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Pediatric abdominal pain is a common presenting complaint in the emergency department. 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, bleeding, jaundice, and masses. 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. Pain may be peritoneal and exacerbated by motion, or obstructive, 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, sore throat in streptococcal pharyngitis, and rash in Henoch-Schönlein purpura (HSP).
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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 process. Bilious vomiting is almost always indicative of a serious process, especially in the neonate. GI bleeding can result from upper or lower sources. 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 hematochesia, and the distinction between painless and painful rectal bleeding can help differentiate likely etiologies (see GI Bleeding below). Jaundice can be an ominous sign, and all icteric infants should be fully evaluated for sepsis, congenital infections, hepatitis, anatomic problems, and enzyme deficiencies. Abdominal masses may be asymptomatic (eg, Wilms tumor) or associated with painless vomiting (eg, pyloric stenosis) or colicky abdominal pain (eg, 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. The patient should be disrobed, and thorough inspection with nontouch maneuvers should precede auscultation and palpation. Extraabdominal areas including the chest, pharynx, testes, scrotum, inguinal area, and neck should also be evaluated. Adolescent females with lower abdominal pain may require a bimanual exam. The likely etiologies of abdominal pain change with age. Table 74-1 classifies emergent and nonemergent conditions by age group.
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