 a very good afternoon everyone today we are going to speak on a very important topic that is recurrent abdominal pain medical and surgical management. It is a very common problem that you see in your day-to-day openly practice. I am Dr. Sukhla Satsena. I am a consultant pediatric gastroenterologist and hepatologist at Manipal Hospital, Tauraka and I have with me Dr. Sabdwal sir as well he's a senior consultant and heading periodic surgery over here at Manipal Hospital. So I'll be talking about the medical aspect and he'll be discussing about the surgical aspect of abdominal pain. So it's always a dilemma whenever the abdominal pain children come to your clinic or OPDs because children are often unique and they are different from adults because they have a deep immune system and they require additional support as compared to adults. So treating a chronic abdominal pain is not only challenging for the pediatrician or the physician itself but it's very very challenging for the child who's suffering from the condition and the pain because they are always worried that there might be some underlying condition that the child may be suffering from serious conditions and why the pain is not getting better wherein the pediatricians are always in a fix that you know when you treat it on OPD basis and you know when to order certain diagnostic tests if the pain is not getting better. So today I'm going to throw light or you share with you how to differentiate between functional abdominal disorders and what all to look out for if you're suspecting an organic person and a generalized approach how to go about a diagnosis and management of chronic abdominal pain. So if we look at the terminology it's an intermittent or constant pain which could be functional or organic in etiology and it should be present at least for two months. Most you know it can most criteria define it should be present for a period of three months but it should at least be present for a period of two months. Important thing is that it encompasses the recurrent abdominal pain which is defined by four criteria that there should be more than three episodes of the abdominal pain. The pain should be sufficiently severe to affect the activities and the episode should occur at least a period of three months without any organic cause. In terms of functional disorders in which the which are the condition in which the patient can have variable combination of symptoms in sign without having any identified organic condition. Usually it is because of the interplay of regulatory factors which are there in the entry and the center nervous system. So a lot of factors interplay for example there may be visceral hyperalgesia which reduce threshold for pain abnormal pain referral after rectal distension or there may be impaired passive relaxation in response to needs. Now if you look at the epidemiology chronic abdominal pain occurs in up to 10 to 20 percent of children in the age of 4 to 6 years. There has been studies done in middle and high school children which have reported 17 percent of them have reported BT episodes of abdominal pain. So it is quite a common problem in childhood. In 2015 a meta-analysis was done of 58 studies which show an overall prevalence around the world of functional abdominal pain of up to 13 percent. Now how and why this pain occurs. So let's look. There are two types of pain receptors which are there. One is in the MISRA and one is in the Karaita, Karaita phalton. So pain receptors which are there in the abdomen usually they respond either to the mechanical stimulus or the chemical stimulus. So whenever there is involvement of MISRA the visceral pain is usually induced by the mechanical stimulus in the form of either distension, contraction, traction or compression. Whereas mucosal receptors which are present in the mucosa primarily responds to chemical stimulus for example predigining, substance the saboteurin etc. And we all know that the chemical stimuli are released in response to inflammation or skin. Sometimes what happen all these different stimuli whether it's mechanical or chemical they can add together and they can influence the perception of pain. For example usually we see that gastric mucosa is insensitive to pain. However when the gastric mucosa gets damaged or inflamed then these stimuli may cause together pain in the gastric mucosa as well. Also the threshold for perceiving the pain for visceral stimuli varies amongst individuals and that's what results in the chronic pain which can be triggered by a initial result. For example a child with functional abdominal pain the brain communication is altered by distortion in visceral sensation. So normal process for example like normal paracelsus may be perceived as painful in some children as compared to others. Also there is visceral hypersensitivity which can occur through peripheral sensitization at the point of inflammation. Then there is central sensitization or recruitment of non-involved adjacent neurons. These all mechanism together may predispose to chronic pain even after the initial stimulus has been resolved. This is just an algorithm how biological environmental and psychosocial factors affect the possession of pain in an individual. The second one is the leopard pain. So sometimes the pain which is originated in the bistra is perceived to originate at the distant side and that pain is called as leopard pain. So usually the leopard pain is located in the cutaneous dermatone same as shared by the spinal cord level as the bistral input. For example the nausea septic stimuli for gallbladder they enter the spinal cord at the T5 and T10 level. So usually whenever the gallbladder pain is perceived it is perceived with the scapula. Similarly if when the overlying parietal peritoneum is involved then the pain will be referred to the right upper quadrant in case of acute polycystitis. This is a dermatomal distribution which we all know that pain from abdominal bistra which are referred to different sides. This is very important that we all know that they localize according to their embryological origin. So four gut structures usually the pain is referred to the upper abdomen for that is the structures which are originating from mouth till the first proximal half of the diodenum. Then the structures from distant half of the diodenum to the middle of transverse cologne the pain is referred to the perium likeus and the perium likeal region. And then for the hind gut structures like the remainder of cologne rectum and the genitio urinary organs the pain is usually present in the lower abdominal region. And radiation of pain may provide the insight into diagnosis for example we have already seen for the gallbladder for pancreatitis the pain may radiate to the back during the gallbladder disease the pain may radiate to the right shoulder or the scapula region. But this is not a hard and fast rule it will you know it will only depend what type of underlying ecology is there. Now it's very very important whenever a child presents to you to take a detail history and look for the location of the pain to rule out an organic ideology because then only you can decide about what investigation to order and how the child would be managed. So it's very important to remember that we always look for any underlying organic cause for example if it's an esophabic disorder usually there will be a history of early morning pain or the pain of waiting the child at night with early society like londia or foul smelling or sour breath or burping they could be occasional local blood and stool as well. And usually the typical location of the pain is in the epigested region. If there is carbohydrate mileage option for example lactose intolerance it's like a crampy pain with diarrhea but usually probably stool bloating with a lot of bloating and gas related issue because of the mileage option of the carbohydrate. And it is aggravated by eating dairy or dairy containing products. Again the pain is very unlikable or it could be in the lower abdomen. In celiac disease so the presentation can be a crampy non-specific abdominal pain. In celiac cases child may present with chronic diarrhea and oryxia distension but in certain cases the child may just present with poor weight gain or weight loss malnutrition. They can also present with constipation and island deficiency in anemia but mostly the pain is in the epigested region. In constipation most of the times you will have a history of periabilical pain but you will see a lot of time the child consistently gives a history of left sided abdominal pain and there will be additional history of incomplete evacuation of stool in infrequent stooling in fecal incontinence or history of large stool once we have given our suppository or some kind of treatment to the child. Again in adolescent age group it is very important to look for dysmenorrhea history of menstruation, gastroesophageal influx. This is very very important because sometimes the respiratory symptoms like chronic curve of easing doesn't get better so it's very important to remember that there could be a underlying influx which may be causing this easing of chronic curve. If in a bigger child they may have associated epigestric or upper abdominal pain then there could be muscle stale little pain if the child has got hernia or hematoma so the pain usually occur with some kind of physical activity they could be underlying muscle tenderness or positive carnal site. I will not go into the details probably sir will be the best person to you know tell differentiate how he differentiate between an abdominal wall and organ pain by using the carnal site. Then there are pain which is related to infections like but those children have associated diarrhea or exposure to history and they usually present with diffuse abdominal pain. Also important to rule out less common causes of pain like endometriosis and adolescent girls. This is very very common with food allergy, rising incidence of food allergy. Kids come with usually upper abdominal pain they may have a history of vomiting or dysphagia or food infection or they may not have a history. Similarly for food allergy as well if it is IG immediately then the abdominal pain is immediate in onset usually within minutes to hours of addition of food and the diarrhea also follows. Whereas if it is non-IG immediately then it can present with chronic diarrhea or weight gain or blood or mucus and stool for a long time. Other less common but important organic disorder is very very important because a lot of time inflammatory bowel disease especially Crohn's may present with just lower abdominal pain with some kind of you know gross or awful blood and this too will short stature and poor weight gain. They may not have always classic history of diarrhea weight loss and blood and stool. So it's very important to remember to rule out these disorders as well. Similarly pelvic inflammatory diseases in adolescent children and UTI which is again a very common cause of abdominal pain in children. This is again a summary of alarm findings. So what you will get in history is and any history of involuntary weight loss probably will point toward malabsorption. Difficulty swallowing or painful swallowing which points towards eosinophilic esophagitis or any kind of esophagitis or ecclesia. Significant vomiting so significant vomiting can be associated with esophagitis disease or cyclic rheumatic syndrome or eosinophilic gastroenteritis. If it is really severe then ball obstruction is another option. Then it present in it is present in hepato-villary disease and cholecystasis as well. Chronic severe diarrhea think about enteric infection, food protein, inducements of the inflammatory bowel disease, urinary symptoms, back pain. So child usually presented with acute back pain and abdominal pain think of chronic pancreatitis and accordingly we have to order the investigation. Family history of IBD, CVF or Peptic ulcer disease is very very important because usually these conditions doesn't especially IBD or functional bowel disorders don't have specific treatment. It's very important to diagnose them right first. Again IBD have variable presentation in the form of bloodied area as well. Then look out for melena, skin changes in different conditions. In examination most important is to plot their growth. So if there is any decrease in the growth or delayed growth or delayed poverty it is very very important. Ulcerations which is common in IBD look for localized upper quadrant tenderness in hepato-villary disease or right lower quadrant tenderness in chronic appendicitis or varian cyst. Left lower quadrant pain as I said earlier in constipation it could be a mass or ulcerative colitis, supra pubic tenderness in UTI, organometallys or post-ovartical left ankle tenderness. So in all a very good history and a clinical examination is must in child presenting with recurrent abdominal pain to look out for any organ. Now there is room for diagnostic criteria which shares with you the functional abdominal pain disorders because we have looked in the organic disorders. Now these are the disorders which are functional in nature and they have been categorized into functional dyspexia, irritable bowel syndrome, abdominal migraine, then function abdominal pain which is not otherwise specified and functional constipation. Each of them is an entity in itself and they need a long discussion because we are always confused that when to label them as functional disorder and how to treat them. So I'm just going to summarize and give you a rough idea what exactly they are and how we should go over. So usually all the functional disorders they are ill-defined and poorly localized or perium-like in episodes of burn usually last less than an hour. They resolve spontaneously. They may be accompanied by pallor nausea or dizziness or may be triggered or exhumated during stress. The most important thing is that child is well and functional normally in between the episodes. So there are no alarming signs in such disorders. And another important thing is there might be family history of positive GI disorders like irritable bowel or blood circulation. If you look at the overall prevalence, so this is again very important slide. The most common functional disorders is functional constipation which shall the highest prevalence around 10% out of all of them followed by functional dyspepsia which is 3%. Functional abdominal pain is again 2.4% and irritable bowel syndrome is 2.3%. So when people ask about abdominal migraine, so it is not a very very very common condition. The overall incidence is only 0.5% out of all the functional disorders. I'll just share one or two cases with you to give you a rough idea what exactly is functional dyspepsia. So 14 year boy with 2 month history of positive post peregral fullness, early satiety, epicastric pain, epicastric burning with normal physical examination, normal screening labs, all labs have been normal. Now should we do a rheological testing in such a way? No, till we don't have an obstructive sign and symptoms it is not needed. Should we go for an endoscopy? Yes, if there is evidence of vomiting or weight loss, if there is evidence of any positive screening tests like the celiac screening or allergic screening, often does not relieve the anxiety. Should we do a pyloric testing? If there is a family history or if the symptoms are really acute, then you should go for a pyloric testing. Now this is the therapy which has been recommended. Total confirmable inhibitors have less than 50% response. There is no increase in response to high doses. Anti-H coli, H pylori drugs have only 10 to 15% response and there is no improvement with repeated process. There is no role of prokinetics or anti-small or anti-dip present in this disorder. The second one is irritable bowel syndrome which presents with abdominal discomfort or pain usually associated with two or more of the following. It may improve identification. It is onset associated with change in stool frequency or stool consistency. There is no evidence of any other disorder and it should be present for two months or more. A lot of studies have been done on various supplements, medications, dietary restrictions and adults. But what have been found to be effective in IPAs in children is only one thing. One is psychosocial support which is most effective and other thing which I come to discuss later is the peppermint oil which should be given for almost a period of more than two weeks. It is abdominal migraine which consists of paracysmal episodes of intense acute perium like the pain that lasts for more than one hour. Intervening periods of normal health which can last for weeks to months. The pain interferes with normal activities and it should be associated with two or more of the following. So the child will either have anorexia, nausea, vomiting, headache, photophobia or fallout to a more of them and there will be a positive history of migraine in the family. This is just a brief treatment of abdominal membrane. Usually it is the non-pharmacological therapy which is recommended initially which is explanation and reassurance, avoidance of trigger, modification of diet. Then if there is pharmacotherapy and prophylactic therapy, use the abortive instances of abortive and the prophylactic then there is functional abdominal pain syndrome which is continuous or nearly continuous abdominal pain. It has little or no relationship of pain with eating, deputation or menses. There is some loss of daily functioning that's why these functional disorders are important. The most important thing is the pain is not pain so there is no malingly involved by the child. It will not fit into another function GI disorders and usually there should be symptoms for at least two months, six duration should be two months to six months. So how do we go for it? It's very important for the child or the parent to be told to keep a pain diary to look at the pain, the duration, the location and severity, the possible triggering factors which could be involved, the remedies or interventions that were tried which made the pain better. For adolescent girls, a menstrual history should be obtained in all adults and women. Investigations that should be ordered, we all know that there are basic investigations and then the second line investigation. So whatever is the underlying organic ideology that we are suspect to, based on that we should order the basic blood and the second line investigations. It goes through Apagia endoscopy although it has been documented that it is the second line investigation and before the introduction of esophageal gastroidinoscopy, the majority of recurrent abdominal pain was categorized as functional. However, after the advent in 1970, organic etiologies gradually became more prominent and nowadays it has been found that 10%, less than 10% to as much of 50% pain are because of recurrent abdominal pain. So this is, there has been study done by Genchupi Dal in which they have done upper endoscopy finding in children with recurrent abdominal pain in which 150 degrees were performed in red flat children. So it's very important. We are going to do only endoscopies in which you see evidence of red flat signs in children with recurrent abdominal pain to find out the etiology of their complaints. The, they found that abnormal findings are present in 84% of patients. The most prevalent were esophageitis which was in 40%. Regarding the high prevalence of abdominal pain complaints and increasing the application of EGD in diagnosis of etiology, findings precise indication for performing EGD in children with recurrent abdominal pain seems mandatory. So the popular approach is all the children with recurrent abdominal pain who have red flat signs should undergo upper GA endoscopy. So this was the indication for doing the upper GA endoscopy, the kids with the raised ESR with severe anemia weight loss. So having one or multiple factors, episode of GI feeding or localized tenderness and these were the findings out of which 16% were normal, 20% had creatinine hernia. You see a large young had a 40% have different rates of esophageitis. So I'm just coming to the end of my presentation. This is just a box type lens to manage recurrent abdominal pain. Most important thing is explain and reassure because if you're dealing with functional abdominal pain, this is what is needed. Identification of red flat sign, avoid psychosocial labeling, allow normal activity. It is very, very important to encourage normal activity in kids in between when the child is pain free. Establish regular follow up also make use of judicious second opinion. If you think that you are stuck or you're not able to understand then obviously you should refer to us. Now there have been various therapies which have been tried and according to last again recommendations, we have seen that only two therapies have been beneficial out of which a cognitive behavior therapy has been beneficial in recurrent abdominal pain. There was no use of femuridine or adding dietary fiber or lactose free diet in recurrent abdominal pain. Peppermint oil as I already said is likely to be beneficial in irritable bowel syndrome. There has been no result of any tryptoline or lactobacillus BV in irritable bowel syndrome. To summarize chronic abdominal pain is a common condition in children and adolescents. In most children it is functional that is without any underlying organic disorder. There is evidence that children with functional pain can have symptom clusters that means they may have features of more than one type of pain. The presence of alarm symptoms of signs such as organic disease and may justify the performance of diagnostic test by the treating position. There is inconclusive evidence that a lactose free diet or a diet which in fiber may decrease the frequency of pain. There is inconclusive evidence of benefit of acid suppression with H2 receptor and tokenase to treat with child with dyspensia. Although there is evidence that treatment for two weeks with peppermint oil may provide benefit in children with IVS also similarly cognitive behavior therapy may be useful in improving functional problem pain. Hi, good afternoon. I am Dr. Arvind Sabarala. I am the pediatric surgeon from Manipal Hospital. Now whereas a physician has got a long period of time to decide that which therapy is needed. A surgeon sometimes gets into problems because a surgeon doesn't know exactly where the pain is originating. The child is a poor communicator and it becomes very important for the surgeon to decide whether he should put the knife on the child or not. And normally a surgeon would have a very short time to decide that what should be done. Abdomen was always thought to be a Pandora's box. Over a period of time however we have gained a lot of access into it. We've got now various diagnostic modalities through which we can know what is happening in the abdomen. And today we are in no hurry now to go in and operate in each and every patient. Now abdominal pain in children can be an acute abdomen which normally comes into the domain of the surgeon. The recurrent pains in the pains which are organic or which are psychogenic and non-traumatic, they normally fall into the realm of a medical treatment on which Dr. Supta has already given you a very nice detailed explanation that how we are going to manage these kids with recurrent pains who may have organic causes or psychogenic causes underneath. Now whenever we are talking of abdominal pain in children from a surgeon's point of view, my first question would be that whether this pain is traumatic or non-traumatic. The pain in kids can originate anywhere from the GIT, from the vertebrary tract, from the genital unitary tract and also from the musculoskeletal system. But luckily only less than 5% of all abdominal pains which would come to us less than 5% will need observation or even lesser than that will need an exploration. Most majority of them would have common causes something like gastrointritis or worms or constipation or gastritis or the other factors which Dr. Supta has already so beautifully explained. Now first is the trauma. Most of the time you will get a history. The child will be able to tell that well my friend kicked me in the tummy during the lunch break or there will be history of falling from cycling or the child would have fallen for a swing. So normally in majority of cases you will get a history of trauma and an ultrasound and a CECD abdomen are the two investigations of choice to pinpoint any abdominal injury. At this point however I must share my experience with you that there are a lot of kids who come with a muscle pull of their period abdominal wall. They will come that there is sudden pain and the pain typically comes when you ask the child to sit up or to raise his legs and you will suddenly find that there is pain in the period abdominal wall. The points of tenderness normally are just under the rib cage or they may be on the rectus abdominis muscle. Lot of these kids undergo unnecessary investigations and whereas they just have a simple muscle pull of the period abdominal wall because of sudden movement or pain. In cases wherever we are suspecting a gut injury which is not picked up by a CECD we might need to do a peritoneal tap to find the presence of bile. Most of the cases of trauma even a major liver trauma if we look at this film you can see a major liver trauma on the liver can be managed non-operatively. They will need an ICU care but most of them would not require any explanation. Now when we come to a non-traumatic acute pain there are two main categories what we are talking about one is a child who is less than one year of age the first thinking is intersection. Any child who is more than two years of age severe abdominal pain the first thinking is appendicitis. The most important thing is that we need to repeatedly observe these children over a period of time maybe a few minutes a few hours to come to a conclusion. Now even if we operate almost 75 percent of the cases who have a negative exploration in spite of the investigations might have a cause something like a mechal or a small ovarian cyst which has ruptured and in 25 percent of the negative explorations the diagnosis may be made in the post-op period as pylonephritis or a Ajaxal and papula. Medivial diseases such as inflammatory bubble disease or primary peritonitis also can lead on to some negative explorations but the central issue will always remain in kids to be appendicitis. So it is very important to take a history in a kid because it may point you out that what is the probable cause of this pain. Less than one year of age a severe acute pain the cause may be an interception, it may be a malrotation, it might be a hernia which has been overlooked by the parents, there might be heart problems. Generally what we see is that if the sequence comes as that the patient had fever first followed by vomiting and then the pain started the pause most likely is going to be a medical pause whereas if the pain is the first symptom and that is followed by vomiting and then the fever comes it is more towards a surgical problem. A pain which starts with sudden severe onset may be a pain which is due to a torsion or due to a operation or due to an interception. Whereas the slower onset pains are the appendicitis pain which may evolve over a period of time. It may be a pain of pancreatitis or cholecystitis or a urinary tract infection. Most of these pains will take a few hours to gradually increase in intensity. If the patient has got recurrent pain then as Dr. Sopla has told inflammatory rebarber disease, constipation are the common causes. If the pain is cholecystitis it is a rising from a hollow viscous, maybe from the gut, maybe from the urinary tract. If the vomiting is right at the onset, it may be associated with the colic. So any abdominal colic can give vomiting immediately along with the colic. If the appetite of the child has decreased markedly then the pain is most likely to rise from the GIT. Whereas if the appetite is normal the pain is more likely to be from the genital urinary tract. A GI bleed along with the pain could indicate a meccal in HSP or HUS or interception or a marvelous. Past history of any medical problems like nephrotic syndrome or cirrhosis can point out that it might be a primary peritonitis. Whereas any previous surgical history of trauma or previous surgeries could indicate that it might be due to additions. In females it is always important to remember that a follicle cis-structure or a topic pregnancy. Yes even a topic pregnancy because as we are going through this age we are likely to see teenage topic pregnancies to happen and they can mislead us. Then it is very important also in the history to see what is the site of the pain and how it radiates. So the working diagnosis by the site of the pain would be that the right upper quadrant pain is either from the liver, cholera crisis or gallbladder. Whereas an epigastric pain is because of GI, gastritis or a practical disease. Appendicitis, mesoteric adenitis, meccals, ovarian torsion will all give a pain which might start in the mid abdomen but will gradually shift over onto the right side of the abdomen. Pancreatitis pain will be normally in the mid abdomen. Obstructions to the small bowel again will give a abdominal pain. Constipation, UTI and ovarian torsion might give the pain in the left quadrant. Now examination of such a child will show that if the child is restless and rising in pain it is more likely to be a colicky pain and if the child is lying still, still complaining of pain it is more likely a peritoneal pain. That means that it is more likely inflammatory pain and the child does not want to move. Tachycardia, tachypnea and a coated tongue again is normally a sign of an inflammatory pathology. In ways small kids or maybe infants or younger kids we might see a abdominal wall edema, we might see visible loops, we might see some motion of these loops on the abdominal wall. We also try to elicit tenderness, guarding, rigidity and rebound tenderness. The best way to elicit a rebound tenderness is to gently tap on the child's abdomen rather than pushing deeply and leaving the abdomen. We also listen to bowel sounds. Bowel sounds might be indicating few tinkling sounds, they may be something like a water gushing through, the sounds may be like something water is pushing through and various bowel sounds will give us an inkling whether it is an idea or whether it is an obstructive bowel. Again free air or fluid can be judged on percussion. It is very important to examine the lower chest or spectrate the lower chest to find any evidence of pneumonia in that area. Lactal examination though not necessary in all the kids may help and to also look for a pediatrics because a henup shallon can give rise to an abdominal pain. Investigations normally are hemoglobin, PCB, TLC, DLC. A rapidly falling hemoglobin could indicate that it is a volvulus. A raised total leukocyte count with neutrophilia points to an inflammatory bowel disease. Urine analysis, renal function, liver functions, amylase of course will also indicate various diseases of the liver or of the pancreas. One of the important investigations for any abdominal pain may be an x-ray. Now most of the time what I have seen is that an x-ray whenever is ordered is ordered as an erect x-ray. Whereas it is mandatory that before you do an erect x-ray a supine x-ray must also be done. The supine x-ray is a must to find out the level of the bowel obstruction to look for calcifications, to look for any central loops, to find fixed loops from prentin which is seen normally in cases of any ischemia. The presence of any mass in the abdomen because the bowel will split around that mass and to see for the preperitoneal line which will get obliterated in case of there's any inflammation. The investigation of choice in most of the cases would be an ultrasound of the abdomen which is non-invasive, easy to do and does not cause any problem to the child. Followed by an ultrasound the CECT becomes the most important investigation whereas both the solid organs, masses and even cases of intestinal obstruction could be easily diagnosed on a CECT. MRI has got a very limited role and kits for evaluating intestinal pain or evaluating abdominal pain rather because number one it needs a sedation and a GA. It's a long period to do an colageogram and it does not give any additional information to a CECT abdominal. However MRI may be useful when we are doing the colageogram to look for a colidogal cyst or a urogram to look for an amylase in the urinary system or it might be helpful if we are suspecting any spinal cause for the abdominal pain. A diagnostic laparoscopy sometimes might be needed in a tubercular abdominal and in contrast studies such as the varium study might be very useful to make a diagnosis of husband disease. Now always beware of a baby who vomits wide. Abdominal pain the common causes constipation, a history and an examination might reveal that is constipation because of an impacted tooth which is palpable. In acute appendicitis may be diagnosed by history, examination with a pain and reboundedness in the right liposa. Similarly a torsion might get diagnosed by doing a CBC by doing an ultrasound or doing a CT scan. It is very important to always look for an guino-scrotal mass in the kit with abdominal pain because we have seen patients with obstructed hernia being missed as in a abdominal pain. Hennep Schoenland-Parpura again is common in kids and can give rise to abdominal pain. Visitoric lymphatic enactors especially after a viral infection is very common and an ultrasound will most of the time make a diagnosis. In a donor sense appendicitis followed by divertiplitis, pancreatitis, gallbladder stone, and torsion of intra-abdominal structures are the common causes of acute abdominal pain and diagnosis again is through all the means that we have already described. So I will delve a little bit more on appendicitis because that is the normal or a very common condition in kids which need surgical attention. It's always important that a patient of appendicitis must be seen after 2-3 hours again and reassessed to see what is the intensity of pain. In neonatal period the diagnosis is almost never done pre-operative and almost 95% of them will have a perforation by the time they are diagnosed. Even in children the rate of perforations are quite high almost 60% described in literature but the normal perforation rate is somewhere around 30 to 40% and in 15% of them they will perforate in less than 24 hours. So that is why most of the time we recommend early surgery in patients with appendicitis. We can have leukocytosis with a left shift, TLC more than 15,000 with a neutrophilia of more than 80%, a CRP which is raised and a chest on an x-ray of the abdomen showing a frecolate in the right like OSAR are almost diagnostic of an acute appendicitis. On an ultrasound increase of diameter of the appendix more than 7 millimeters in the AP diameter, non-compressible structure has a sensitivity of about 85%. Normally today we are tending to do more and more CCT abdomens because the ultrasound lot of times is inconclusive. But if on an ultrasound a diagnosis is clear cut I don't think that we need to really go in and do a CCT. However if we are suspecting in a particular mass we must do a CCT to look for local collections any other pathologies which might be related in that area. In children chronic and recurrent appendicitis is a definite clinical entity and as I will go to the next slide to tell you the non-operative treatment of appendicitis. We see that in early appendicitis most of the kids will get okay after getting some antibiotics but then they will recur. They will come back, a small percentage will come back and these are the patients who will be diagnosed as recurrent appendicitis. Variable and edema used to be done initially but I think today it has been replaced by doing a CCT The treatment of choice is to do a laparoscopy today. Open surgery is hardly now done in these days and most of the kids we are able to resolve them with the laparoscopy. But sometimes if because of local mass or because of problems we might need to convert these patients into an open surgery. There is lot of talk today of appendicitis non-operative treatment but one should remember that the non-operative treatment requires antibiotics for 7 to 10 days. There are various scores which have been set up such as the pediatric appendicitis score which is based on vomiting, writer-like osapine, tenderness, temperature and these scores are able to predict whether we should operate these kids or not. But normally if an appendix is less than 10 millimeter the leukocytosis is less than 15,000 with a real normal CRP with no petrolate and no pus on either ultrasound or on a CCT and with a pass score of less than 6. These are the patients who can be managed non-operatively. There this non-operative treatment in non-complicated appendicitis may be effective in 71 to 94 percent of cases but almost 30 percent of these cases will return back within six months with a recurrent episode which may need surgical intervention. At any time whenever we are doing a non-operative treatment if the treatment is not giving response within 24 to 48 hours or if there is any deterioration in the condition patient should be immediately taken up for surgery. Interception is another common condition seen in younger children around nine months to one year of age. They normally have had a recent viral illness. They will have intermittent severe miscellaneous pain where the child is cramping and the mother and the parents can visibly see the cramps. The rectal examination or even the per rectal blood will clinch the diagnosis. Eventually they will develop a distal bowel obstruction and behave like an obstructed bowel. This is the typical red current which comes in these kids. Diagnosis is by doing an ultrasound or a valuation of a mass. The treatment is most of the time hydrostatic reduction and surgical reduction is very infrequently done these days. Most of these kids will go well with an hydrostatic reduction. However I must point it out that there is a condition where we have an ideal interception. These are the kids which will not need any surgical treatment immediately. Most of them will reduce by themselves. They may become recurrent, but most of them will not require any self. Then the children could have interstinal obstruction. The differential diagnosis would be a paralytic alias, nitrotizing internal colitis or peritonitis caused mostly man rotation. Could be bands which are not very common. Could be additions due to early surgery. Could be an obstructed hernia. Ultrasound, CCT, abdomen. These are the various causes for obstruction in kids. Important is to find out a mid-gut wall blouse and treat it as the unbiased. Now surgery becomes essential in cases of appendicitis and obstruction, perforations, gonad panes, and wall bladder disease and medicals. It may become essential if there is a primary torsion of the momentum. If there is a perineptic abscess, bladder calculus. If there is a liver abscess or an ectopic pregnancy. Liver and wall bladder disease are not common. We very frequently see liver abscesses giving rise to severe abdominal pain with fever. Majority of them are staff oriented biogenic infections and they may need exploration and drainage. Polycystitis is becoming more and more common in kids. The guidelines are the same as we are calling for adults and a polycystectomy is the routine frequent. A laparoscopic polycystectomy is the standard for treatment and we normally use smaller instruments to take out the gonad. A urinary tract pain is also very commonly seen in kids which might be because of a pilonaphytis or cystitis. There might be urinary calculus. The pain is usually in the flanks and the back and it is superb if the pain is because of cystitis. The pain usually will get referred from the flanks towards the grind or towards the back. There might be pain which gets referred to the tip of the penis and there are tumors like Wilms and neuroplastomas which also can give rise to abdominal pain which might be persistent. Then very important to note that gonadal pain can initially present as a very severe middle abdominal pain. The most important thing is that the time factor is very important. A pain which is arising from a testis and coming to the middle abdomen may be because of a torsion and within six to eight hours this testis will degenerate. So it is very important to keep that in mind. A follicular cyst, monarchy or an ovarian torsion can also give rise to severe abdominal pain and should be diagnosed early if we have to salvage that ovary. Ultrasound is the most important diagnostic tool. So with that I think I wrap up the surgical problems and we are ready to take any questions when the bite comes. So there is a question from Dr Vivek. First he has asked which painkiller do you prefer in abdominal functional pain and its duration and is there a role of lactobacillus re-utri in functional pain? So I will answer them one by one. Dr Vivek, usually in functional abdominal pain there is no role of painkillers unless it's extremely, extremely severe because most of the kids when you see this pain comes and goes off. If there is only in certain conditions like in irritable if we are suspecting an irritable bowel syndrome or if there is a functional constipation then we know the definitive treatment. Other than that we only give them supportive care and behavioral therapy. Probably ask them to keep a painkiller because in most of these cases painkillers are not useful or helpful. The second one, yes, is there a role of lactobacillus re-utri in functional pain? Yes, there has been recent studies which have been done using lactobacillus re-utri and lactobacillus GG and those studies have shown that conditions like functional dyspepsia, functional constipation, there has been some role of using lactobacillus GG but they need to be given for a period of at least two to three weeks or more to have their effect. I hope I have answered your questions, both of them. So with this we end our session. Thank you very much for attending this medical and surgical aspect of abdominal pain which is a common feature or disease that you are seeing in your opening practice. I hope it has been useful. Thank you very much.