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The assessment of acute abdominal pain can be challenging given the preverbal state of young children, the varied number of diagnoses that present similarly, and increasing appreciation of risks associated with pediatric diagnostic imaging.
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Presenting signs and symptoms differ by age. The key gastrointestinal (GI) signs and symptoms include pain, vomiting, diarrhea, constipation, fever, jaundice, and masses. Abdominal pain in children younger than 2 years typically manifests as fussiness, irritability, lethargy, or grunting. Toddlers and school-age children often localize pain poorly and point to their umbilicus, or may present as refusal to ambulate. Pain may be peritoneal and exacerbated by motion, or spasmodic, and associated with restlessness. Abdominal pain may originate from non-GI sources, and associated symptoms may help localize extra-abdominal causes such as cough with pneumonia or sore throat in streptococcal pharyngitis.
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Vomiting and diarrhea are common in children. These symptoms may be the result of a benign process or indicate the presence of a life-threatening condition. Bilious vomiting is almost always indicative of a serious process, especially in the neonate. Upper GI bleeding in children presents with hematemesis, which is often frightening to caretakers, but rarely serious in an otherwise healthy infant or child. Lower GI bleeding presents with melena or hematochezia, and the distinction between painless and painful rectal bleeding can help differentiate likely etiologies. Jaundice can be an ominous sign, and sepsis, congenital infections, hepatitis, anatomic problems, and enzyme deficiencies should be considered in the evaluation of these patients. Abdominal masses may be asymptomatic (e.g., Wilms tumor) or associated with painless vomiting (e.g., pyloric stenosis) or colicky abdominal pain (e.g., intussusception).
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Diagnosis and Differential
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Obtain a thorough history from parent and child (if possible), including the quality and location of pain, chronology of events, feedings, bowel habits, fever, weight changes, and other systemic signs and symptoms. Begin the physical examination with an assessment of the child's overall appearance, vital signs, and hydration status. Observation should precede auscultation and palpation. Extra-abdominal areas including the chest, pharynx, testes, scrotum, inguinal area, and neck should also be evaluated. Adolescent females who are sexually active with lower abdominal pain may require a bimanual exam. The likely etiologies of abdominal pain vary with age. Table 74-1 classifies emergent and nonemergent conditions by age group.
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