- A surgical emergency should always be ruled out when evaluating a patient with abdominal pain.
- If a patient complains of abdominal pain, an examination of the external genitalia and a digital rectal examination should be a part of a routine examination.
- Ovarian and testicular torsions are important causes of abdominal pain that should not be overlooked.
- Ionizing radiation exposure should be considered when ordering CT for determination of the cause of abdominal pain.
- Intussusception should always be considered in infants/children with intermittent abdominal pain associated with vomiting.
- If an organic cause of abdominal pain has been ruled out, the patient and family need to be reassured and given appropriate, close follow-up through a primary care physician.
The chief complaint of abdominal pain elicits a broad differential in the mind of the practitioner. The most common discharge diagnoses in pediatric patients with abdominal pain are conditions such as acute gastroenteritis, constipation, and “viral syndrome.” However, serious clinical problems that require medical or surgical intervention may present with the same symptoms as disease processes that are benign and self-limited. No differential for abdominal pain is complete without abuse or nonaccidental trauma, especially in the younger, more vulnerable patient. Traumatic abdominal pain, as well as pain related to tumors, will be addressed in Chapters 32 and 103, respectively. The most frequently encountered surgical and medical causes of abdominal pain are addressed in this chapter including causes of abdominal pain that are unique to the female and male reproductive tracts.
Abdominal pain can be either visceral or somatic in nature. Visceral pain is poorly localized and may be difficult to describe, even in older children. Somatic pain is an intense and readily localized sensation that indicates the presence of inflammation. The brain modulates the perception of pain; patients with comparable pathologies may range from stoic to incapacitated depending on the influence of the environment upon their perception of pain. Referred pain syndromes manifested as abdominal pain may be characteristic of a variety of clinical problems.
The history and physical examination of a pediatric patient with abdominal pain can be complex due to the frightening and unfamiliar environment of the emergency department (ED). Communication is enhanced when the provider can establish an effective relationship with the patient and the caregiver. Infants and toddlers may not provide useful or relevant information, so the physician must rely on the caregivers for historical data. Careful observation may provide abundant information about a child's diagnosis. With older patients, the presence of a parent or caregiver may influence the effectiveness of an interview. This is certainly true for adolescents where an accurate sexual history may be impossible to obtain with a parent at the bedside. Creating an opportunity for the patient to be examined in private without presence of the caregiver can be an effective way of establishing a trusting relationship that may yield important historical information. Finally, the physician should attempt to formulate questions that are ...