Investigating paediatric abdominal pain to determine the proper extent of investigations

178 Pages·2017·2.49 MB·English

Paediatric Abdominal Pain: a case of trials and tribulations mixed with
phantoms of the operating theatre? Or maybe just a case of going back to
the future!

CJ Beardsley
B.Comm (ANU)
M.B.B.S (ANU)

A thesis submitted in fulfillment of the requirements of the degree of Master of
Philosophy (Surgery), Australian National University.

Advanced Trainee-General Surgery
Department of Surgery,
Canberra Hospital, Canberra (2012-2014)
Royal Prince Alfred Hospital, Sydney (2015- present)
Australia
January, 2017

© Copyright by Christian Jean Beardsley (2017)
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Declaration

I hereby certify that the work contained within this document is the result of original
research and is not being submitted for a higher degree at another university or
institution. All research was principally carried out by the author, with some assistance
with data collection and statistical analysis, as noted in acknowledgements on page 4

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Date

Word count: 27993
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Ethics Clearance
The study conducted was approved by the Australian Capital Territory Health ethics
committee and was conducted in line with the National Health and Medical Research
Council and Australian Health Ethics Committee guidelines. All involved participants
gave informed consent for their participation in the studies. Where minors were
involved, consent was sought from the parent or guardian.

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Dedication:
To my mother and father who have always been my vanguard.

Acknowledgements:
Dr Mimi Chiu- for help with data collection for the demographic component (For data
collected for the PAIN study on November and December 2005).
Professor Croaker- for help with study design, thesis preparation and for being a mentor
both as a surgeon and as a researcher.
Dr Alex Dillon-for help with statistical analysis, data collection (October 2005) and advice
on data analysis.
Dr Florence Nguyen-for help with data collection (Ultrasound data 2011 and 2012).
Ms Gloria Spiropoulos-for being an exceptional aide to data collection by promptly
enabling access to medical records and for her support.

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Thesis Abstract

Background:
Paediatric abdominal pain has long been a diagnostic dilemma facing the emergency
physician and surgeon alike. The majority of childhood abdominal complaints are
benign. However, appendicitis represents the most common surgical emergency of
childhood and if excessive delay in diagnosis and management occurs, serious
complications and death can result. Expensive tests such as biochemical investigations
and ultrasonography are often over-stated in their true value to the clinician.
Aim and Methods:
This thesis hopes to enhance the management of paediatric abdominal pain in three
ways:
 By analyzing the epidemiology and presentation patterns in paediatric
abdominal pain. This is discussed in chapter 3 and was conducted via a year’s
review of paediatric abdominal pain for the calendar year 2005.
 By investigating the role of biomarkers such as white cell count, neutrophil
count, C-reactive protein and radiological investigations such as ultrasound in
the management of paediatric abdominal pain. This study extrapolates some of
the findings discussed in chapter 3 and examines them in greater detail. This is
discussed in chapter 4 and was conducted through a ten year review of patients
referred by Emergency physicians and surgeons for further work up of their
abdominal pain between 1st of January 2002 and 31st December 2012.
 By investigating the role of socioeconomic factors, heritable conditions and
extra-abdominal conditions in paediatric abdominal pain. This is discussed in
chapter 5 and was conducted via a prospective review conducted between 2012
and 2013.

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Results:
1) Appendicitis represented 6% of all presentations
2) Historical findings of most use included worsening pain, associated with nausea
or vomiting which yielded moderate sensitivities and specificities (combined
values over 70%).
3) Localised tenderness and percussion-tenderness were the only useful abdominal
examination findings with sensitivities and specificities over 90%, respectively,
when associated with moderate tenderness.
4) White Cell Count and CRP yielded sensitivities and specificities below 80%
5) Ultrasonography yielded high sensitivity (>95%) when only ultrasounds which
visualise the appendix are analysed but, as the appendix is often not visualised,
the actual sensitivity is only 70%. Ultrasound has a greater diagnostic yield for
females than males.
6) Functional abdominal pain is the most common cause for presentation, followed
by mesenteric adenitis and appendicitis. Children with Functional Abdominal
Pain were more likely to have regular bowel habits and present in winter than
those with other medical conditions. Of note, both groups had higher rates of
parental smoking, atopic conditions and migraine than is usually seen in the
general population.

Conclusion:
Paediatric abdominal pain is a common yet challenging scenario for clinicians. However,
the most useful tools are an accurate history, thorough examination and sensible use of
biomarkers and radiological investigations. Other factors affecting children should be
taken into account, e.g. the family medical history, though they should not significantly
alter the child’s workup. Biomarkers and radiological investigations should only be used
where doubt exists as to the diagnosis, and we suggest ultrasonography only in those
children in whom significant diagnostic uncertainty exists and where the clinical picture
clashes with the prior mentioned investigations.

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Publications and Presentations arising directly from this review:

 Beardsley CJ, Dillon A, Chiu M, Shah R, Croaker GDH. Paediatric Abdominal Pain:
Diagnostic nihilism rules? Royal Australian College of Surgeons Annual Scientific
Meeting (Canberra, A.C.T). 5th November 2011. Oral presentation.
 Beardsley CJ, Dillon A, Chiu M, Shah R, Croaker GDH. Paediatric Abdominal Pain
in Emergency Medicine. Convention of European Academy of Paediatric
Societies (EAPS), Istanbul, Turkey. 5th October 2012. Oral presentation.
 Beardsley CJ, Nguyen F, Croaker GDH. Ultrasonography in paediatric abdominal
pain: a case of trials and tribulations? 4th World Congress of Pediatric Surgeons.
13th-16th October, Berlin.
 Beardsley CJ, Dillon A, Nguyen F, Croaker GDH. Ultrasonography and paediatric
appendicitis: A story of great expectations and the phantom appendix. Presented
at the Convention of European Academy of Paediatric Societies (EAPS),
Barcelona, Spain. 21st October 2014. Oral presentation.
 Beardsley CJ, Dillon A, Chiu M, Florence N, Croaker GDH. A case of back to the
future: paediatric abdominal pain. Thorough history, clinical examination and
senior clinician involvement remain imperative for successful management.
Poster presentation at the Convention of European Academy of Paediatric
Societies (EAPS), Barcelona, Spain. 21st October 2014. Poster presentation.

 Beardsley CJ, Melino J, Croaker GDH. External influences on paediatric
abdominal pain: a holistic view may help. Poster presentation at the Convention
of European Academy of Paediatric Societies (EAPS), Barcelona, Spain. 21st
October 2014. Poster presentation.

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Publications and presentations arising indirectly from this review:

 Dillon A, Beardsley CJ, Croaker GDH. Paediatric abdominal investigations: are all
the tests useless? Royal Australian College of Surgeons Annual Scientific
Meeting (Canberra, A.C.T). 5th November 2011. Oral presentation.
 Chiu M, Beardsley CJ, Dillon A, Croaker GDH. Paediatric abdominal
investigations: epidemiology of casualty presentation. Royal Australian College
of Surgeons Annual Scientific Meeting (Canberra, A.C.T). 5th November 2011.
Oral presentation.
 F Nguyen, CJ Beardsley, GDH Croaker. “The Appendix is not visualised: how
useful is ultrasound in the evaluation of possible appendicitis in children
presenting to The Canberra hospital?” Royal Australian College of Surgeons
Annual Scientific Meeting (Canberra, A.C.T). November 2012. Oral presentation.

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Outline

Thesis abstract Page 5
Publications and presentations relating to this work 7
Chapter 1 Aim of the Thesis 10
Chapter 2: Literature Review 12
Chapter 3: Epidemiology of Paedatric Abdominal Pain and the
utility of clinical examination with investigations in the
assessment of the child with abdominal pain. 31
Chapter 4: Investigations in Paediatric Abdominal Pain 60
Chapter 5: Background factors in paediatric abdominal pain:
A holistic view may help 100
Chapter 6: Thesis summary and conclusions 114
Appendix 1: Calculations 121
Appendix 2: ROC curves for predicting appendiceal visualisation 123
Appendix 3: ROC curves for biomarkers 142
Appendix 4: Copy of survey questionnaire 167
References 172

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Chapter 1. Aim of the thesis

To investigate the underlying aetiologies behind paediatric abdominal pain
presentations, including both intrinsic and extrinsic factors, and the utility of
investigations such as laboratory tests and ultrasound in aiding the diagnostic acumen of
the clinician.

1.1 Hypothesis
That simple clinical parameters and tools are equal or superior to more advanced
investigations in the management of paediatric abdominal pain, and that extrinsic
factors may play a role in the aetiology of paediatric abdominal pain.
1.2 Specific predictions
1.2.1 That the majority of conditions underlying paediatric abdominal pain
investigations are benign and that simple clinical tools (history & examination) fare no
worse than more advanced investigations in helping to manage paediatric abdominal
pain.
1.2.2 That there are extrinsic factors at play in the child who presents with paediatric
abdominal pain and that factors including socio-economic parameters, familial
conditions and extra-abdominal conditions that may influence paediatric abdominal
pain.
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