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Key Points

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  • Currant jelly stool is a late finding in intussusception.

  • In appendicitis, young children have a very high rate of rupture on presentation.

  • If bilious vomiting is present, think malrotation with volvulus.

  • Nonabdominal conditions including strep pharyngitis and pneumonia often present with abdominal pain.

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Introduction

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Abdominal pain in children is one of the most common complaints in pediatrics. Etiologies range from benign conditions such as constipation to surgical emergencies such as malrotation with volvulus. The challenge for the clinician is to distinguish between these diseases in preverbal children and in those with limited ability to describe their symptoms. Some conditions such as pyloric stenosis are unique to young children, but others, such as appendicitis which occur in all ages, have dramatically different presentations in the very young. Although less common than in adults, children may still suffer from gallstones, peptic ulcer disease, and kidney stones. Pelvic disorders including ovarian cysts and torsion must be considered in all girls over the age of menarche.

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Surgical Causes of Abdominal Pain

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Pyloric stenosis. Usually presents in the newborn period from 2 to 6 weeks of age. It is more common in first-born male children (4:1) and has a familial inheritance. The typical presentation is with postprandial projectile vomiting. After vomiting, children still appear hungry and will readily feed. Early on they seem well, but as symptoms progress they become dehydrated and develop the stereotypical electrolyte abnormality of hypokalemic, hypochloremic metabolic alkalosis.

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Intussusception. This is a telescoping of bowel into a proximal segment. In young children 2 months to 2 years old, the condition is usually idiopathic, and the most common location is ileocolic. Over the age of 3 years, a lead point such as a polyp or Meckel diverticulum may be the culprit. The typical presentation is intermittent colicky abdominal pain of a few minutes' duration associated with vomiting. These episodes of pain are followed by periods of lethargy. Unfortunately, the classic triad of symptoms—currant jelly stools, vomiting, and colicky abdominal pain—occurs in only 20% of patients. Physical exam may reveal an empty right lower quadrant and nontender mass in the right upper quadrant. Prolonged duration leads to bowel ischemia and necrosis. Henoch-Schönlein purpura is associated with ileo-ileal intussusception. Because of this unusual location, it is neither visualizable nor reducible by standard methods and requires computed tomography (CT) scan and surgical reduction.

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Meckel diverticulum. The most common congenital abnormality of the gastrointestinal tract, Meckel diverticulum is the remnant of the vitelline duct. In half of all cases there is ectopic tissue (usually gastric). Painless rectal bleeding is the most common presentation of Meckel, but other symptoms include abdominal pain, nausea, and vomiting. The rules of 2s is a good way to classify the condition (Table 50-1).

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Table Graphic Jump Location
Table 50-1.

Meckel diverticulum and rule of 2s.

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