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PEDIATRIC ABDOMINAL EMERGENCIES
Category: Pediatric Surgery
Abstract : • Two principles apply to all visceral pain - Neurological mechanisms
involved in visceral pain are different than those involved in somatic pain -
Perception and psychological processing of visceral pain differs from that of
somatic pain • Visceral pain has five important characteristics - It
is not evoked from all viscera (e.g. liver, lung) - It i
• Two principles apply to all visceral pain
- Neurological mechanisms
involved in visceral pain are different than those involved in somatic pain
-
Perception and psychological processing of visceral pain differs from that of
somatic pain
• Visceral pain has five important characteristics
- It
is not evoked from all viscera (e.g. liver, lung)
- It is not always linked
to visceral injury (e.g.
incision in gastrointestinal tract)
- It is diffuse
and poorly localized
- It is referred to other locations
- It is
accompanied by motor and autonomic reflexes (e.g. nausea, vomiting)
•
There are two classes of nociceptive sensory receptors that innervate internal
organs
- The first class of receptors has a high threshold to natural stimuli
(mostly mechanical and entirely in the noxious range)
- The second class of
receptors has a low threshold to natural stimuli (mostly mechanical and in the
range of stimuli from innocuous to noxious)
• The strongest current
evidence suggests that high threshold receptors contribute to the peripheral
encoding of noxious events in the viscera
• More extended forms of visceral
stimulation (e.g. hypoxia and tissue inflammation) sensitize high threshold
receptors and recruit previously unresponsive nociceptors
• Once sensitized,
the nociceptors begin to respond to innocuous stimuli including changes in the
normal pattern of motility and secretion
• A barrage of signals is
transmitted to the central nervous system due in part to acute injury and in
part to ongoing ischemia and/or inflammation
• There are two biochemical
classes of fine caliber unmyelinated primary afferents that innervate somatic
and visceral tissues
- Neurons that express peptide neurotransmitters (e.g.
Substance P, CGRP). Most visceral afferent neurons are in this class
-
Neurons that do not express peptide neurotransmitters (e.g. Substance P,
CGRP)
• The neurons of the enteric system are arranged in interconnected
plexuses that extend over much of the gastrointestinal tract and also invest the
pancreas and gall bladder
• There are two major intrinsic plexuses
-
Myenteric (Auerbachs) plexus
- Submucous (Meissners) plexus
• There
are numerous receptors in the viscera whose afferent fibers, myelinated or
unmyelinated, travel centrally by way of both sympathetic and parasympathetic
autonomic nerves
• Sensory fibers from the thoracic, abdominal and pelvic
viscera traverse sympathetic and splanchnic nerves to reach the sympathetic
trunk
• They pass uninterrupted through the trunk and white communicating
rami to their parikarya of origin
Types Of Pain
• Sharp Pain
• Dull
Pain
• Bad Pain
• Really Bad Pain
pediatric abdominal emergencies -
Appendicitis
• Diagnosis
- History
- Physical Examination
-
Laboratory Examination
- Radiological Evaluation
• Therapy
-
Immediate Appendectomy
- Delayed Appendectomy
• Pain
- Visceral
pain
• Transmitted primarily through sympathetic fibers traveling to the
superior mesenteric plexus and the lesser splanchnic nerve to the spinal cord
(T10)
- Somatic Pain
• Results from inflammatory irritation of the
parietal peritoneum which is innervated by the T12 and L1 spinal nerves
•
Caution !!! The truly pelvic appendix !!!
pediatric abdominal emergencies
- Incarcerated Inguinal Hernia
• Diagnosis
- History
- Physical
Examination
- Laboratory Examination
- Radiological Evaluation
•
Therapy
- Reduction
» Manual
» Surgical
- Hernia repair
» Urgent
(possible bowel resection and/or orchiectomy)
» Non-urgent following
successful manual reduction
• Pain
- Visceral pain
• Transmitted
primarily through sympathetic fibers traveling to the superior mesenteric plexus
and the lesser splanchnic nerve to the spinal cord (T10). L1 may be involved if
there is associated testicular ischemia
- Somatic Pain
• Results from
inflammatory irritation of the parietal peritoneum which is innervated by the
T12 and L1 spinal nerves
note : Simplicity is the key to success in the
management of hernias of the groin in infants and children. The diagnosis is
simple, reduction of an incarceration when present is simple, the surgery should
be kept simple, and after repair, which should not take more than a few minutes,
the child can be sent home on complete activity without external sutures or
bandages.
Hit: 270 times
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