Functional abdominal pain. Abdominal syndrome (acute abdomen): causes, manifestations, diagnosis, how to treat. Imaging research methods

It is necessary to remember the so-called “ Munchausen syndrome”, when a child with specific personality characteristics feigns or aggravates his condition, imitating abdominal pain and “ Odyssey syndrome” with false-positive symptoms: such “patients” are forced to undergo a long journey of examination using the most modern diagnostic methods before any pathology can be rejected.

Medical tactics for abdominal pain in children.

Correct and quick interpretation of abdominal pain is a responsible task, since this involves carrying out emergency measures. For acute abdominal pain, an accurate, timely diagnosis is necessary. A large number of diseases can have catastrophic consequences if there is a delay in diagnosis. Difficulty of interpretation pain syndrome requires the development of optimal diagnostic algorithm.

General provisions:

1. Degree of urgency of diagnostic measures

2. Taking into account the leading clinical signs of diseases occurring with abdominal pain syndrome

3. Scope of diagnostic measures

4. Frequency criterion for the occurrence of conditions occurring with acute abdominal syndrome depending on the age of children

5. The degree of reliability and information content of clinical and paraclinical data.

6. Stagedness and consistent exclusion of the most dangerous diseases that occur with abdominal pain syndrome

7. Time factor

In most children, acute abdominal pain is caused by non-surgical causes, however, the doctor is first of all obliged to exclude life-threatening conditions that require surgical intervention and, therefore, differentiate between diseases that require rapid diagnosis and immediate treatment.

Features of examination of children with abdominal pain syndrome.

It should be remembered that children under three years of age do not localize their pain at all and almost always experience it as a general severe reaction. Young children localize any pain in the navel area, which, naturally, is neither an informative nor a reliable diagnostic criterion.

Older children Also, as a rule, pain is localized inaccurately, so this symptom has a relative diagnostic value.

More important role objective local survey data:

Inspection: general appearance of the child, body position, nature of mobility, facial expressions and facial expressions, configuration of the abdomen, signs of bloating, type of vomit, stool, urine.

Palpation: protective muscle tension, their resistance, results of rectal examination, pulse character.

Auscultation: peristaltic noise, friction noise of the inflamed capsule of an organ (spleen).

Paraclinical studies: ESR, leukocytosis, urine and stool tests, X-ray and endoscopic examinations, sonography.

At the first stage diagnostics exclude the most dangerous diseases that require immediate help. About the disaster that occurred The following clinical picture indicates: an acute illness with severe, acutely developing abdominal pain and a severe general condition. The following signs indicate need for urgent measures: acute abdominal pain, vomiting, protective tension of the abdominal wall muscles, severe general condition with a frightened facial expression, sunken eyes, pointed nose, anxiety, vascular collapse, stool retention, gas or diarrhea, flatulence.

Table 1

The degree of urgency of diagnostic and therapeutic measures

with a leading symptom - acute abdominal pain.

In the concept “ acute stomach” include appendicitis, intussusception, intestinal obstruction and peritonitis. These conditions require particularly careful differential diagnosis (Table 2)

Table 2

Examination scheme for acute abdomen (Hertle M., 1990)

Table 3

The likelihood of certain abdominal diseases

in children of different age groups (Hertle N., 1990)

Note:

(+++) - high probability

(++) - average probability

(+) - low probability

(-) - does not occur

Second stage of diagnosis. After excluding diseases that require immediate surgical care, differential diagnosis of dangerous, but non-surgical diseases is carried out: acute enteritis with exicosis, pneumonia, myocarditis, acetonemic vomiting, eclampsia, urolithiasis, meningitis, poisoning, foreign bodies, hydatid cyst. At this stage, it is important to search for leading, key features. Laboratory and instrumental research in a fairly minimal volume and with a targeted focus. The following provisions must be observed:

1. Special attention pay attention to anamnesis(duration of pain, severity of pain, its nature, localization, symptoms accompanying pain; diarrhea, shortness of breath, cyanosis, vomiting, twilight state, fever, etc.

2. Objective Research: should be as complete as possible (do not focus attention only on the abdominal organs!)

3. Targeted laboratory and instrumental examination, which does not require significant time

4. The time spent on examination reduces the possibility of adequate emergency therapeutic measures (life-threatening!), therefore complex examinations are resorted to only in extreme cases, and not in the first place!

5. Remember about atypical forms of the disease, especially in young children with underlying conditions (rickets, malnutrition, anemia), as well as with organic damage to the central nervous system

6. Remember about the “masks” of an acute abdomen (“false abdominal” syndrome)

Third stage of diagnosis possible only after eliminating dangerous conditions (see Table 1). At this stage, diseases occurring with chronic recurrent pain syndrome are differentiated. Since these are most often gastroenterological diseases, the scope of the study can be expanded: from simple to complex methods, taking into account information content, accessibility, and economic feasibility. The “planned” nature of the main gastroenterological diseases allows the doctor to more clearly determine the scope of the examination with the construction of a diagnostic hypothesis at each stage of the clinical analysis of the disease.

From a practical point of view, you can use the following diagnostic algorithm for identifying the causes of chronic recurrent abdominal pain.

1. Identification of the most significant risk factors for the development of gastroenterological pathology (Baranov A.A. et al., 1979):

1) Hereditary burden of pathology of the gastrointestinal tract

2) Frequent colds

3) Viral hepatitis in the anamnesis

4) Giardiasis, ascariasis

5) History of dysentery

6) Appendectomy

7) Foci of infection in the nasopharynx

8) Chronic lung diseases

9) Allergic conditions

10) Neurotic conditions

In children with high-risk factors, further examination is carried out on an outpatient basis, which, in addition to carefully collected anamnesis (1), physical examination (2) and syndromic history of clinical data, includes routine examinations (3): analysis of blood, urine, stool for worm eggs, enterobiasis, giardiasis, coprogram, stool culture for typhoid-paratyphoid group and yersiniosis.

If necessary, carried out on an outpatient basis instrumental research(4): sonography of the abdominal organs, cholecystography (for “right hypochondrium” syndrome), endoscopic examination, determination of the state of secretory-enzymatic function.

It is necessary to remember the diagnostic feasibility of each research method, because the information content of any examination in gastroenterology is not high. In addition, the passion for instrumental methods often leads to formalism and the emergence of stereotypical diagnoses of “chronic gastroduodenitis”, “biliary dyskinesia” in the overwhelming number of children with chronic recurrent abdominal pain.

If it is impossible to make an accurate topical diagnosis at an outpatient stage, further research is carried out in inpatient conditions or at a diagnostic center. The range of examination at this stage is determined by clinical data, uncertainty of diagnosis, as well as complex and rare diseases: malabsorption syndrome, suspected Crohn's disease, pancreatitis, ulcerative colitis, congenital anomalies of the gastrointestinal tract, Mallory-Weiss and Solinger-Elison syndromes, multiple ulcerations of the mucous membranes membranes of the stomach and intestines, tumors. The absolute indication for hospitalization is peptic ulcer with signs of bleeding. At the stationary stage, endoscopic examination, sonography, radiography (cholecystography, irigography, contrast examination of the stomach and duodenum), acidometry, determination of enzymatic function, electrophysiological study, morphological study of biopsy specimens, stress tests, study of individual biochemical parameters of blood and urine, genetic examination, study of the microbial landscape of the intestine, laparoscopy, etc.

Chronic recurrent abdominal pain may be associated with the so-called pseudo-abdominal syndrome. The most common diseases accompanied by abdominal pain have been described previously (see section “false abdominal syndrome” and table 1).

Medical tactics for these conditions consist of searching for the leading, key symptoms of extra-abdominal diseases and, accordingly, choosing the optimal instrumental and laboratory research methods.

It is also necessary to remember rare causes of abdominal pain.

Metabolic disorders: porphyria, uremia, addissonian crisis.

Hematological diseases: sickle cell anemia, leukemia.

Toxic reactions: heavy metal poisoning, drug disease, reaction to insect bites.

The cause of recurrent abdominal pain may be psychogenic disorders without a somatic-organic component. If a psychogenically caused abdominal syndrome is suspected (in any case, the organic nature of the disease must be excluded), consultation with a psychologist, neuropsychiatrist or psychotherapist is necessary.

The complexity of interpreting abdominal pain in children, the abundance of abdominal and extra-abdominal causes requires highly professional knowledge. An accurate diagnosis of abdominal pain is based primarily on a carefully collected history, physical examination data, supplemented by several simple laboratory and instrumental methods.

“The efforts and search of the doctor on the path to the correct diagnosis contribute to the clarity of his thoughts, the play of the mind and the athletic tension of thought (Hertle M., 1990).

References:

1. Andreev I., Vatsparov I., Mikhov H., Angelov A. - Differential diagnosis of the most important symptoms of childhood diseases. - Sofia, 1981

2. Gubergrits A.Ya. Pain in the abdominal cavity and their diagnostic significance. - Kyiv, 1968.

3. Darbinyan V.Zh., Yegishyan R.E. Abdominal pain. Neurological and gastroenterological differential diagnostic aspects. - M, 1987.

4. Kalyuzhny L.V. Systemic mechanisms of pain.//Fundamentals of the physiology of functional systems. - M, 1983. - pp. 226-242.

5. Limansky Yu.P. Physiology of pain. - Kyiv, 1986.

6. Skumin V.A. Psychogenically caused mental disorders in children with chronic diseases digestive system// Issues of protection of motherhood and childhood. - 1989. - No. 8. - pp. 17-21.

7. Tebenchuk G.M., Unich N.K., Bilskaya L.G. and others. Abdominal pain syndrome and its significance in pediatric practice//Pediatrics.-1988.-No. 7.-p.72-77.

8. Hertl M. Differential diagnosis in pediatrics. volume 1 (translated from German) - M., 1990. - p. 60-78.

9. Chronic diseases of the digestive system and nutritional disorders in children. Textbook, ed. Alexandrova N.I. - Leningrad, 1989. - p.5-57.

10. Functional diseases of the digestive system in children. Textbook, ed. Belousova Yu.V. - Kharkov, 1981.

11. Dotvav D.G. Analysis of symptoms of diseases of the upper digestive tract // Gastroenterology. volume 1 (translated from English). - M., 1988. - p.56-110.

12. Apley J. Family patterning and childhood disorders // Lancet. - 1967.

13. Lask B. Chidhood Illness: The Psychosomatic Approach - Chichester, 1989.

14. Lipowski Z. Review of consultation psychiatry and psychosomatic medicine// Psychosomatic medicine.- 1967.- No. 29.- p. 201- 224.

At least once in his life, a person has experienced discomfort from the abdominal tract and liver. Abdominal pain is pain in the abdominal area. This condition can be caused by various factors and reasons. Most often, ARVI with abdominal syndrome is diagnosed in children, although the pathology is also present in adults. Let's take a closer look at what abdominal pain is and what it can be like.

Reasons

Abdominal pain syndrome is not a separate disease, it is a whole complex of symptoms indicating various pathologies. It develops, as a rule, not as a result of surgical internal interventions, but due to diseases of internal organs and systems.

It is worth noting that pain in the abdominal area can be caused by many ailments, so they are classified according to the root causes of this condition.

Abdominal syndrome is a complex of symptoms that primarily manifests itself as abdominal pain

Namely:

• intra-abdominal;
• extra-abdominal.

In the first case, aching or acute abdominal pain is localized in the abdominal cavity, as is the cause that causes it.

These are all kinds of diseases and pathological conditions of internal organs located in the abdominal cavity:

• liver, gall bladder and ducts;
• spleen;
• stomach;
• pancreas;
• all parts of the intestine;
• reproductive organs (uterus, ovaries);
• kidneys, bladder and its ducts.

Pain syndrome is caused by inflammation, obstruction, and ischemic pathologies of organs. As a result, the normal functionality of entire systems is disrupted. Unpleasant sensations can have different locations in the abdominal cavity.

The main causes of the development of the syndrome are spasms of certain parts of the gastrointestinal tract

In the case of extra-abdominal pain, which is also localized in the abdominal cavity, the causes are outside this area.

Abdominal syndrome of this type is caused by diseases:

• upper respiratory tract and lungs;
• cardiovascular system;
• esophagus;
• spine.

This group also includes syphilis, herpes zoster, stress, and diabetes.

Symptoms of the syndrome

The main symptom of abdominal syndrome is pain. Based on its intensity and location, we can guess in which organ the failure occurred.

For example, based on the nature of the pain, they distinguish:

1. Renal and hepatic colic, myocardial infarction, rupture of a vascular aneurysm are characterized by an attack of very strong, intense pain.
2. If a person has an obstruction of the large intestine, its torsion, as well as in acute pancreatitis, pain will rapidly increase, and will remain at its peak for a long time.
3. In acute cholecystitis, appendicitis, unpleasant sensations are nagging, medium in intensity and very long.
4. If the pain resembles colic, but the attack is short-lived, the patient most likely has an obstruction of the small intestine or initial stage acute pancreatitis.

Abdominal pain syndrome is characterized by intermittent pain, the localization of which is difficult to determine

As you understand, abdominal syndrome is characterized by pain of varying intensity and duration. They can be either sharp and long-lasting, or aching, cramping, and barely noticeable. In any case, pain in the abdominal area requires seeing a doctor, since many organs and vital systems are located in this area.

In addition, the patient can observe:

• nausea and vomiting;
• dizziness;
• increased gas formation, flatulence;
• hyperthermia, chills;
• changes in the color of stool.

In what cases does a patient require urgent hospitalization?

You need to closely monitor your health and the well-being of your family members.

If abdominal syndrome is accompanied by these signs, you should immediately contact a medical institution for qualified help:

• rapid increase in body temperature;
• dizziness, fainting;
• painful acts of defecation;

Symptoms requiring emergency hospitalization - a complex of neurological disorders (severe weakness, dizziness, apathy)

• abundant spotting from the vagina;
• acute paroxysmal pain;
• disorders of the cardiovascular system, arrhythmias, chest pain;
• profuse vomiting;
• subcutaneous hematomas over large areas of the body;
• Gases accumulate in the intestines, the volume of the abdomen intensively increases;
• there are no signs of peristalsis in the intestines.

Diagnostics

It is important to identify abdominal syndrome in time and distinguish it from other diseases. There are a number of diseases that have similar symptoms to abdominal syndrome. An inexperienced specialist may confuse this pathology with appendicitis, renal or hepatic colic, acute cholecystitis or pancreatitis, pleurisy and pneumonia.

Various diagnostic methods are needed to accurately identify the cause of the syndrome. If an adult can still accurately answer where and how it hurts, then when the situation concerns children, the doctor’s task becomes more complicated.

For pain in the abdominal area, the doctor will prescribe:

• blood, urine and stool tests;
• liver tests (detailed biochemical blood test).

Ultrasound of the abdominal cavity: if pathology of the biliary tract is suspected, ectopic pregnancy, abdominal aortic aneurysm or ascites

These techniques are not specific, but they will help identify diseases of the genitourinary system, inflammatory processes in the body (leukocytosis will indicate appendicitis or diverticulitis), pathologies of the liver and pancreas.

The doctor will prescribe a pregnancy test for all women of reproductive age. If this is confirmed, it will be necessary to undergo an ultrasound to exclude the risk of ectopic attachment of the fetus.

Patients will be prescribed the following diagnostic methods:

• computed tomography;
• radiography;
• sigmoidoscopy;
• colonoscopy.

Diagnostic methods for each patient may vary slightly, depending on the location of pain and other pathologies. In any case, the patient’s task is to strictly listen to the doctor and follow his prescriptions and recommendations.

Treatment

The doctor will tell you in more detail what abdominal pain is and how to treat it. Therapy is aimed at eliminating the cause of this syndrome. If doctors cannot identify the original cause of the disease, symptomatic treatment is prescribed. To eliminate pain, it is not recommended to use analgesics, because they can blur the overall clinical picture.

Therefore, they are appointed:

1. M1-cholinergic receptor blockers. They are divided into selective (Gastrocepin) and non-selective (Belalgin, Bellastesin, Buscopan).
2. Antispasmodics – Drotaverine, Platiphylline, NoShpa, Mebeverine.
3. Sedatives for plant based and chemical.

It is worth remembering that abdominal syndrome is not an independent disease, it is a symptom. Only a doctor will be able to select treatment tactics and correctly diagnose this pathology.

The primary recommendation of specialists is to improve the functioning of the entire digestive and nervous system. Many doctors pay attention to traditional medicine. For example, decoctions of chamomile and mint can have a mild antispasmodic effect on the intestines. The main thing is to listen to your body and keep it in good shape. Adhere to the right lifestyle and the risk of abdominal syndrome will significantly decrease.

Resume

Based on an analysis of literature data and our own observations, the article presents the features of clinical manifestations of abdominal pain syndrome and outlines modern ideas about the mechanisms of development of abdominal pain in children. Information about modern antispasmodic drugs, indications for their use, and features of use in pediatrics are provided.

Keywords

abdominal pain syndrome, antispasmodics, children.

Abdominal pain syndrome (APS) is the leading clinical manifestation of many diseases and conditions of organic and functional nature in childhood. Abdominal pain is the most common complaint when seeking treatment. medical care. Features of ALS in children are the child’s difficulty in describing their sensations, their localization, and irradiation. Young children tend to identify any discomfort in the body (often incomprehensible sensations of nausea, dizziness, toothache or ear pain) with abdominal pain. At the same time, it is important to remember that a complaint of abdominal pain can manifest itself as diseases of the lungs, pleura, heart, kidneys, pelvic organs, etc. The validity of the figurative expression “the gastrointestinal tract is the lightning rod of the nervous system” has been repeatedly proven. A child’s complaint of abdominal pain always causes concern for parents and requires the exclusion of an emergency condition, including surgery, and the provision of adequate assistance. The above determines the relevance of the problem of ALS in pediatrics.

Pain is an important adaptive reaction of the body, serving as a danger signal in response to the action of a damaging factor. The appearance of pain is a multicomponent reaction of the body, closely related to the motor, sensory, autonomic, emotional, and analytical systems of the brain and spinal cord. The persistence and/or progression of ongoing processes disrupts the complex relationships of the physiological multicomponent pain response and forms a number of stable pathological conditions.

It is customary to distinguish three types of abdominal pain: visceral, parietal and referred. Visceral pain occurs as a result of spasm and/or stretching of the walls of hollow organs, capsules of parenchymal organs, tension of the mesentery, and circulatory disorders. The mucous membranes and smooth muscles of the internal organs are equipped with visceral polymodal receptors, which do not provide a clear localization of pain. Visceral pain is often cramping in nature, accompanied by pronounced autonomic reactions, nausea, vomiting, anxiety, but can be dull. An example of visceral pain is biliary colic. Parietal pain occurs when the parietal layers of the peritoneum containing large number somatic mechanoreceptors, which have a high pain sensitivity threshold. This provides distinct pain localization in the area of ​​origin and irradiation. An example of parietal pain is peritonitis. Referred pain is a projection pathological process, localized in organs outside the abdominal cavity, onto the anterior abdominal wall through the central pathways of afferent neurons. Its examples are myocarditis, pneumonia, meningitis, etc.

Based on duration, abdominal pain is divided into acute and chronic. Acute pain provides the body with the opportunity to select certain programs of pain reflexes, thanks to which the behavior that is most optimal in a particular situation is formed. Repeated many times, pain loses its protective function, becoming one of the clinical symptoms of the disease.

According to the mechanism of occurrence, abdominal pain is divided into spastic (spasm of smooth muscles of the digestive tract), distensional (stretching of the hollow organs of the abdominal cavity), peritoneal (damage to the peritoneum), vascular (ischemia of the abdominal organs).

Abdominal pain may be the result of organic or functional changes in the gastrointestinal tract (GIT). The most common causes of organic abdominal pain are inflammation of the peritoneum as a result of peritonitis; inflammation of individual organs (stomach, gallbladder, intestines, liver, kidneys, etc.); obstruction of a hollow organ (intestinal obstruction, cholelithiasis and urolithiasis etc.); ischemic changes (mesenteric ischemia, infarction of the intestine, liver, spleen, organ torsion, etc.). With functional changes, abdominal pain is caused by impaired motor function (spastic contractions of smooth muscles, atony and increased intracavitary pressure, stretching of the wall of a hollow organ, etc.), visceral hypersensitivity, flatulence.

Thus, abdominal pain arises from multiple etiological factors through various mechanisms. This emphasizes the importance of identifying the cause as quickly and accurately as possible in order to provide timely and adequate assistance to the child.

Considering that the universal mechanism of ALS is spasm of the smooth muscles of the walls of the gastrointestinal tract (esophagus, stomach, intestines, bile and pancreatic ducts), after excluding surgical pathology, the inclusion of antispasmodic drugs in the treatment of patients is justified. Since ancient times, the antispasmodic effect of the alkaloids of the soporific poppy (Papaver somniferum), belladonna (Atropa belladonna), henbane (Hyoscyamus niger), datura (Datura Stramonium), mint (Mentha piperita), valerian (Valeriana officinalis) and others has been known, used in in the form of various infusions, tinctures, decoctions.

Modern antispasmodic drugs are presented in table. 1.

According to their mechanism of action, they are divided into myotropic antispasmodics, which affect the biochemical processes that regulate the contraction of smooth muscle cells, and neurotropic antispasmodics, which interrupt the transmission of nerve impulses to smooth muscle cells at the level of the autonomic ganglia or the nerve endings of the parasympathetic nerves. There are drugs that have properties of both groups. Thus, the neurotropic antispasmodic platifillin has myotropic properties, and the myotropic antispasmodic dicetel has weak M-anticholinergic activity.

The mechanism of action of myotropic antispasmodics is the accumulation of cyclic adenosine monophosphate (cAMP) in cells and a decrease in the concentration of calcium ions, which prevents the interaction of actin and myosin or may be the result of suppression of phosphodiesterase activity, activation of adenylate cyclase, blockade of adenosine receptors, or a combination of these factors. This was the basis for the isolation of drugs that affect ion channels - calcium channel blockers (Dicetel), sodium channel blockers (mebeverine), phosphodiesterase inhibitors (papaverine, no-shpa), nitric oxide donors (nitrates, sodium nitroprusside), peripheral antagonists serotonin receptors (ondansetron, alosetron).

Among the myotropic antispasmodics, the drug no-spa (drotaverine hydrochloride), which blocks the enzyme type IV phosphodiesterase, which destroys cAMP, can be used in pediatrics. This provides a direct non-selective antispasmodic effect in the gastrointestinal tract, organs of the genitourinary system, bronchi, and peripheral vessels. The drug also has the effects of calcium antagonists, blocks calcium channels in smooth muscle cells and reduces the motor activity of smooth muscles. Along with the above, no-spa has antagonistic properties towards calmodulin. When administered intravenously, the effect of the drug appears after 2-4 minutes, the maximum effect develops after 30 minutes. When taken orally, the drug is rapidly absorbed. The antispasmodic effect of the drug is many times more pronounced and lasting than that of other non-selective antispasmodics (papaverine). The selectivity of no-shpa is 5 times higher than that of papaverine, due to which the frequency side effects significantly lower. The drug noshpa is used to relieve spastic conditions of smooth muscles during peptic ulcer stomach and duodenum, spasms of the cardiac and pyloric parts of the stomach, chronic colitis, irritable bowel syndrome. The drug is prescribed to children over 14 years old at 0.04-0.08 g (1-2 tablets) 2-3 times a day, if necessary, the same dose is administered intramuscularly, for children under 6 years old - 10-20 mg 1-2 times per day, from 6 to 12 years - 20 mg 1-2 times a day. The drug is well tolerated, but when administered parenterally, feelings of heat, dizziness, palpitations, and sweating are possible. One of the possible reactions is a short-term decrease in blood pressure, which is especially important to remember in children in the first year of life who have initially low levels, and in children with arterial hypotension.

Of the selective calcium channel blockers, pinaveria bromide is used in children aged 14-18 years to treat biliary and intestinal spastic pain. The effect of pinaverium bromide is dose-dependent, the maximum daily dose is 300 mg. However, it must be taken into account that with prolonged use of the drug, the development of constipation syndrome is possible.

The Na+ channel blocker mebeverine can cause relaxation of gastrointestinal smooth muscle cells. The mechanism of action of this drug is that preventing sodium from entering the smooth muscle cell blocks the entry of calcium, causing muscle relaxation. Mebeverine has been proven effective for irritable bowel syndrome. It is the only long-acting antispasmodic due to the fact that the granules have a semi-permeable membrane, which ensures gradual release of the drug over 16 hours throughout the intestine. Mebeverine has a modulating effect on the sphincters of the gastrointestinal tract, resulting not only in relieving spasms, but also in preventing excessive hypotension, which makes it possible to prescribe it to patients with constipation. The drug is prescribed to children over 12 years of age, 200 mg 2 times a day 20 minutes before meals.

Myotropic antispasmodics from the group of nitric oxide donors (nitrates) and peripheral serotonin receptor antagonists (ondansetron, alosetron) have not found use in pediatric practice due to undesirable side effects.

Neurotropic antispasmodics are usually divided into groups of natural alkaloids (atropine, platiphylline, scopolamine); semisynthetic derivatives of alkaloids (hyoscine butyl bromide - buscopan); synthetic compounds (prifinium bromide - Riabal, etc.). The mechanism of action of M-cholinergic blockers is due to a violation of the binding of acetylcholine (a neurotransmitter of the parasympathetic nervous system) with M-cholinergic receptors located in the autonomic ganglia and on smooth muscle cells. This leads to a decrease in the tone of the smooth muscles of the bronchi, gastrointestinal tract, bladder, and uterus. It is important to remember that non-selective M-anticholinergic blockers (atropine, platyphylline, scopolamine) block receptors located on cardiomyocytes, glandular cells, neurons, which reduces the secretion of salivary, sweat, bronchial, gastric glands, causes tachycardia, mydriasis, paralysis of accommodation and increased intraocular pressure, causing various side effects. Contraindications to the use of M-anticholinergic drugs in children are diseases of the cardiovascular system, accompanied by tachycardia, intestinal obstruction, organic stenosis of the gastrointestinal tract, glaucoma, and urinary retention.

Targeted M-cholinergic blockers include hyoscine butyl bromide, or buscopan, which selectively suppresses the release of acetylcholine in the area of ​​the peripheral endings of type I-III muscarinic receptors, which are localized primarily in the intestinal wall, gall bladder and biliary ducts. Buscopan also has a ganglion-blocking effect, suppressing the release of acetylcholine in the spinal ganglia, which provides a pronounced antispasmodic effect. The drug is distinguished by its low bioavailability: only 0.5% enters the systemic circulation (when taking no-shpa - 25-91%). Buscopan does not penetrate the blood-brain barrier, so it has no anticholinergic effect on the central nervous system. The therapeutic effect of the drug is ensured in small doses. The drug is characterized by a rapid onset of antispasmodic effect (20-30 minutes after oral administration) and its persistence for 2-6 hours. The drug is excreted unchanged by the kidneys, the half-life is 4.2 hours. Buscopan is prescribed to children over 6 years old, 1-2 tablets. (10 mg) 3 times a day or 1 rectal suppository (10 mg) 3 times a day. Buscopan can be used both for the symptomatic treatment of cramping abdominal pain and for long-term treatment of irritable bowel syndrome and biliary dysfunction.

The selective M-anticholinergic blocker prifinium bromide, Riabal, deserves attention; its range of action includes all parts of the digestive tract, biliary and urinary tracts, and pelvic organs. When administered enterally, Riabal has good bioavailability, is quickly excreted in the urine and partially in bile, and has an antisecretory effect. By relieving spasms, Riabal eliminates pain, regurgitation, flatulence, vomiting, and stool disorders. It is important to note that Riabal is recommended for use in pregnant women at any stage, in lactating women, and in children starting from the first days of life. The daily dose of the drug is 1 mg/kg body weight. Children weighing 4-7 kg are prescribed 1 measuring pipette (0.4 ml of syrup), 7-10 kg - 1.5 pipettes, 10-20 kg - 2 pipettes, 30-40 kg - 6 pipettes. The drug is diluted in a small amount of water and taken three times a day. The course of treatment for functional digestive disorders ranges from several days to 2 weeks.

The high effectiveness of the drug Riabal in the treatment of gastroduodenitis and biliary dyskinesia in children is noted by Yu.V. Belousov et al. , M.F. Denisova et al. . Our experience with the use of the drug Riabal testified to the rapid relief of the main clinical symptoms of intestinal colic in young children (from 1 month to 3 years): a decrease in the severity of abdominal pain, anxiety, irritability, and normalization of sleep by the end of the first day were documented in 27.3% patients. According to the results provided by the parents, the responses of the medical staff, the dynamics of the indicators of the level of adaptation, after 7 days of treatment in all patients it was stated that there was no pain syndrome; 14 days after discontinuation, the therapeutic effect remained in all those examined. In all cases, the drug was well tolerated, and no side effects were noted.

Conclusions

Abdominal pain syndrome is the leading clinical symptom of many organic and functional disorders of the digestive system in children. Its presence requires clarification of the cause in order to choose the optimal treatment tactics. In ALS caused by motor impairment, selective antispasmodics are most effective. Knowledge of the pharmacological characteristics of a particular drug and its release forms, taking into account the age of the patient with ALS, and an adequate duration of treatment are the key to successful treatment of the child and prevention of recurrence and progression of this pathological process.

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Introduction

Abdominal pain is one of the most common reasons hospitalization of children in an emergency hospital. The preliminary diagnosis upon admission of such children to the clinic most often sounds like “suspicion of acute appendicitis,” since this is the most common surgical pathology that needs to be confirmed or excluded within several hours of dynamic observation. Given the complexity of the clinical diagnosis of acute appendicitis in children, numerous laboratory, instrumental and special research methods have been proposed, which, however, only cope with their task to a certain extent. Laparoscopy (an invasive examination requiring anesthesia) is recognized as the most accurate method. The possibilities of ultrasound diagnosis of acute appendicitis in children are limited by the need to organize a round-the-clock ultrasound service, a certain preparation of patients for the study and, finally, the actual physical principles of ultrasound scanning. Domestic and foreign studies in recent years, as well as significant personal experience working with a similar patient population, show that sensitivity ultrasound examination in the diagnosis of acute appendicitis is about 80% (the operator is a dependent variable), while the specificity reaches 98%.

Ultrasound examination (US) plays a huge role when it is necessary to differentiate abdominal pain syndrome in children after clinical exclusion of acute appendicitis. Previously (before the widespread introduction of ultrasound), such children were discharged home with a diagnosis of “intestinal colic” or “acute mesadenitis”. In some cases, children were sent to specialized departments: if changes were detected in urine tests, to the nephrology department with a diagnosis of infection urinary tract", if pathological changes are detected in girls - to the gynecological department. A separate group consisted of children with infectious diseases (ARVI, intestinal infection, etc.).

The purpose of this study is to demonstrate the capabilities of ultrasound diagnostics in the differential diagnosis of abdominal pain syndrome in children in a large multidisciplinary emergency children's clinic.

Research results

During the period from January to June 2002, 3,716 children hospitalized with a diagnosis of suspected acute appendicitis were examined in the ultrasound department of the clinic. In 85% of cases (3159 cases), ultrasound was performed after the clinical diagnosis was rejected. Children who did not undergo ultrasound before surgery were excluded from the analysis. The frequency of detected changes is presented in Table 1.

Table 1. Diseases detected by ultrasound.

Deformities in children were a common echographic finding and were not always accompanied by subjective complaints. To reliably assess the shape of the bladder, the study was carried out strictly on an empty stomach. When a deformity was detected, polypositional scanning and studies in ortho- and clinostasis were performed, which made it possible to differentiate the labile nature of the bend, which had practically no clinical significance. At the conclusion of the ultrasound examination, only persistent deformations of the gallbladder were recorded (Fig. 1 a). Changes in its walls were also noted in the form of mild thickening and increased echogenicity.

Echo signs of fine suspension in the lumen of the gallbladder were rare in children of the study group. To avoid diagnostic errors associated with the occurrence of various kinds of artifacts during the study of the gallbladder, polypositional scanning was used, sometimes with light compression on the area of ​​interest to displace adjacent intestinal loops with gas, which in most cases were the cause of false-positive results.

The echographic picture of acute cholecystitis in children of the study group was rare and did not differ fundamentally from that in adult patients. Against the background of pronounced thickening of the walls of the bladder (up to 3-4 mm, rarely - 5-7 mm), a dispersed suspension in its lumen and a zone of perifocal decrease in echogenicity, corresponding to edematous changes in the peri-vesical tissues, were determined. Also rare echographic findings were stones (single or multiple) and polyps of the gallbladder (Fig. 1 b, 6, d).

Rice. 1. Gallbladder diseases.

A) S-shaped deformation of the cervical part of the bladder.

b) Child, 5 years old, acute cholecystitis. A significant, uneven thickening of the gallbladder wall, a dispersed component in the lumen, and a perifocal zone of decreased echogenicity, corresponding to an edematous change in the peri-vesical tissues, are detected.

V) Child, 13 years old. Gallbladder calculus (echo-dense inclusion in the lumen with a clear acoustic shadow.

G) Child, 11 years old, gallbladder polyp (medium echogenic formation, fixed to the bladder wall, non-displaceable, without acoustic shadow; duplex Doppler scanning reveals echo signs of blood flow in the polyp.

Changes in the pancreatic parenchyma in children were quite common, and the use of the term “reactive pancreatitis,” often used by outpatient pediatricians, does not seem entirely correct. The absence of clinical and laboratory manifestations of pancreatitis (and, naturally, the absence of morphological verification of the pathological process) forced the use of the concept of “diffuse changes of a reactive nature” in the ultrasound protocol. Similar echographic changes (an uneven increase in echogenicity in the form of small-point echogenic foci) were observed in children against the background of intestinal infection, ARVI, exudative diathesis, bronchial asthma, etc. Perhaps the morphological substrate of these changes are changes in the walls of small vessels. Today we have to admit that this issue requires additional study. Acute pancreatitis itself in children is extremely rare, characterized by a diffuse or focal decrease in the echogenicity of pancreatic tissue, and the problem of ultrasound diagnosis of this condition requires special discussion.

Acute appendicitis had a fairly clear echographic picture, however, the atypical location of the appendix (in particular, retrocecal) significantly limited the possibilities of echographic diagnosis, and the condition of filling the bladder was strictly necessary. In addition, it was necessary to take into account that:

1. Only a fragment of the appendix is ​​visualized in the scan, and it is not always possible to judge the condition of all parts of the appendix,
2. flatulence significantly interferes with the study,
3. To conduct an echographic assessment of the abdominal cavity, it is necessary that the patient’s bladder is full, which is not always feasible (especially in young children),
4. a destructively altered fragment of the appendix, when the differentiation of its layers is lost, can be difficult to differentiate echographically from a transformed lymph node (especially in obese children).

The appendix with inflammatory changes was visualized as an oval-shaped structure with clearly differentiated layers (Fig. 2). Its diameter is from 8 mm and above. In some cases, low resistive arterial blood flow was recorded in the wall of the appendix (in the unchanged appendix, the resistive index of arterial blood flow is usually above 0.7). In isolated cases, coprolites were visualized in the lumen of the process. Often in children, a small amount of an unfixed fluid component was determined in the projection of the small pelvis (retrovesical - in boys, retrouterine - in girls).

Rice. 2. Acute appendicitis.

a, b) an unchanged fragment of the appendix in B-mode and in color Doppler mode. The cross section of the appendix (its fragment is indicated by a white triangular arrow) is a rounded structure 5 mm in diameter with an echogenic central part (mucosa), a hypoechoic muscular layer and an echogenic peripheral part (serous membrane).

Digital designations: 1 - subcutaneous fat, 2 - rectus abdominis muscle, 3 - iliac artery, 4 - iliac vein, 5 - iliopsoas muscle, 6 - fragments of intestinal loops, 7 - vertebral body.

c, d) A fragment of the appendix with inflammatory changes (white triangular arrow), diameter - 9 mm, the contour is preserved, Doppler examination reveals an increased vascular pattern in the wall of the appendix, surrounded by hyperechoic tissue (omental fragment).

d, f) Vermiform appendix with inflammatory destruction (intraoperative - gangrenous appendicitis). The contours of the process fragment are uneven, unclear, unevenly hyperemic, surrounded by heterogeneous tissue (a fragment of the omentum, resected during surgery).

g, h) Coprolite in the lumen of the appendix.

Progressive inflammatory changes, accompanied by destruction of the walls of the appendix, led to changes in the ultrasound picture - the contours of the appendage became unclear, sometimes lost, and echogenic areas - fragments of the omentum - were sometimes identified around the appendix. Appendiceal abscesses were identified as delimited, inhomogeneous structures; sometimes it was possible to differentiate fragments of the base of the appendix (Fig. 3).

Rice. 3. Complicated forms of acute appendicitis.

a, b) Gangrenous-perforated appendicitis. The contours of the process are unclear, poorly traced, the walls do not enhance the vascular pattern, the latter is enhanced in the surrounding tissues;

c, d, e) Appendiceal infiltrate due to the pelvic location of the appendix in a 3-year-old child. The duration of the disease is at least 5 days. The walls of the process are hyperemic, its contours can be traced reliably.

e, g) Appendiceal abscess, disease duration - at least 2 weeks. Retrovesical, slightly to the right of the midline, a heterogeneous fixed formation up to 6 cm in diameter is determined, the walls of the bladder are significantly thickened, and there is a dispersed suspension in the lumen. The vermiform appendix itself is not identified.

h) Appendiceal abscess in a 14-year-old child, the duration of the disease is about 7 days. To the right of the bladder (the walls of the latter are significantly changed: edematous, thickened) a fixed formation with unclear contours and hypo-, anechoic contents is determined.

And) Appendicular abscess in the right half of the abdomen (white triangular arrow). The open arrow shows the lower pole of the right kidney.

Mesadenitis (inflammatory transformation of mesenteric lymph nodes) was often found in children admitted to the clinic with suspected acute appendicitis. After excluding acute surgical pathology, the diagnosis in such children is often formulated as “ARVI with abdominal syndrome.”

Ultrasound of the abdominal organs in the right iliac region and/or slightly higher (paracaval) revealed lymph nodes with inflammatory changes, which looked like single or multiple (often a conglomerate) irregularly rounded formation with smooth, clear contours, reduced echogenicity (Fig. 4 a-d). The maximum size of lymph nodes in children with banal mesadenitis reached 25-28 mm. Usually in the conglomerate there were 2-3 large lymph nodes, to which numerous smaller ones were adjacent.

Acute inflammation of the lymph node was manifested by a change in its shape (it became more rounded) and a diffuse decrease in echogenicity; Doppler examination revealed hyperemia of the lymph nodes in the form of an increase in the vascular pattern with a decrease in the resistive index of arterial blood flow to 0.6 and below. As the severity of the inflammatory process subsided, the echogenicity of the lymph nodes increased, the shape became flattened, the lymph nodes gradually (weeks, sometimes months) decreased in size and disappeared. Echographic changes, regarded as manifestations of acute inflammatory transformation of lymph nodes (round in shape, hypoechoic, more often more than 10-14 mm in diameter depending on the age of the child), were clinically manifested by abdominal pain syndrome, as the inflammatory changes subsided (flat lymph nodes of medium echogenicity) subjective The children made no complaints. In one case, abdominal pain syndrome in a child was caused by a foreign body in the duodenum with the development of erosive gastroduodenitis and mesadenitis. Detection of linear foreign bodies by ultrasound is very difficult and is only possible with careful polypositional scanning (Fig. 4e-h).

Rice. 4. Changes in lymph nodes and foreign body of the duodenum.

a, b) B-mode study and Doppler scanning in energy mode for mesadenitis. Child, 6 years old. A conglomerate of hyperemic lymph nodes of reduced echogenicity is determined.

c, d) Enlarged pelvic lymph nodes with lymphosarcoma in a 5-year-old child; a white triangular arrow shows an unchanged fragment of the appendix.

d, f) B-mode study and duplex Doppler scanning, respectively, in the periumbilical region on the right, longitudinal approach. In the intestinal lumen there is a tubular structure up to 5 cm long and about 3.5 mm thick. Blood flow in the intestinal wall is increased.

and) B-mode examination in the periumbilical region on the right, transverse approach. In the intestinal lumen there is a ring-shaped inclusion up to 3.5 mm in diameter (white arrow), difficult to differentiate from fragments of altered intestinal mucosa.

In our observation, a fragment of a tubular foreign body (a lollipop stick) 5 cm long, 3.5 mm in diameter was visualized echographically in the lumen of the intestinal loop in the right half of the abdomen, and echo signs of severe mesadenitis. A plain X-ray of the abdominal cavity revealed no pathological inclusions; during repeated examinations (3 times over 1 day), the position of the foreign body did not change; the latter was removed endoscopically.

Intussusception occurred predominantly in young children (from 5 to 30 months of life), although, as anecdotal evidence, it was also observed in infants 2 months old and in adolescents. Our own experience shows that this pathology must be remembered in all cases of ultrasound examination of toddlers with abdominal pain and a targeted search for this pathology. In the vast majority of cases, intussusception was determined in the right half of the abdomen, subhepatically or at the level of the navel. With transverse scanning, the intussusception has a round shape (up to 25-35 mm in diameter), a layered structure caused by differentiated layers of the intestinal wall (the so-called “target” symptom). With longitudinal scanning, an oval-shaped layered structure measuring about 30 x 50 mm was visualized (the so-called "layer pie" symptom). The causes of intussusception are different, and the genesis of the pathology has not yet been definitively determined. In some cases, intussusception was provoked by the inflammatory transformation of mesenteric lymph nodes, which were involved in the structure of the intussusception and could be differentiated echographically as round-shaped hypoechoic structures in it. the central part (Fig. 5). Doppler examination made it possible to determine whether the vascular pattern was preserved in the fragments of the intestine involved in the intussusception, which was a prognostically favorable sign (such intussusceptions were usually easily resolved with pneumoirrigography). in the involved intestinal fragments. Sonographic evaluation of other parts of the intestine suggested the presence of intestinal obstruction.

Rice. 5. Intussusception.

A) Child 2 years old, pneumoirrigography. The head of the intussusception is shown by a white arrow.

b, c) The same child, B-mode study. Polypositional scanning in the right hypochondrium. A layered aperistaltic structure of irregular cylindrical shape is determined. Transverse scanning (b) reveals an echographic symptom of a “target”, longitudinal scanning (c) reveals a symptom of a “layer cake”.

G Another child. An echographic symptom of a “target”, in the center of which an oval-shaped formation of medium echogenicity is visualized (white arrow) - a lymph node with inflammatory transformation.

d Another child, duplex Doppler scan in color mode. Multiple vessels are identified in intestinal fragments forming intussusception.

e Doppler scanning in energy mode (another child). A fragment of a large vessel is identified; blood flow within the intussusception is not visualized.

and Intestinal obstruction in an 18-month-old child due to small-colic intussusception (sick for 22 hours). The head of the intussusception is shown by a white triangular arrow; the afferent loop of intestine (paired white arrow) is dilated to 27 mm.

Gynecological diseases in children were quite common, in most cases in adolescence. Volumetric processes of a cystic or solid nature in the projection of the ovaries required consultation with a pediatric gynecologist and treatment in a specialized hospital (Fig. 6). A rare pathology requiring emergency intervention (mainly laparoscopic) was adnexal torsion, which occurs even in young girls (6 observations). Echographically, in the projection of the appendage, an irregularly rounded, poorly displaced structure (about 4-6 cm in diameter depending on the age of the child) of uniformly increased echogenicity with small anechoic inclusions of a rounded shape (follicles against the background of infiltrated, edematous parenchyma with areas of hemorrhage) was determined. The vascular pattern was traced only along the periphery of the ovary; no vessels were identified in its parenchyma. Emergency intervention made it possible to preserve the organ, and echographic observation in the postoperative period allowed to monitor the results of treatment. Relatively rare pathologies of adolescence were hematometra and hematocolpos. The echographic diagnosis of this pathology is quite simple; the ultrasound picture was very characteristic.

Rice. 6. Gynecological diseases.

A) Child, 12 years old, scanning in the suprapubic region, oblique transverse approach. In the projection of the left appendages, a round-shaped inclusion up to 48 mm in diameter is determined, thin-walled, with liquid contents, without signs of blood flow inside.

b) Child, 13 years old. In the projection of the right appendages, a rounded inclusion is determined, up to 56 mm in diameter, of average echogenicity, without signs of blood flow inside.

c, d) Hematometra, child, 13 years old. B-mode study, cross-sectional and respectively. In the projection of the small pelvis behind the bladder (the latter is sharply deformed), a very large (at least 24 x 14 x 12 cm) irregularly shaped thin-walled formation filled with a dispersed suspension (the contents move when the position of the child’s body) changes.

d, f) Child 2 years old. B-mode examination in the suprapubic region, oblique transverse approach. In the projection of the left appendages, an irregularly rounded inclusion is determined, measuring up to 56 x 42 mm, of medium echogenicity, with single small irregularly shaped liquid inclusions inside (ovarian torsion). The vascular pattern in the projection of the transformed ovary is not visible.

g, h) Hematocolpos, child, 14 years old. In the projection of the small pelvis behind the bladder, a large (12 x 10 x 9 cm) irregularly shaped thin-walled formation is determined, filled with a dispersed suspension (the contents move when the position of the child’s body changes), above which the body of the uterus is differentiated.

Frequent ultrasound findings were pathological conditions of the urinary system. Cystitis as a cause of abdominal syndrome was identified with approximately the same frequency in both girls and boys (Fig. 7). In some cases, dilatation of the distal ureters with symptoms of ureteritis was determined. Acute pyelonephritis was detected more often in girls. Thickening and double contour of the pelvis (edema) was determined against the background of impaired cortico-medullary differentiation due to edematous-infiltrative changes in the renal parenchyma. The intrarenal vascular pattern was preserved, and no ischemic zones were detected in the renal parenchyma. In more severe cases, a focal increase in echogenicity was determined with the loss of the characteristic echographic pattern of the parenchyma, local depletion of parenchymal blood flow during Doppler examination. Detection of such changes required immediate consultation with a urologist and correction of the treatment. The urological diseases identified were numerous, and within the framework of this study there is no point in trying to present in detail the entire variety of pathologies. We will limit ourselves to listing the identified diseases: hydronephrosis - 11, pyeloectasia - 22, ureterohydronephrosis - 2, suspected - 5, renal duplication - 18, renal aplasia - 4, horseshoe deformation of the kidneys - 2, cystic dysplasia of the kidneys - 7, dystopia of the kidney - 3 Approximately 2/3 of the patients were discharged home with a recommendation for observation by a specialist at the place of residence (doubling of the kidneys, anomalies in the position, number and relative position of the kidneys, pyelectasis, single small cysts, etc.). The remaining children needed transfer to a specialized department, examination and determination of further management tactics.

Rice. 7. Inflammatory diseases of the kidneys and bladder.

a, b) Pronounced diffuse changes in the renal parenchyma are detected (corticomedullary differentiation is not visible) against the background of slight pyelectasia, pronounced echo signs of edema of the pelvic mucosa (white arrow). The intrarenal vascular pattern is preserved.

c, d) Infiltrative form of acute pyelonephritis in a 2-year-old child. In the projection of the lower fragment of the kidney, a vaguely demarcated zone of heterogeneous increase in echogenicity up to 5 cm in diameter is determined, the contour of the kidney is uneven, corticomedullary differentiation is not reliably traced, in the zone of increased echogenicity the intrarenal vascular pattern is significantly depleted.

d) Indirect echo signs of cystitis: the wall of the bladder is unevenly thickened, there is a fine suspension in the lumen.

e) Indirect echo signs of cystoureteritis: the wall of the bladder is unevenly thickened, there is a fine suspension in its lumen, swelling of the mucous membrane of the distal ureters is determined (white triangular arrows).

g, h) Acute obstruction of the urinary tract. Dilatation of the collecting system of the kidney and a calculus at the mouth of the ureter are determined (white triangular arrow).

Tumors were rare among the analyzed group of children, but, nevertheless, it was necessary to remember this pathology. In our observations, in 1 case there was a malignant tumor emanating from the crest of the right iliac bone, in 3 cases - malignant tumors of the kidneys, in 1 case - lymphosarcoma of the abdominal cavity, in 3 cases - lymphangiomas emanating from the root of the mesentery (Fig. 8). Carrying out a comprehensive ultrasound examination using Doppler technologies made it possible to accurately determine the location of the tumor and the features of intratumoral hemodynamics.

Rice. 8. Tumors.

A) Child, 5 years old. Excretory urography. The 6-minute image shows no function of the right kidney.

c, d) The same child, B-mode study and power Doppler scan, respectively. A large tumor (up to 8 cm in diameter) is detected in the lower fragment of the right kidney; the intrarenal vascular pattern in the upper fragment of the kidney can be traced, but in the projection of the tumor it is not reliably determined.

d) Child, 6 years old. Duplex Doppler scanning in color Doppler mode. A very large (up to 13 cm in diameter) mass formation is detected emanating from the lower fragment of the right kidney. A single large vessel can be seen in the tumor projection.

e) Dopplerography of an intratumoral vessel. An arterial type of blood flow with very low peripheral resistance (RI = 0.31) can be observed.

and) Lymphangioma of the abdominal cavity in a 2-year-old child (multi-chamber formation with total dimensions of about 9x5 cm).

h) Lymphosarcoma in a 13-year-old child (unclearly demarcated formation up to 13 cm in diameter with heterogeneous contents).

A rare echographic finding in a child with abdominal syndrome was cavernous transformation. The typical echographic picture allowed us to accurately differentiate the disease.

Discussion

Acute appendicitis is the most common surgical disease in children, with an overall incidence rate of 3.2 per 1000 children per year. Accordingly, if a child has complaints of abdominal pain, this particular disease must be confirmed or refuted as soon as possible. A thorough clinical examination does not always allow an accurate diagnosis, which determines the constant interest in assessing the diagnostic effectiveness of various auxiliary research methods. Laboratory methods (changes in blood tests) are nonspecific and cannot significantly help in diagnosis. A fundamental contribution to the diagnosis of acute appendicitis in children was made by laparoscopy, which allows not only to assess the condition of the appendix itself, but also to differentiate diseases of other abdominal and pelvic organs. Only in 1.2% of cases laparoscopy does not provide an accurate assessment of the condition of the appendix. The main disadvantage of the method is its invasiveness.

In the 80s, much attention began to be paid to non-invasive diagnostic methods, the main of which was electromyography of the anterior abdominal wall, which makes it possible to quantify muscle tension. However, this method is not absolutely accurate; even with maximum experience and skills in working with patients of this group, diagnostic errors are noted in at least 6% of cases. Overdiagnosis (4% of errors) occurs in children with inflammatory processes in the abdominal cavity of non-appendicular origin (primarily mesadenitis). Underdiagnosis is due to the atypical location of the process. Similar problems arose when using thermal imaging, that is, recording infrared radiation from the anterior abdominal wall. As with electromyography, non-appendicular inflammatory process difficult or impossible to differentiate from acute appendicitis.

Ultrasound has introduced fundamentally new possibilities into the diagnosis and differential diagnosis of abdominal pain syndrome. The advent of high-frequency sensors has made possible the echographic assessment of small objects, including the appendix. Research in this area began in the late 70s, but became widespread in the mid-80s. Studies carried out on a huge clinical material confirmed the possibility of echographic diagnosis of acute appendicitis, but also revealed the limitations of the method associated with the peculiarities of the location of the appendix and the physical principles of ultrasound scanning. According to the most thorough studies, the accuracy of ultrasound diagnosis of acute appendicitis under the most favorable conditions (high-resolution technology, significant personal experience doctor) in adult patients does not exceed 70-85%, and during routine examination it decreases to 50-60%. Several studies of the concurrent use of ultrasound and computed tomography (CT) among pediatric patients with suspected acute appendicitis have found some benefit to CT. Thus, for ultrasound, sensitivity was 74-92%, specificity - 94-98%, and for CT - sensitivity - 84% and specificity - 99%. In the group of adult patients, the advantage of CT was more obvious: the accuracy of ultrasound was 68%, the accuracy of CT was 94%. The introduction of Doppler technologies with the ability to assess blood flow in a visualized fragment of the appendix increases the diagnostic accuracy (sensitivity - 90%, specificity - 94%). In any case, ultrasound is of great help to clinicians: for example, the initial examination by a surgeon in diagnosing acute appendicitis had a sensitivity of 50% and a specificity of 88%, and ultrasound - 85% and 96%, respectively.

Over 2.5 years of operation of the ultrasound department, out of 3716 children with suspected acute appendicitis, the clinical diagnosis was rejected in 3159 children, and only in 557 children the clinical picture of acute appendicitis was pronounced or doubtful. In 287 cases, echographic changes were regarded as manifestations of acute appendicitis. In total, 337 children were operated on in the study group of patients; intraoperative diagnosis of acute appendicitis (various clinical forms and stages) was established in 298 cases. The distribution of ultrasound findings of “acute appendicitis” was as follows:

• true positive results - 275 cases,
• false positive - 12 cases,
• true negative - 247 cases,
• false negative - 23 cases.

Accordingly, the diagnostic performance indicators of ultrasound in our clinic over the past 2.5 years have been as follows:

• sensitivity - 92.3%,
• specificity - 95.4%,
• predictive value of a positive result - 95.8%,
• negative predictive value - 91.5%,
• accuracy - 93.7%.

False-positive results were considered not only those when an unchanged appendix was detected intraoperatively (4 observations), but also cases when echographic signs of inflammatory transformation of the appendix were not accompanied by clinical manifestations, and the children were not operated on. During dynamic ultrasound control, in 2 cases the echographic picture did not change; in 6 cases, the appendix was not detected after 2-5 days.

The high diagnostic efficiency of ultrasound diagnostics of acute appendicitis in our own study can be explained by several factors:

1. adequate preparation of patients. At the same time, it is necessary to emphasize the importance of adequate interaction between the diagnostic service (ultrasound department) and surgical departments that provide patient training,
2. significant experience in working with this population of patients, ultrasound doctors’ knowledge of scanning techniques and clinical features of acute appendicitis in children,
3. using high-resolution ultrasonic technology, multi-frequency sensors, including linear 5-8 MHz.

We cannot ignore the enormous importance of ultrasound examination for identifying “non-appendicular” pathology. Moreover, in contrast to laparoscopy (the most accurate method for diagnosing acute appendicitis today), echographic assessment is available not only to the abdominal and pelvic organs, but also to the pleural cavities and organs of the retroperitoneal space. In domestic and foreign literature There are a lot of publications devoted to the ultrasound diagnosis of a wide variety of diseases when examining patients admitted to the hospital with suspected acute appendicitis. These are mainly diseases of the hepatobiliary system and gastroenterological diseases. In our own studies, in children admitted to the hospital with suspected acute appendicitis, the following were found echographically: inflammatory diseases and developmental anomalies of the kidneys and urinary tract, diseases of the hepatopancreatobiliary system, gynecological diseases, tumors of the abdominal cavity and kidneys, etc. The results presented in this publication cover only 2.5 last year and only in one Moscow clinic, but the variety and number of diseases gives a clear idea of ​​the value of ultrasound in children with abdominal pain syndrome.

Thus, an ultrasound examination of children admitted to the hospital with suspected acute appendicitis allows not only to confirm the presence of the suspected diagnosis, but also to establish the cause of the pain syndrome after clinical exclusion of acute surgical pathology. The experience of the ultrasound diagnostic department of a multidisciplinary emergency children's hospital suggests that ultrasound of the abdominal cavity, retroperitoneal space and pelvis is indicated for all patients admitted to the hospital with suspected acute appendicitis, even in the absence of clinical manifestations of acute abdominal pathology. Accordingly, based on the echographic findings, the issue of further examination of the child or transfer to a specialized department is decided, which contributes to a more complete and early detection and correction of various diseases in children.

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Pain in the abdominal region in children ranks first among the most common pains and leads to numerous surgical interventions. Also, recurrent pain of this type is the cause of most attacks of crying and anxiety in children. Children under six months of age mostly experience pain from colic. IN school age Abdominal pain can either disappear without a trace or become the cause of the development of gastroenterological pathologies.

Every doctor faced with this problem must first determine whether abdominal pain and bloating surgical nature of an emergency order or not. Its next step is to identify the etiology of the disease, that is, whether the cause of the pain is organic or is it associated with functional disorders.

Pain is an uncomfortable sensation that accompanies the process of damage to tissue integrity and other non-physiological pathology.

Almost all people can experience pain. Even the fetus’s body, while in the womb, already transmits pain impulses by 24 weeks. Children, just like adults, by the time of birth have a complete pain alert system. They are equally capable of experiencing stress and recording painful moments in their memory as an adult.

Mechanism of abdominal pain

Pain in the abdominal area occurs due to excitation of damaged tissues.

Receptor groups:

1. Nociceptors, or pain somatic mechanoreceptors. They have a high sensitivity threshold. When they are stimulated, a feeling of pain occurs.
2. Polymodal visceral receptors. When irritation is weak, it gives information about the general condition of the body, and when it is strong, it causes pain.

The pain impulse from the receptors of the affected area enters the horn of the spinal cord and passes along spinal cord and reaches the cerebral cortex. Thus, a person becomes aware of pain and the pain itself. In addition, a person develops a painful memory. What is characteristic of somatic pain is that the patient can accurately indicate the location of its location, or rather with one or two fingers. The muscular and mucous membranes of hollow organs, such as the stomach and intestines, are not equipped with somatic receptors, therefore, when they are damaged, a pronounced pain syndrome occurs.

Visceral receptors are more widespread and do not have strict localization, which also applies to pain.

Painful impulses can layer on top of each other and intensify. And the interweaving of visceral and somatic pathways can lead to irradiation of pain.

Types of pain in the abdominal cavity

• Acute (acute surgical pathology, trauma, acute infectious disease. The time frame depends on the cause of occurrence.) This type of pain characterizes diseases that are included in the group of diseases under the general name “acute abdomen”:

a) Acute inflammatory diseases of the abdominal cavity:

• acute appendicitis;
• acute Meckel's diverticulitis;
• acute pancreatitis and cholecystitis;
• peritonitis.

b) Violation of gall-intestinal patency:

• acute intestinal obstruction;
• intussusception;
• strangulated hernia.

c) Perforation of hollow organs:

• perforation of diverticula;
• perforation of stomach and duodenal ulcers;
• neoplasms.

d) Internal bleeding into the lumen of hollow organs or the abdominal cavity:

• liver rupture;
• splenic rupture;
• aortic rupture;
• apoplexy (rupture of the ovaries).

e) Failure of blood circulation in the abdominal organs as a result of thrombosis and embolism of intestinal vessels.

• Chronic (course duration exceeds three months);
• Recurrent (repeated periodically for three months).

The chance of a positive outcome depends on timely, qualified care with a correct diagnosis and competently prescribed treatment. And in order for the diagnosis to be made correctly, it is necessary to first collect a complete history and carefully examine the patient.

Recurrent abdominal pain is most common. They are caused by various reasons. In newborns, this is colic in the intestines, which is characterized by: twisting of the legs, bloating and tension in the abdomen, and the attack of pain after passing gas and defecation is relieved. Intestinal colic can be diagnosed by:

• I cry for more than three hours;
• at least three days a week;
• for three weeks in a row.

Despite all this, the children feel good, are in a positive mood and gain weight.

Other causes of abdominal pain in children may be intestinal infections, food allergies, gastrointestinal abnormalities, and GERD.

Alarming symptoms of the development of abdominal pathology are:

• loose stools, mucus in it, possibly blood;
• skin allergies;
• frequent vomiting and regurgitation;
• weight loss;
• frequent constipation.

Diagnostic capabilities

Each person describes pain to the best of his ability, in accordance with his life experience. A newborn baby is not able to answer the doctor’s questions, so the doctor needs to focus on the child’s behavioral signs (position, crying, changes in behavior).