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The diagnoses discussed in this chapter are challenging, since emergent surgical conditions in children may present with predominant symptoms other than pain, including vomiting, fever, irritability, or lethargy. Table 126-1 classifies conditions by age, although many conditions cross categories.

Table 126-1 Causes of Abdominal Pain by Age Group

The pathophysiology of abdominal pain is discussed in Chapter 68, Acute Abdominal Pain and gynecologic causes are discussed in Chapter 94, Abdominal and Pelvic Pain in the Nonpregnant Female.

The assessment of young children depends on careful observation for subtle clues. Stillness suggests conditions that irritate the peritoneum, such as appendicitis. Writhing for a position of comfort suggests obstruction, such as intussusception or renal colic.

Inspect, auscultate, and then palpate the abdomen, starting away from the expected area of maximal tenderness. Bringing the knees up relaxes the abdominal muscles. Move the hips to test for hip pathology or irritation caused by appendicitis or a psoas abscess. Thoroughly examine the diaper area to identify testicular torsion, paraphimosis, hair tourniquet, hernia, and imperforate hymen, as the young child may be unable to articulate problems in that area and the older child may be embarrassed to do so. Rectal exam may identify gross or occult blood, constipation, abnormalities of anogenital anatomy, and inflammatory processes. Evaluate for extra-abdominal causes of abdominal pain such as pharyngitis or pneumonia.

Neonates and Young Infants (0 to 3 Months)

The major life-threatening diagnoses in young infants are necrotizing enterocolitis, malrotation with midgut volvulus, incarcerated hernias, and nonaccidental trauma. Young infants typically eat every 2 hours, so inconsolability and lethargy with poor feeding are signs of serious disease. The maxim that bilious vomiting portends a surgical emergency until proven otherwise is well supported, since between 27% and 51% of children with bilious vomiting require surgery.1

Intermittent, paroxysmal pain is often associated with intussusception, colic, and gastroenteritis. Necrotizing enterocolitis and volvulus are associated with constant pain. Pain after feeding may be caused by gastroesophageal reflux. Pyloric stenosis causes progressive painless projectile vomiting followed by renewed interest in feeding.

Past medical history includes the complications of pregnancy and delivery. Constipation, with a history of not passing meconium within the first 24 to 48 hours of life, suggests Hirschsprung's disease. ...

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