The Acute Abdomen

  • Monica Khurana
  • Wendy SuEmail author
Part of the Pediatric Oncology book series (PEDIATRICO)


Pediatric oncology patients develop similar abdominal emergencies as immunocompetent children in addition to acute abdomen from malignancy or secondary to treatment. Cytotoxic chemotherapy, radiotherapy and extensive surgical resection all contribute to the risk of gastrointestinal symptoms. Immunocompromised children may lack the inflammatory signs of acute abdomen making prompt diagnosis of pediatric oncologic abdominal emergencies challenging. Here we review the most common abdominal emergencies secondary to malignancy including gastrointestinal hemorrhage, infection, mechanical obstruction, and perforation as well as management strategies for these conditions. A high index of suspicion and a prompt multidisciplinary approach are essential for optimal patient care. Early initiation of aggressive medical management reduces the need for invasive surgical treatment and concomitantly improves mortality rates. As there is a lack of evidence-based guidelines, the reviewed recommendations for supportive care and treatment of pediatric oncologic abdominal emergencies predominantly stem from expert opinion.


Acute Pancreatitis Necrotizing Fasciitis Acute Abdomen Abdominal Compartment Syndrome Burkitt Lymphoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Abdulrahman MA, Fallone CA, Barkun AN (2004) Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper GI bleeding. Gastrointest Endosc 59:172–178CrossRefGoogle Scholar
  2. Albano EA, Sandler E (2004) Oncologic emergencies. In: Altman AJ, Reaman GH (eds) Supportive care of children with cancer: current therapy and guidelines from the children’s oncology group, 3rd edn. The John Hopkins University Press, BaltimoreGoogle Scholar
  3. Andreyev HJ, Davison SE, Gillespie C et al (2012) Practice guidance on the management of acute and chronic gastrointestinal problems arising as a result of treatment for cancer. Gut 61:179–192CrossRefPubMedCentralPubMedGoogle Scholar
  4. Arul GS, Spicer RD (2008) Gastrointestinal complications. In: Carachi R, Grosfeld JL, Azmy AF (eds) The surgery of childhood tumors, 2nd edn. Springer, New YorkGoogle Scholar
  5. Beck R, Halberthal M, Zonis Z et al (2001) Abdominal compartment syndrome in children. Pediatr Crit Care Med 2:51–56CrossRefPubMedGoogle Scholar
  6. Büyükaşik Y, Ozcebe OI, Sayinalp N et al (1988) Perianal infections in patients with leukemia: importance of the course of neutrophil count. Dis Colon Rectum 41:81–85CrossRefGoogle Scholar
  7. Cheatham ML, Malbrain ML, Kirkpatrick A et al (2007) Results from the International Conference of Experts on intra-abdominal hypertension and abdominal compartment syndrome. II. Recommendations. Intensive Care Med 33:951–962CrossRefPubMedGoogle Scholar
  8. Chui CH, Chan MY, Tan AM et al (2008) Appendicitis in immunocompromised children: still a diagnostic and therapeutic dilemma? Pediatr Blood Cancer 50:1282–1283CrossRefPubMedGoogle Scholar
  9. Cloutier RL (2010) Neutropenic enterocolitis. Hematol Oncol Clin North Am 24:577–584CrossRefPubMedGoogle Scholar
  10. De Backer D (1999) Abdominal compartment syndrome. Crit Care 3:R103–R104CrossRefPubMedCentralGoogle Scholar
  11. Demshar R, Vanek R, Mazanec P (2011) Oncologic emergencies: new decade, new perspectives. AACN Adv Crit Care 22:337–348CrossRefPubMedGoogle Scholar
  12. Fisher MJ, Rheingold SR (2011) Oncologic emergencies. In: Pizzo PA, Poplack DG (eds) Principles and practice of pediatric oncology, 6th edn. Lippincott Williams & Wilkins, PennsylvaniaGoogle Scholar
  13. Gagneja HK, Sinicrope FA (2002) Gastrointestinal emergencies. In: Yeung SJ, Escalante CP (eds) Oncologic emergencies. BC Decker Inc, HamiltonGoogle Scholar
  14. Garg R, Agarwala S, Bhatnagar V (2010) Acute pancreatitis induced by ifosfamide therapy. J Pediatr Surg 45:2071–2073CrossRefPubMedGoogle Scholar
  15. Gray TL, Ooi CY, Tran D et al (2010) Gastrointestinal complications in children with acute myeloid leukemia. Leuk Lymphoma 51:768–777CrossRefPubMedGoogle Scholar
  16. Gupta H, Davidoff AM, Pui CH et al (2007) Clinical implications and surgical management of intussusception in pediatric patients with Burkitt lymphoma. J Pediatr Surg 42:998–1001CrossRefPubMedGoogle Scholar
  17. Guyatt G, Gutterman D, Baumann MH et al (2006) Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest 129:174–181CrossRefPubMedGoogle Scholar
  18. Haut C (2005) Oncological emergencies in the pediatric intensive care unit. AACN Clin Issues 16:232–245CrossRefPubMedGoogle Scholar
  19. Hobson MJ, Carney DE, Molik KA et al (2005) Appendicitis in childhood hematologic malignancies: analysis and comparison with typhlitis. J Pediatr Surg 40:214–220CrossRefPubMedGoogle Scholar
  20. Kaste SC, Rodriguez-Galindo C, Furman WL (1999) Pictorial essay: imaging pediatric oncologic emergencies of the abdomen. AJR Am J Roentgenol 173:729–736CrossRefPubMedGoogle Scholar
  21. Kearney SL, Dahlberg SE, Levy DE et al (2009) Clinical course and outcome in children with acute lymphoblastic leukemia and asparaginase-associated pancreatitis. Pediatr Blood Cancer 53:162–167CrossRefPubMedCentralPubMedGoogle Scholar
  22. Knoderer HM, Robarge J, Flockhart DA (2007) Predicting asparaginase-associated pancreatitis. Pediatr Blood Cancer 49:634–639CrossRefPubMedGoogle Scholar
  23. Krishnamoorthi R, Ramarajan N, Wang NE et al (2011) Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 259:231–239CrossRefPubMedGoogle Scholar
  24. Kumar A, Singh N, Prakash S et al (2006) Early enternal nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol 40:431–434CrossRefPubMedGoogle Scholar
  25. Kumar S, Gariepy CD (2013) Nutrition and acute pancreatitis: review of the literature and pediatric perspectives. Curr Gastroenterol Rep 15:338CrossRefPubMedGoogle Scholar
  26. McAteer JP, Sanchez SE, Rutledge JC, Waldhausen JH (2014) Isolated appendiceal typhlitis masquerading as perforated appendicitis in the setting of acute lymphoblastic leukemia. Pediatr Surg Int 30:561–564CrossRefPubMedGoogle Scholar
  27. McCarville MB, Thompson J, Li C et al (2004) Significance of appendiceal thickening in association with typhlitiis in pediatric oncology patients. Pediatr Radiol 34:245–249CrossRefPubMedGoogle Scholar
  28. McCarville MB, Adelman CS, Li C et al (2005) Typhlitis in childhood cancer. Cancer 104:380–387CrossRefPubMedGoogle Scholar
  29. Mercer-Falkoff A, Lacy J (2013) Oncologic emergencies. In: Rose MG, Devita VT Jr, Lawrence TS, Rosenberg SA (eds) Oncology in primary care. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  30. Morgan C, Tillett T, Braybrooke J et al (2011) Management of uncommon chemotherapy-induced emergencies. Lancet Oncol 12:806–814CrossRefPubMedGoogle Scholar
  31. Petrov MS, van Santvoort HC, Besselink MG et al (2007) Oral refeeding after onset of acute pancreatitis: a review of literature. Am J Gastroenterol 102:2079–2084CrossRefPubMedGoogle Scholar
  32. Pizzo PA (2011) Management of oncologic emergencies. In: Lanzkowsky P (ed) Manual of pediatric hematology and oncology, 5th edn. Elsevier, San FranciscoGoogle Scholar
  33. Silliman CC, Haase GM, Strain JD et al (1994) Indications for surgical intervention for gastrointestinal emergencies in children receiving chemotherapy. Cancer 74:203–216CrossRefPubMedGoogle Scholar
  34. Silverman LB, Gelber RD, Dalton VK et al (2001) Improved outcome for children with acute lymphoblastic leukemia: results of Dana-Farber Consortium Protocol 91-01. Blood 97:1211–1218CrossRefPubMedGoogle Scholar
  35. Silverman LB, Supko JG, Stevenson KE et al (2010) Intravenous PEG-asparaginase during remission induction in children and adolescents with newly diagnosed acute lymphoblastic leukemia. Blood 115:1351–1353CrossRefPubMedCentralPubMedGoogle Scholar
  36. Steinberg R, Freud E, Yaniv I, Katz J, Zer M (1999) A plea for incidental appendectomy in pediatric patients with malignancy. Pediatr Hematol Oncol 16:431–435CrossRefPubMedGoogle Scholar
  37. Sundell N, Boström H, Edenholm M et al (2012) Management of neutropenic enterocolitis in children with cancer. Acta Paediatr 101:308–312CrossRefPubMedGoogle Scholar
  38. Tenner S, Baillie J, DeWitt J et al (2013) American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 108:1400–1415CrossRefPubMedGoogle Scholar
  39. Terpe F, Siekmeyer M, Bierbach U et al (2012) Fulminant and fatal course of acute lymphoblastic leukemia due to lactic acidosis and suspected abdominal compartment syndrome. J Pediatr Hematol Oncol 34:e80–e83CrossRefPubMedGoogle Scholar
  40. Thompson DR (2001) Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol 96:1266–1272CrossRefPubMedGoogle Scholar
  41. Top PC, Tissing JW, Kuiper JW et al (2005) L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage. Pediatr Blood Cancer 44:95–97CrossRefPubMedGoogle Scholar
  42. Trivedi C, Pichumoni CS (2005) Drug-induced pancreatitis: an update. J Clin Gastroenterol 39:709–716CrossRefPubMedGoogle Scholar
  43. Tsuang W, Navaneethan U, Ruiz L et al (2009) Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 104:984–991CrossRefPubMedGoogle Scholar
  44. Wolfe RE, Kennedy ES (2011) Granulocytopenia. In: Schaider JJ, Barkin RM, Hayden SR, Wolfe RE, Barkin AZ, Shayne P, Rosen P (eds) Rosen & Barkin’s 5-minute emergency medicine consult, 4th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  45. Wan MJ, Krahn M, Ungar WJ et al (2009) Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis–a Markov decision analytic model. Radiology 250:378–386CrossRefPubMedGoogle Scholar
  46. Wiegering VA, Kellenberger CJ, Bodmer N et al (2008) Conservative management of acute appendicitis in children with hematologic malignancies during chemotherapy-induced neutropenia. J Pediatr Hematol Oncol 30:464–467CrossRefPubMedGoogle Scholar
  47. Wu SF, Chen AC, Peng CT et al (2008) Octreotide therapy in asparaginase-associated pancreatitis in childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 51:824–825CrossRefPubMedGoogle Scholar
  48. Yip D, Goddard N (2010) Oncological emergencies: diagnosis and management. In: Robotin M, Olver I, Girgis A (eds) When cancer crosses disciplines: a physician’s handbook. Imperial College Press, LondonGoogle Scholar

Copyright information

© Springer Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Division of Hematology/OncologyRiley Children’s HospitalIndianapolisUSA
  2. 2.Division of Pediatric SurgeryChildren’s Hospital and Research Center OaklandOaklandUSA

Personalised recommendations