles- In the traumatic group, liver and spleen lacerations
cents (44.1% vs. 44.5%) and there was a female:male were the two most common indications for surgery
ratio of 7:13 (91/165), the perforation rate in our (21.5% and 18.5%, respectively), suggesting that the
study was 20.3% (52/256). Other studies have re- spleen is injured nearly as frequently as the liver
ported a slight male predominance for appendici- (Figure 3D). Previous studies have shown the spleen
tis, with a peak incidence at 9−12 years old,7,8 and to be the most commonly injured intra-abdominal
Acute abdomen in children and adolescents 133

organ in adults who sustained abdominal trauma, diagnosing pediatric appendicitis was relatively low,
while blunt liver trauma was the most common fatal compared with a previous study in adults, which
abdominal injury.7,10,11 The spleen and liver are both showed that ultrasonography had 96% sensitivity
fragile intra-abdominal organs, which can easily be and 94% specificity for establishing a diagnosis of
injured in a crash. We also noted that the patients appendicitis.14,16,17 A lack of compliance and the
with spleen lacerations had the shortest duration relatively small size of the appendix in children
in the ICU and shortest duration of hospital stay in may be the primary reasons for this discrepancy.
our study, while patients with liver lacerations had Ultrasonography may, however, be helpful in trauma
the longest durations. patients. More than half of our patients received
Although the mean Hb level did not differ signifi- sonogram examinations (61.5%, 40/65), and the ac-
cantly among patients in the traumatic group, it may curate diagnosis rate was 77.5% (31/40). Bedside
still be an important means of evaluating blood abdominal sonograms in trauma patients can also be
loss.7,10,11 For example, one patient with multiorgan useful for tracking persistent intra-abdominal bleed-
injury suffered from massive bleeding and had the ing. However, many factors can affect the accuracy
lowest level of Hb (1 g/dL) in our survey. Also, a pa- of ultrasonography, including obesity, free air, scar
tient with liver laceration had an Hb level of 4.3 g/ tissue, or physician’s personal experience. Primary
dL, and a patient with intestinal perforation had physicians in the pediatric ED therefore need a
an Hb level of 3.8 g/dL. Intestinal perforation and better diagnostic tool when doubt exists about the
liver laceration both carry high risks of massive need for surgical intervention. In our study, both
bleeding.10,11 Lacerations of other organs such as plain film X-rays and abdominal ultrasonography had
the spleen, kidney or pancreas were associated with lower diagnostic accuracies than abdominal CT scans
the lowest Hb levels, of 10.2, 10.2, and 12.1 g/dL, in both the traumatic and non-traumatic groups.
respectively. The spleen, kidney and pancreas may We therefore suggest that abdominal CT can pro-
be less likely to produce massive internal bleeding vide important data for rapid diagnosis during the
than the liver and intestine. course of management of a child with suspected
In our study, imaging studies performed in chil- acute abdomen, and propose that abdominal CT
dren with acute abdomen included plain radiographs, should be used by primary emergency clinicians for
contrast studies, abdominal ultrasound, and abdo- the early differentiation of surgical emergencies in
minal CT scans.7,12 In the non-traumatic group, patients whose conditions cannot be confirmed by
bowel loop dilation and local ileus were the most plain film examinations or abdominal ultrasonogra-
common findings on plain abdominal films. However, phy in the ED.
an accurate diagnosis could not be made in most of In conclusion, the etiology of acute abdomen
these patients based on plain films. One prospec- varied depending on the age of the patient. Acute
tive study reported that the presence of prior ab- appendicitis was the most common cause of acute
dominal surgery, foreign body ingestion, abnormal abdomen in children older than 1 year of age, fol-
bowel sounds, abdominal distension or peritoneal lowed by traumatic injury. Abdominal CT was a use-
signs were 93% sensitive and 40% specific for con- ful diagnostic imaging modality in patients with
firming diagnostic or suggestive radiographs in pa- both traumatic and non-traumatic abdominal pain.
tients with major disease; in the absence of any of
these five clinical features, the sensitivity and spe-
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