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If a patient complains of abdominal pain, an examination of the external genitalia should be a part of a routine examination.
Ovarian and testicular torsions are important causes of abdominal pain that should not be overlooked.
Intussusception should always be considered in infants/children with intermittent abdominal pain associated with vomiting.
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Abdominal pain accounts for approximately 10% visits and elicits a broad differential, with more serious etiologies often presenting similar to processes that are benign and self-limited.1 The most frequently encountered surgical and medical causes of abdominal pain are addressed herein, including causes of abdominal pain that are unique to the female and male reproductive tracts.
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History and Examination
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Abdominal pain can be visceral or somatic. Visceral pain is poorly localized and difficult to describe, even in older children; somatic pain is intense and readily localized. Referred pain syndromes manifested as abdominal pain may be characteristic of a variety of clinical problems. An effective relationship with the caregiver and careful observation can provide abundant information about a child's diagnosis. With older patients, the presence of a caregiver may hinder communication, particularly when needing an accurate sexual history. Overall, formulate questions appropriate for the child's level of development, regardless of the patient's age. Use open-ended inquiries over “yes or no” questions.
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Create a preliminary differential diagnosis, including abdominal conditions, systemic illnesses, and referred pain syndromes. Afferent nerves from distant organs can share central pathways that allow pain from one organ to be interpreted as if the stimulus is affecting another organ. A classic example is a right lower-lobe pneumonia that refers pain to the abdomen mimicking appendicitis. Conversely, some conditions that are intra-abdominal in origin may produce pain syndromes that are manifested in other locations; for example, shoulder pain due to hepatic irritation (right), or splenic rupture (left), and groin pain from renal stones. Table 69-1 lists extra-abdominal and systemic conditions that can present with abdominal pain.2
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When considering possible etiologies of abdominal pain, the provider must consider entities that are more common in specific age groups (Table 69-2). A traditional bedside examination may be limited in frightened infants and small children and should begin with observation. While the child is in the parent's lap, carefully observe, auscultate, palpate, and percuss the child's abdomen. Include an examination of the genitalia and perineum, considering diagnoses such as an incarcerated inguinal hernia, or a testicular torsion. In cases of severe stranger anxiety, further assess the abdomen while the child sleeps or alternatively, ...