A detailed history should be performed only after the practitioner has evaluated and stabilized the patient, and established that no life-threatening conditions are present. A meticulous history is crucial in guiding the practitioner in the management of abdominal pain including laboratory and radiographic evaluations, differential diagnosis, necessity for specialist consultation, and disposition. Depending on the age of the child, obtaining a detailed history of abdominal pain can be challenging. In younger children, parents often perceive that their child’s abdomen hurts based on facial expression or body movements such as writhing or drawing up the knees. Localization of pain may prove difficult based on history alone. Key features of history include presence, duration, and location of pain; presence or absence of fever; feeding and bowel habits; last oral intake; frequency and character of stools and vomitus; presence of blood in stools or vomitus; urinary symptoms; menstrual history; vaginal discharge/bleeding; respiratory symptoms; travel history, and changes in weight.
Special attention should be paid to significant past medical history including history of prematurity, congenital anomalies, inborn errors of metabolism, sickle cell disease, necrotizing enterocolitis, cystic fibrosis, and intussusception. A thorough review of systems is mandatory as abdominal pain is often a symptom of disorders originating in other organ systems such as ear, nose, and throat (ENT [pharyngitis]), genitourinary(GU [UTI, ectopic pregnancy, hernia]), vascular (Henoch-Schönlein purpura), and pulmonary (lower lobe pneumonia). The discriminating practitioner keeps in mind an age-appropriate differential during the history as common causes of abdominal pain vary significantly in the pediatric population, especially among infants. The differential diagnosis of common causes of acute abdominal pain is listed in Table 15–1.
Table 15–1.Differential diagnosis of acute abdominal pain. |Favorite Table|Download (.pdf) Table 15–1. Differential diagnosis of acute abdominal pain.
|Disease ||Characteristics of pain ||Epidemiology ||Associated Symptoms ||Physical examination ||Laboratory and radiographic evaluation |
|Appendicitis +/- perforation ||Periumbilical gradually localized to RLQ becoming acute and persistent ||Peaks in adolescence (due to maximal lymphoid hyperplasia) & rare < 2 y; often presents with peritonitis or sepsis due to delayed diagnosis in young children; perforation: (90% < 3 y, < 15% adolescents) ||Fever, vomiting, diarrhea, diffuse pain, distention, right hip complaints, lethargy, or irritability ||Fever, RLQ, or periumbilical tenderness ||Leukocytosis not sensitive; abdominal ultrasound (sensitivity, 80-92%; specificity, 86-98%; appendix not visualized in 10% with appendicitis); abdominal CT (sensitivity, 87-100% and highest with both oral and colonic contrast; specificity 83-97%) |
|Intussusception ||Colicky, severe, and intermittent. Child may draw legs up to abdomen and kick legs in air. Child appears calm and relieved between attacks. ||Peak at 10 mo; rare < 3 mo; 2-4 times more common in males ||Intermittent pain, fever, vomiting, poor feeding, lethargy, bloody or mucous stools ||“Dance sign” or “sausage” in RLQ; abdominal mass ||Barium or water-soluble enema gold standard for diagnosis and therapy; US (sensitivity, 95-98%; specificity 88-94%) as adjunct to monitor therapeutic effect |
|Malrotation/midgut volvulus ||Vague, diffuse, or nonexistent || |
75% diagnosed by 1 y;
Peak at < 1 mo (50%)
|Feeding intolerance, bilious emesis, abdominal pain, peritonitis and shock ||Normal abdominal examination in 50% of patients due to proximal obstruction; distention; peritoneal signs; signs of shock ||Upper GI is gold standard, revealing taper/beak of contrast and malpositioned ligament of Treitz; plain films may reveal SBO, LBO, or nothing |
|Pyloric stenosis ||Intermittent, diffuse, vague, or nonexistent || |
Peaks at 3-5 wk;
Males 2-5 times more common (especially firstborn or with family history)
|Postprandial projectile nonbilious emesis; dehydration ||May reveal palpable “olive-sized” mass at RUQ (90% specific, < 50% sensitive) or increased LUQ peristalsis ||Hypochloremic metabolic alkalosis, hypokalemia, hyponatremia, paradoxical aciduria; US or UGI is gold standard (both > 90% sensitive and specific) |
|Incarcerated hernia ||Intermittent at first; then steady in unilateral groin ||Inguinal hernia ranges from 3-5% in term; 7-30% preterm; familial; 90% of inguinal hernias occur in males; 6:1 male to female ratio of incarcerated inguinal hernia; R 60%, L 30%, 10% bilateral. Highest risk of incarceration is 1st y of life, hence most congenital hernias repaired ||Painful, swollen bulge under the skin, usually worse with crying or straining; anorexia, nausea, vomiting, and fever ||Tender inguinal bulge cannot be reduced; worse when child crying; dusky overlying skin. Reduction of nonincarcerated hernia easier with analgesics and/or sedation ||Testicular ultrasound helpful to rule out testicular torsion but should not delay immediate surgical consultation |
|Necrotizing enterocolitis ||Diffuse, vague, or nonexistent ||Neonates–equal gender term infants < 7 d; premature infants < 21 d ||Distention; poor feeding; vomiting; diarrhea; lethargy; apnea; gross blood in stool (25%) ||Increased abdominal girth, visible intestinal loops, decreased bowel sounds, palpable mass, abdominal wall erythema ||KUB shows pneumatosis intestinalis in 50-75%; delayed gastric emptying |
|Hepatitis ||RUQ, vague, or nonexistent ||HBV and HCV can be transmitted in utero; 70-80% are HAV ||Headache, anorexia, malaise, abdominal discomfort, nausea, vomiting ||Hepatomegaly, sometimes tender; icterus, jaundice; ascites, varices, or splenomegaly ||Serum AST, ALT, alkaline phosphatase, GGT, bilirubin, and albumin; coagulation studies; lactic acid; consider viral serology |
|Pancreatitis ||Epigastric—radiates to back; post prandial; rapid onset; continuous; severe ||Mostly idiopathic or congenital; sometimes medications, hypertriglyceridemia, cholelithiasis, or trauma ||Nausea; vomiting; diarrhea; sometimes fever or lethargy ||Epigastric tenderness; ecchymosis at epigastrium or flank; severe cases may present with sepsis ||Serum lipase, amylase, electrolytes, and CRP; CBC; ultrasound for cholelithiasis and pancreatic edema; CT with PO and IV contrast may help to evaluate pseudocyst |
|Cystitis & pyelonephritis ||Suprapubic or generalized abdominal pain; sometimes flank or back pain ||Account for 5-14% of pediatric emergency department visits; prevalence highest for females < 2 y and males < 1 y; uncircumcised males 6-20 times risk vs circumcised; females < 12 mo 3-4 times risk ||Vomiting; poor feeding; fussiness; dysuria, frequency, or new incontinence; fever (2-12%) more likely in younger patients ||Suprapubic tenderness; fever; costovertebral angle tenderness ||Clean catch or catheterized urinalysis; consider urine culture |
|Renal colic ||Costovertebral or lower quadrant along course of ureter ||10 times less common than in adults; 20-40% incidentally found; associated with family history, congenital diseases and metabolic derangements ||Asymptomatic; generalized pain; hematuria; recurrent UTI; vomiting; constipation; enuresis ||Abdominal examination usually normal; generalized tenderness ||Urinalysis; serum creatinine; renal/abdominal ultrasound adequate primary imaging modality; CT more sensitive and specific (may require contrast to evaluate obstruction or radiolucent stones) |
|Ovarian torsion ||Unilateral ||Females; 25% have normal ovaries ||Unilateral lower abdominal pain (maybe intermittent); nausea, vomiting; ||Adnexal mass palpable 20-40% ||Ultrasound diagnostic (Doppler); may be false negative if study done during period of detorsion; US or CT may show ovarian cyst/mass or pelvic fluid; laparoscopy diagnostic |
|Ectopic pregnancy ||Unilateral early; may become diffuse after rupture ||Females; sudden onset of sharp pain with rupture ||Nausea, vomiting, abdominal pain, vaginal bleeding; frequently asymptomatic ||Adnexal tenderness +/- palpable mass ||Ultrasound showing extrauterine pregnancy +/- pelvic free fluid; positive pregnancy test |
|Testicular torsion ||Unilateral in scrotum or groin; may wax and wane ||Males; rarely before puberty; 12% bilateral ||Testicular, inguinal, lower abdominal, or flank pain; nausea, vomiting ||Tender, “high-riding” testis with horizontal lie; epididymis indistinguishable from testis; absent cremasteric reflex; ipsilateral leg flexed at hip and knee; ||Ultrasound diagnostic (Doppler); may be false negative if study done during period of detorsion; surgical exploration definitively diagnostic |
Age-specific causes of abdominal pain help determine the differential diagnosis, as many causes occur primarily during infancy, the toddler years, or after further development. For example, appendicitis is exceedingly rare in children younger than 2 years and malrotation is extremely uncommon in children older than 2 years. Necrotizing enterocolitis can present with very few symptoms before overt sepsis, but knowing that a neonate was born at 29 weeks’ gestation and is presenting with apparent abdominal pain 3 weeks later will aid the practitioner in early diagnosis.
There are several conditions that tend to occur with greater frequency in either males or females, which can help the clinician further narrow the differential diagnosis. In addition to the more complex differential diagnosis for females of reproductive age, there are other disease processes when gender makes a diagnosis more or less likely in the pediatric patient with abdominal pain. Both intussusception and pyloric stenosis occur more than twice as frequently in males. Females have three to four times the incidence of urinary tract infections (UTIs) as uncircumcised males.
Anorexia, Nausea, & Vomiting
While common, the presence or absence of anorexia, nausea, and vomiting does not rule out surgical causes of abdominal pain in children. A key distinguishing factor in the pediatric patient is the presence of bilious emesis, usually indicative of a surgical emergency such as obstruction, intussusception, malrotation with or without midgut volvulus, or incarcerated inguinal hernia. Bilious emesis typically requires emergent surgical consultation.
Fever is a common presenting symptom for which parents seek emergency treatment of their child. It is also commonly associated with many causes of abdominal pain, mostly infectious. In cases of delayed diagnosis, especially with nonverbal children, fever or sepsis may be the presenting symptom in the absence of any known abdominal pain. Systemic inflammatory signs such as fever and rigors, when observed in patients with abdominal pain, suggest either an extrabdominal/systemic disease with abdominal manifestations or abdominal pathology that has progressed to become systemic. The combination of vital signs, physical examination, including a detailed abdominal examination, and a review of symptoms should help differentiate these two possibilities.
Diarrhea, Constipation, & Obstipation
It is important to ask about the frequency and characteristics of stool in the pediatric patient as details can hint toward causes of abdominal pain. Diarrhea in the setting of abdominal pain suggests an infectious or allergic process. It is of special consequence in younger children as they may dehydrate much more quickly than adults. The parents and clinician should focus on signs of dehydration and attempt rehydration via oral, intravenous, or the emerging dermoclysis method. Constipation is a common cause of functional abdominal pain in children, particularly if it is chronic. New onset constipation combined with abdominal pain or nausea and vomiting is more suggestive of an obstructive process. Beware the patient with diarrhea and a history of constipation and laxative use, as there is likely encopresis with ongoing fecal impaction.
Hematochezia is associated with conditions such as constipation with hemorrhoids, anal fissure, and lower gastrointestinal (GI) bleeding. In children, this may be in the form of Meckel diverticulum which can also serve as a lead point for intussusception. Melena is generally from upper GI bleeding, but in breast-fed infants, it can also be from swallowed maternal blood or a nasopharyngeal source such as epistaxis. The classic “currant jelly” stool in intussusception is a late and somewhat ominous finding as it suggests bowel necrosis.
The abdominal examination in younger children can be quite difficult resulting from pain and trust issues, thus requiring the utilization of more nontraditional methods than with adults. Distraction is especially helpful as are serial examinations. When possible, examine the younger child’s abdomen while he or she is being held by the parent. Assess peritoneal signs by secondary methods such as having the child skip, hop, climb, or play. Engage the child or parent in palpation of the abdomen by having him or her place a hand on the abdomen with the practitioner’s on top, which can also reduce ticklish sensation. Close examination of the overall appearance (lethargic versus playful, hydration status, toxic appearance) of the child may be as helpful as the abdominal examination itself.
A thorough general physical examination is required in addition to a focused abdominal examination to exclude extra-abdominal causes of abdominal pain such as pharyngitis and pneumonia. When appropriate, a pelvic examination should be performed.
Evaluate for scars, feeding tubes, ostomies, distention, ecchymosis, erythema, jaundice, abnormal vasculature, peristalsis, and protruding masses.
With the bell of the stethoscope, listen in all four quadrants and midline for peristaltic sounds. High-pitched sounds are indicative of partial obstruction.
Normal percussion should elicit dullness in the right upper quadrant (RUQ) over the liver, hollow note over the stomach in the left upper quadrant (LUQ), and a flat percussion note elsewhere. Splenic enlargement produces dullness in the LUQ over the lower ribs. Bladder enlargement produces dullness in the suprapubic area. Rebound is pain elicited by percussion remote to the immediate site of examination and is suggestive of peritoneal inflammation.
Relaxation of the abdominal musculature is necessary for diagnostic abdominal palpation. This can often be best achieved in sheepish children while in their parent’s arms. Distractive conversation may aid in relaxation of some children. Always begin with light palpation and palpate the area of maximal tenderness last. Watch the child’s face for evidence of discomfort as you palpate. In ticklish children, deep palpation may be accomplished with pressure from the stethoscope or have the older child place his or her fingers on top of the examiner’s and follow the motions. The examiner should also assess for hepatosplenomegaly. Note palpable feces. Rectal examination, both external and internal, should be done when indicated to assess for fissures, skin tags, presence of fecal impaction, and presence of gross and occult blood.
While supine, the patient flexes the right thigh to 90 degrees and then gently rotates internally and externally. Pelvic pain indicates an inflamed muscle and raises the possibility of appendicitis.
While supine, the patient with extended knee flexes thigh against the resistance of the examiner’s hand. If painful, it indicates an inflammatory process involving the psoas muscle.
Positive when palpation of the left lower quadrant (LLQ) causes increased pain in the right lower quadrant (RLQ) and is suggestive of appendicitis.
Similar to fever and rigors, leukocytosis and thrombocytosis are neither specific nor sensitive for a surgical abdomen, nor does their absence rule out serious pathology, especially in children with immunie compromise. Likewise, leukopenia may be a presenting sign of sepsis in the presence of other SIRS criteria. Polycythemia vera, although rare in children, is consistent with severe dehydration. Anemia in the absence of trauma should alert the practitioner to an underlying hematologic sequestration or an anemic process such as infectious mononucleosis or sickle cell anemia.
Elevated amylase and lipase in the presence of epigastric pain suggest pancreatitis. Their degree of elevation is not predictive of the severity of pancreatitis. Serum lipase is more specific for pancreatitis as it is found only in the pancreas, while measurement of the less-specific amylase has become less common.
Elevated hepatic function tests including transaminases and bilirubin in the setting of abdominal pain suggest hepatocellular dysfunction, and confirmatory viral serology should follow. Elevated alkaline phosphatase and gamma-glutamyl transferase (GGT) with or without hyperbilirubinemia is more indicative of a cholestatic process, usually idiopathic or medication induced.
Urine should be sent for urinalysis and microscopy in order to rule out cystitis or pyelonephritis. In the febrile child or child with history of UTIs, urine should also be sent for culture and sensitivities. Leukocyte esterase has fairly good sensitivity and specificity (both 80-90%) for UTIs. Conversely, nitrites are insensitive (49%) but highly specific (98%) for UTIs. Urine should be collected in a sterile fashion from a urinary catheter when indicated. In addition to cystitis, hematuria can be associated with poststreptococcal glomerulonephritis or renal colic, although red blood cells can be absent in the latter in cases of obstruction.
Serum Electrolytes & Renal Function Tests
Although the results of a basic chemistry panel may indicate varied metabolic derangements, in the setting of abdominal pain the focus is an objective assessment of volume status, and can refute, confirm, or emphasize findings on physical examination. Findings consistent with dehydration include hypobicarbonatemia and an elevated BUN-to-creatinine ratio.
Pregnancy Test & Polymerase Chain Reaction for Chlamydia/Gonorrhea
A pregnancy test should be ordered in all perimenarchal and postmenarchal females. A positive pregnancy test in the presence of abdominal pain is an ectopic pregnancy until proven otherwise. A quantitative beta-human chorionic gonadotrophin of 1500 IU/L defines the discriminatory zone for visualizing an intrauterine pregnancy with an intercavitary ultrasound probe, whereas 5000 IU/L is the value consistent with transabdominal visualization. For patients in whom pelvic infection is suspected but who lack specific physical examination findings, the results of polymerase chain reaction (PCR) for gonorrhea and chlamydia can increase clinical accuracy.
Fecal Occult Blood Testing of Stool
Testing for the presence of occult blood in stool is helpful in certain gastrointestinal bleeding disorders and intussusception. It may also be positive in severe constipation due to internal hemorrhoids or anal fissures.
When history is lacking, radiologic examination may be especially helpful in diagnosis of abdominal disease, and in some cases, even therapeutic. In recent years, there has been a trend toward minimizing the amount of radiation exposure from radiographic studies in emergency departments, especially for pediatric patients. In general, start with plain abdominal radiographs to assess for free air, constipation, obstruction, foreign bodies and stones. A chest radiograph may reveal lower lobe pneumonia. Abdominal ultrasonography is often practical when diagnosing appendicitis, cholelithiasis, pancreatitis, pyloric stenosis, intussusception, obstructive renal colic, and in evaluation of the liver. Pelvic ultrasound will evaluate for ovarian cysts, ovarian torsion, and ectopic pregnancy. Scrotal ultrasound assesses for testicular torsion and inguinal hernia. Air enema studies with or without contrast can sequentially diagnose and treat intussusception. Upper GI studies can diagnose malrotation and pyloric stenosis.
Abdominal computed tomography (CT) (ideally with enteric, rectal, and intravenous [IV] contrast) can diagnose appendicitis, pancreatitis, and obstruction, among others. Noncontrast abdominal CT can reveal ureterolithiasis. Compared with other common radiographic modalities, CT exposes patients to much more ionizing radiation. Given the stochastic risk for neoplasm, conservative guidelines for risk reduction include limiting scans to the anatomy of interest, limiting multiphase studies, scaling radiation dose to patient size, and appropriate use of alternative modalities such as ultrasound when possible.
ADDITIONAL MEASURES FOR THE MANAGEMENT OF ABDOMINAL PAIN
Serial Examination & Evaluation
When opting to minimize radiation, repeated or serial abdominal examinations (ideally by the same clinician) are useful in tracking progression of disease and can aid decisions regarding the acquisition of a radiographic study and the patient’s disposition. This is especially true when the diagnosis is uncertain based on history and initial physical examination alone. The practitioner should inquire as to the progression of symptoms, need for analgesia, change in vital signs, and repeat the abdominal examination. Successful serial examinations can avoid unnecessary radiation or surgeries without the risk of delayed diagnosis. If patients remain unimproved after a period of hours, the prudent clinician may admit for observation and/or seek surgical consultation. If the patient is discharged home, the guardian should always be given both verbal and written precautions for return to the hospital.
In general, a patient presenting with abdominal pain should be made nil per os (nothing by mouth [NPO]) until it is determined that the pain is nonsurgical in nature or until an oral challenge is necessary. In the setting of ongoing losses or prolonged withholding of oral intake, start appropriate weight-based maintenance intravenous fluids.
Traditionally, analgesia was withheld in the setting of abdominal pain to avoid masking the degree of discomfort prior to deciding the need for surgical intervention. However, especially in the pediatric patient, analgesia may aid in a more accurate physical examination with a relaxed patient and improve the overall experience for the family. A recent study revealed no delay in diagnosis after administration of 0.05-0.1 mg/kg IV morphine sulfate.
Emesis Control & Nasogastric Suctioning
Children may often complain of abdominal pain due to emesis. In the vomiting patient, begin with parenteral or orally dissolving antiemetics. A nasogastric catheter and suctioning may be necessary in refractory cases or in the setting of obstruction.
Antimicrobials should be reserved for abdominal pain with at least a tentative diagnosis unless there are overt signs of sepsis such as high fever, rigors, and hemodynamic instability. In some cases, surgical consultants may ask that perioperative antimicrobials be given in the emergency department. However, administering antimicrobials in undifferentiated abdominal pain can lead to complications due to subclinical progression and delayed diagnosis or abscess formation.
Early surgical consultation is helpful in cases of pediatric abdominal pain, especially in efforts to minimize radiation exposure. Some surgeons will operate based on history and physical examination alone, and early consultation can thus prevent undesirable sequelae. It is also helpful in establishing a baseline for serial examinations in the case of admission for observation of undifferentiated abdominal pain. In cases of apparent surgical emergency, a surgical subspecialist should be consulted as soon as possible, even before confirmatory studies have been performed.
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