| Abstract |
Background: Αcute abdomen is defined as acute onset of abdominal pain which necessitates immediate
investigation and determination of the cause, close observation, prompt treatment and possibly but not
necessarily surgical intervention.
Imaging in the acute setting at the Paediatric Accident and Emergency Department, has been proven
useful and necessary, can provide an accurate diagnosis or a relatively limited differential diagnosis in a large
number of children and can therefore contribute to the therapeutic approach of the child.
Objective: The aim of this diplomatic thesis is to investigate in a series of children with acute abdomen who
were admitted in the Paediatric Intensive Care Unit (PICU), the percentage that underwent imaging
procedures, imaging modalities utilized and the contribution of imaging modalities (separately, in
combination with each other and with clinical data) in the diagnosis and therapeutic management of these
patients.
Methods: In this retrospective, single-centre study, we investigated children, aged 1 month old to 18 years
old. All children had presented with signs and symptoms of acute abdomen at the Accident and Emergency
Department or were admitted in a paediatric or paediatric surgery clinic, and were hospitalized in the
paediatric ICU of University County Hospital of Heraklion, either pre- or post-operatively. These children
were hospitalized between 2009 and 2019. Based on the files stored at the PICU of our Hospital, we
recorded data regarding demographics, reason for admission, outcome, diagnosis at discharge, and
laboratory findings. With regard to imaging, we recorded imaging modalities that were used and how they
interfered with the preoperative diagnosis and postoperative management during Paediatric Intensive Care
Unit (PICU) stay. Data were statistically analysed using SPSS 25. P-value < 0.05 was considered statistically
significant.
Results: All children admitted in PICU (n=81) were operated upon. Reason for PICU admission was mostly
monitoring after surgery (93.8%), with the most common type of operation being exploratory laparotomy
(45 %). The cause in most cases of peritonitis was ruptured appendix (100% of appendectomies had already
established peritonitis). Peritonitis was also identified in 1/3 of exploratory laparotomies. Moreover, out of
81 children requiring abdominal surgery, 20 (24.7%) had visited a private physician and 50/81 children
(61.7%) had visited a different hospital without paediatric surgery support, a few days earlier.
41% of children undergone exploratory laparotomy, 18% of appendectomies and 14% of pyloromyotomies
had visited the Emergency Departments during the previous days (p<0.001), which mostly occurred 1-2 days
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prior to final admission in PICU (p=0.015). Pyloromyotomies mostly occurred in children previously
hospitalized in a paediatric clinic. In many children with acute abdomen (36/81, 45%) the cause could only be
identified during operation.
Out of 81 patients admitted in the ICU, 68 (84.0%) had received therapy prior to admission with intravenous
fluid administration and 58 (71.6%) with antibiotics. Children undergone more than 1 exploratory
laparotomies had statistically significant difference in the administration of the above (13.9%).
With regard to imaging, 71/81 (87.6%) children were imaged preoperatively. Ultrasonography (U/S) was the
most common examination performed before PICU admittance (66%). US was sensitive and showed
abnormalities in 50 out of 56 children (89.3%). The most common abnormality identified was peritoneal fluid
collection (occurred in 72.7% of children with peritonitis, and in all children with pelvic abscesses). US
exhibited high sensitivity when investigating the pylorus (100% sensitivity for hypertrophic pyloric stenosis)
and the bowel (100% sensitivity for intussusception, bowel necrosis and inguinal hernia). Finally, US
determined the surgical or medical cause of acute abdomen in 48/57 patients (85.7%) while it also changed
the initial diagnosis / therapeutic plan in a significant number of patients (31/57, 55%, p=0.001).
Radiographs revealed all 6 cases of ileus (3 cases of bowel obstruction and 3 cases of bowel necrosis)
exhibiting air-fluid levels (100%), as well as in right lower quadrant abnormalities in 6 cases of peritonitis.
Radiography determined the cause for abdominal pain and further management in all cases of ileus (n=6).
CT was performed in 8/81 children (9.9%), was abnormal in all examinations (100%) and confirmed the
diagnosis of peritonitis in 5 children (62.5%), and made the diagnosis in 1 case of bowel obstruction, 1 case
of bowel necrosis and 1 case of congenital anomaly of the bowel.
In 43/62 cases (69.4%), in at least one of the imaging methods the result was diagnostic for the cause of the
abdominal pain. After various diagnostic laboratory and clinical parameters of disease severity where
examined, only the diagnostic determination of the imaging diagnosis (AUROC 0.82, p = 0.037) and CRP
(AUROC 0.86, p = 0.01) reached a significant predictive capacity, regarding the risk of acute disease to
necessitate urgent surgery.
Conclusions:
The contribution of imaging is crucial in the diagnostic approach of children with acute abdomen. The
prognostic capacity of the appropriately selected imaging method to determine the risk of the underlying
condition and the need for immediate surgery is high. The most commonly used imaging method is
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ultrasonography with a high degree of diagnostic accuracy. Radiography is useful in cases of ileus, while in
rarer cases, selective performance of Computed Tomography proves to be particularly reliable.
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