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Approach to Pediatric Abdominal Pain

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General Presentation

BACKGROUND

Abdominal pain in a child is one of the most common presentations with both trivial and life-threatening etiologies, ranging from functional pain to acute appendicitis.  The majority of pediatric abdominal complaints are relatively benign (e.g. constipation), but it is important to pick up on the cardinal signs that might suggest a more serious underlying disease.

Diagnosing abdominal pain in children is also a challenging task. Conditions vary amongst age groups (ie. volvulus in neonates, intussusception in toddlers) and trying to thoroughly evaluate a child in pain can make the process all the more challenging.

BASIC ANATOMY AND PHYSIOLOGY

When taking a history and examining a child with abdominal pain, consider all the organs in the abdominal area.  Pathologies of the lower lung (i.e. pneumonia) can often be interpreted as abdominal pain; similarly, genitourinary pathology (i.e. testicular torsion) can be as well.  A sharp stabbing pain may suggest somatic involvement – this type of sensation is usually well localized; while dull, non-specific, throbbing pain suggests visceral involvement that is difficult to localize.  Remember, the differential diagnosis of a child varies depending on their age group. (Table 1)

Table 1: Common causes of abdominal pain

Newborn

Intestinal obstruction (ie. volvulus, Hirshsprung, pyloric stenosis) Peritonitis (i.e. necrotizing enterocolitis, GI perforation)
Hernia Gastroesophageal Reflux
Trauma (i.e. during birth)

Infant (<2 years)

Constipation Toxin ingestion
Acute gastroenteritis Trauma
Hernia, volvulus, intussusception Infantile dyschezia
Colic Respiratory illness

Children (2 – 18 years)

Acute gastroenteritis Urinary tract infection/ Pyelonephritis
Constipation Toxin ingestion, food poisoning
Intestinal obstruction Trauma
Testicular torsion Henoch-Schnolein Purpura
Respiratory illness, pneumonia, Appendicitis, pancreatitis, cholecystitis
Mesenteric adenitis

Adolescents (12 – 18 years)

Trauma Toxin ingestion, food poisoning
Dysmenorrhea Pregnancy (i.e. ectopic)
Pelvic inflammatory disease Testicular torsion
Ovarian torsion/cysts Gastroenteritis
Constipation

PRESENTATION AND EMERGENT CONSIDERATIONS

Acute pain lasts several hours to days while chronic pain can last from days to weeks to months.  In a child presenting with abdominal pain, it is important to identify any emergent concerns and reach a timely diagnosis.

Red flag signs include:

  • Bilious vomiting
  • Bloody stool or emesis
  • Night time waking with abdominal pain
  • Hemodynamic instability
  • Weight loss

Questions to ask

HISTORY

  • PQRSTAAA:
    • Place/Location: identify the specific location of the pain, have child use one finger to locate her pain.
    • Quality: pain can be a sharp stabbing pain (i.e. trauma) or diffuse, poorly, localized pain (i.e. chronic or visceral pain)
    • Radiation: pain can radiate from its point of origin in any direction
    • Severity: degree of pain on a scale of 10
    • Timing/Onset: onset of the pain, duration of pain, course during the day, does it  wake them at night, and the frequency of episodes
    • Alleviating Factors: anything that reduces the pain – body position, movements (or lack thereof), medications.
    • Aggravating Factors: anything that increases the pain – body position, movements, relation to food intake.
    • Associated Symptoms: can include hematemesis, vomiting, nausea, hematochezia, melena, diarrhea, fever, and weight loss. (Relevant findings: See Table 2)
  • Ask about bowel movement patterns and stool quality (size, hard/soft, odour).
  • Ask about ingestion of toxin or foreign object; accidental or non-accidental trauma
  • Ask about dietary history: in young children, too much milk can lead to constipation.
  • Ask about past medical history and medical comorbidities.
    • Cystic fibrosis predisposes to gallstones.
    • Spina bifida/cerebral palsy/developmental delay predisposes to constipation.
    • Sickle cell disease predisposes to splenic auto-infarction.
    • Recurrent respiratory tract infections suggest mesenteric adenitis.
  • Ask about sexual history – screen for STI
    • Females: don’t forget about menstrual cycles (regularity, amount of bleeding, relation to abdominal pain)
  • Ask about family medical history, especially inflammatory bowel diseas.
  • Ask about travel history, social and psychiatric (potential stressors) history.

Table 2: Associated symptoms for abdominal pain

Associated Symptom Relevance
Diarrhea Gastroenteritis, Protein losing enteropathy
Bloody stool UGIB/LGIB, Ulcerative colitis, necrotizing enterocolitis, dysentery, constipation
Hematemesis UGID, Peptic Ulcer Disease, Gastritis
Bilious emesis Small bowel obstruction
Jaundice Hepatitis or Biliary Tree obstruction
Joint pain/swelling IBD, HSP
Skin Lesions IBD, HSP, Liver disease
Testicular pain Testicular torsion
Dysuria/polyuria/hematuria Urinary tract infection/Pyelonephritis
Vaginal/Penile discharge STI
Dysmenorrhea Endometriosis
Shortness of breath Pneumonia or empyema

 

Common differential diagnoses and potential complications

table 3: common differential diagnoses for abdominal pain

Medical Condition Relevant Findings and Potential Complications

Gastrointestinal

Constipation Infrequent bowel evacuations, difficult or painful defecation, can see blood in stool from anal fissures, low fibre diet, high milk consumption (>2-3 cups per day)
Acute appendicitis Right lower quadrant pain with fever, anorexia, nausea, vomiting, can rupture and lead to sepsis
Gastroenteritis Vomiting and diarrhea with or without fever and nausea, can have bacterial or viral etiologies
Irritable bowel syndrome Change in stool frequency, bloating, abdominal distension, may be associated with certain foods
Trauma History and signs of bruising
Ulcerative colitis Bloody and/or chronic diarrhea, crampy lower abdominal pain, anorexia, weight loss, fever, fecal urgency, can develop to toxic megacolon
Crohn’s disease Intermittent diarrhea, weight loss, crampy right lower quadrant pain, anorexia, weight loss, fatigue
Celiac Disease Abdominal pain, bloating, growth failure, gluten insensitivity
Inflammatory Bowel Disease Associated with diarrhea, bloody stools, weight loss, can lead to significant growth failure if missed.

Genitourinary

Urinary tract infection Dysuria, polyuria, hematuria, can progress to pyelonephritis
Primary dysmenorrhea History of menstrual periods and regularity, consider sexual history

Pulmonary

Pneumonia and Empyema Consider respiratory history, past medical history and recurrent respiratory tract infections

Physical exam and investigations

a) physical exam

ABCs; vitals; and growth parameters (is there evidence of failure to thrive).

  • Inspection: look for contour, symmetry, pulsations, peristalsis, vascular irregularities, skin markings, wall protrusions (hernias), any signs of trauma (ie. bruising, swelling), and abdominal distension
  • Auscultation: auscultate before palpation in the abdominal exam, listen for bowel sounds, abdominal bruits, pressure of the stethoscope also tests for tenderness
  • Percussion: assess general tone (tympanic vs non-tympanic), percuss for liver span and spleen tip, assess for ascites (find edge of percussion tone change).
  • Palpation: assess tenderness with light and deep palpation, assess for guarding and rebound tenderness, palpate for liver, spleen, kidney and abdominal masses (including fecal mass).
  • Digital rectal exam: first exam the anus for fissures and skin tags, then assess for tone, stool, and blood
  • Special Tests: there are a number of special tests for each differential diagnosis

table 4: findings on physical exam for common differential diagnoses

Medical Condition Findings on Physical Exam

Gastrointestinal

Constipation Abdominal tenderness, palpable fecal mass, look for imperforate anus or stenosis, spina bifida, developmental delay, cerebral palsy
Acute appendicitis Patient avoids movement, rebound tenderness, McBurney sign (pain at 2/3 between umbilicus and right ASIS), Rovsing sign (pain in right lower quadrant on left-sided palpation), Psoas sign (pain in right lower quadrant when child on left and right hip hyperextended), obturator sign (pain in right lower quadrant on internal rotation of flexed right thigh)
Gastroenteritis Diffuse pain with no rebound tenderness, abdominal distension, hyperactive bowel sounds
Irritable bowel syndrome Periumbilical tenderness, no rebound tenderness
Trauma Signs of bruising and tenderness
Celiac Disease Growth failure, distended abdomen, diffuse abdominal tenderness.
Inflammatory bowel disease Appears thin/cachetic, abdominal tenderness, anal skin tags, possible sign of bloody stool on DRE, examine for skin lesions (erythema nodosum, pyoderma gangrenosum), iritis, and joint inflammation

Genitourinary

Urinary tract infection Fever, suprapubic and costovertebral angle tenderness, irritability, foul-smeling urine, gross hematuria
Primary dysmenorrhea Lower abdominal tenderness

Pulmonary

Pneumonia and Empyema Tachypnea, cyanosis, decreased breath sounds, crackles and rales, dullness on percussion, febrile

b) Laboratory investigations

table 5: Laboratory investigations for common differential diagnoses

Medical Condition Relevant Diagnostic Tests

Gastrointestinal

Constipation None if history does not suggest an alternative diagnosis.
Acute appendicitis CBC (WBC normal or elevated), urinalysis, urine pregnancy
Gastroenteritis Serum electrolytes, stool culture, stool for virology
Irritable bowel syndrome None, based on history and clinical findings
Trauma CBC for blood loss, abdominal CT with contrast
Celiac Disease Anti-TTG, IgA
Inflammatory Bowel Disease CBC, ESR/CRP, electrolytes, albumin, LFTs, Bilirubin, Stool culture, AXR

Genitourinary

Urinary tract infection Urine dipstick (for leukocyte esterase and nitrite), urine microscopy, urine culture (best if suprapubic aspirate)
Primary dysmenorrhea None, based on history and clinical findings

Pulmonary

Pneumonia and Empyema CBC, Chest x-ray, sputum culture

Supplementary information

a) Uncommon differential diagnoses and potential complications

table 6: uncommon differential diagnosis for abdominal pain

Medical Condition Relevant Findings and Potential Complications

Gastrointestinal

Intussusception Colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in children at 6 months of age
Mekel’s diverticulum Similar presentation to appendicitis, profuse GI bleeding, can develop to diverticulitis
Mesenteric adenitis Can present like acute appendicitis, recurrent respiratory tract infections
Hirschsprung disease Vomiting, abdominal distension, enterocolitis, primarily in first year of life
Small bowel obstruction Bloating, vomiting, failure to pass flatus or stool, bilious emesis
Volvulus Can present like small bowel obstruction, due to intestinal twisting
Large bowel obstruction Abdominal distension, hard feces and rectal bleeding, can lead to bowel perforation
Necrotizing enterocolitis Feeding intolerance, apnea, lethargy, bloody stools, abdominal distension and tenderness, abdominal erythema, hematochezia, bradycardiac, primarily in premature infants
Peptic ulcer disease Epigastric tenderness, pain related to eating a meal, ulcer can perforate
Viral hepatitis Fever, malaise and jaundice, consider fecal-oral or vertical transmission
Acute pancreatitis Steady and sudden-onset pain radiating to the back, nausea, vomiting, history of cholelithiasis
Splenic infarction Personal or family history of sickle cell disease

Genitourinary

Nephrolithiasis Acute renal colic, flank pain radiating to groin
Testicular torsion Testicular pain with acute onset, nausea, vomiting
Ovarian torsion Pain with nausea, vomiting, diarrhea
Ruptured ovarian cyst Bloating, early satiety
Pelvic inflammatory disease Consider sexual history
Pregnancy and related complications Nausea and vomiting, review sexual history and consider ectopic pregnancy and associated ruptures

table 7: findings on physical exam for uncommon differential diagnoses

Medical Condition Findings on Physical Exam

Gastrointestinal

Intussusception Gross or occult blood, abdominal tenderness and palpable abdominal mass
Merkel diverticulum Bloody stools, abdominal tenderness with guarding, rebound tenderness
Mesenteric adenitis Diffuse abdominal tenderness, rhinorrhea and pharyngitis, extramesenteric lymphadenopathy
Hirschsprung disease Abdominal distension, palpable fecal mass, small rectum
Small bowel obstruction Hyperactive or hypoactive bowel sounds
Volvulus Diffuse abdominal distension, no bowel sounds, guarding, rebound tenderness, rigid abdomen, fever, hematochezia
Large bowel obstruction distended abdomen, hyperactive bowel sounds
Necrotizing enterocolitis Abdominal distension, tenderness, abdominal wall erythema, hematochezia, bradycardia
Peptic ulcer disease Epigastric tenderness, melena or occult blood
Viral hepatitis Jaundice, hepatosplenomegaly, lymphadenopathy, wasting, cachexia, ascites, asterixis, caput medusa
Acute pancreatitis Epigastric tenderness, tachycardia, irritability, abdominal distension, Cullen sign (discoloration around umbilicus), Grey-Turner sign (discoloration around flanks)
Splenic infarction Left upper quadrant tenderness

Genitourinary

Nephrolithiasis Costovertebral angle and flank tenderness, tachycardia
Testicular torsion Tender, edematous testicle, affected testicle higher than unaffected, absent cremasteric reflex
Ovarian torsion Tender pelvic mass, cervical motion tenderness
Ruptured ovarian cyst Adnexal tenderness
Pelvic inflammatory disease Slight fever, cervical motion tenderness, adnexal tenderness, vaginal or cervical mucopurulent discharge
Pregnancy and related complications Abdominal tenderness, vaginal bleeding

The differential diagnosis of abdominal pain is extensive making a concise approach sometimes difficult.

Key points:

1.    Determine if abdominal pain is acute or chronic

2.    Is the abdomen acute/surgical or benign

3.    Are red flags present.

References

Major Sources

Misra S. Approach to Acute Abdominal Pain in Children. Pediatric Oncall. [Internet] 2005 [updated 2005 May 1; cited 2010 Mar 6].  Available from: http://www.pediatriconcall.com/fordoctor/diseasesandcondition/gastrointestinal_disorders/acute_abdominalpain_children.asp

Neuman MI, Ruddy RM.  Emergent evaluation of the child with acute abdominal pain. UptoDate. 2010 [updated 2010 Aug 2; cited 2011 Mar 6].

Shah SK, Allison ND, Tsao K. Evaluation of abdominal pain in children. Epocrates Online: BMJ Group. [Internet] 2011 [updated 2010 Oct 19; cited 2011 Mar 6].  Available from: https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=787

Minor Sources

Diaz JJ Jr., Bokhari F, Mowery NT, et al. EAST Practice Parameter Workgroup for Management of Small Bowel Obstruction. Guidelines for small bowel obstruction. J Trauma. 2008;64:1651-1664.

Hackam DJ, Newman K, Ford HR. Pediatric surgery: gastrointestinal tract. In: Schwartz’s principles of surgery. 8th ed. New York: McGraw-Hill; 2005: 1493-1494.

Acknowledgements

Writer: Christopher Cheung

Edited by: Gaby Yang, Pediatric Resident

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