2 Abdominal Pain in Children

Because functional abdominal pain (previously called chronic or recurrent abdominal pain) is uncommon in children, the main emphasis of this chapter is the differential diagnosis of acute and recurrent abdominal pain. Abdominal pain in children has many potential causes, so a detailed history and a very careful physical examination are necessary. A small number of selected laboratory studies may also be required. Accurate diagnosis is essential because abdominal pain may be a manifestation of a surgical emergency, which must be identified promptly. Whenever significant concern exists about the presence of a surgical condition, the patient should be hospitalized to permit serial abdominal examinations and laboratory studies.

Red flags for chronic abdominal pain in children include: age less than 5 years, nocturnal pain, blood in stool, dysphagia, arthritis, family history of inflammatory bowel disease, unexplained fever, persistent vomiting (especially bilious) or diarrhea, and weight loss or growth failure.

Gastroenteritis is the most common cause of acute abdominal pain in children, and appendicitis is the second most common. Constipation, another common cause of abdominal pain, may be acute but is more often recurrent. Other common nonsurgical causes of acute abdominal pain are mesenteric adenitis, urinary tract infection, sickle cell disease, poisoning, and diabetes. Functional abdominal pain is defined as weekly episodes of abdominal pain occurring over 2 or more months. It is quite common in children older than 5 years and usually has a psychosomatic cause (Table 2-1). Irritable bowel syndrome is similar, but in addition, there is a change in frequency or form of stool and/or the pain is relieved by defecation.

TABLE 2-1 Causes of Acute Abdominal Pain in Children

Gastrointestinal causes	Gastroenteritis Appendicitis Mesenteric lymphadenitis Constipation Abdominal trauma Intestinal obstruction Peritonitis Food poisoning Peptic ulcer Meckel’s diverticulum Inflammatory bowel disease Lactose intolerance
Genitourinary causes	Urinary tract infection Urinary calculi Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Endometriosis Hematocolpos
Drugs and toxins	Erythromycin Salicylates Lead poisoning Venoms
Pulmonary causes	Pneumonia Diaphragmatic pleurisy Pharyngitis Angioneurotic edema
Metabolic disorders	Diabetic ketoacidosis Hypoglycemia Familial Mediterranean fever Porphyria Acute adrenal insufficiency
Liver, spleen, and biliary tract disorders	Hepatitis Cholecystitis Cholelithiasis Splenic infarction Rupture of the spleen Pancreatitis
Hematologic disorders	Sickle cell anemia Henoch-Schönlein purpura Hemolytic uremic syndrome
Miscellaneous	Infantile colic Functional pain

From Leung AK, Sigalet DL: Acute abdominal pain in children. Am Fam Physician 67:2321-2326, 2003.

The most common surgical causes of acute abdominal pain are appendicitis, hernia strangulation, and intussusception.

Nature of Patient

Presentation and causes of abdominal pain vary according to three age groups, as follows:

1. Children younger than 5 years

2. Patients between 5 and 12 years of age

3. Adolescents (Table 2-2)

TABLE 2-2 Differential Diagnosis of Acute Abdominal Pain by Predominant Age

From Leung AK, Sigalet DL: Acute abdominal pain in children. Am Fam Physician 67:2321-2326, 2003.

When otherwise healthy and well-fed infants cry for more than 3 hours a day, for more than 3 days a week, and for more than 3 weeks, the probable cause is infantile colic. The cause of abdominal pain in very young children is difficult to determine unless abdominal tenderness, guarding, doubling up, or vomiting is present. With the exception of infantile colic, when children less than 3 years old complain of abdominal pain, it is usually organic in origin. Physical examination is particularly important in this age group. Intussusception is likely when signs of intestinal obstruction are found in infants (peak incidence, 6 months). A lead point such as Meckel’s diverticulum is seldom found. Appendicitis is uncommon in infants and children up to age 5 years, but it is the most common condition causing abdominal pain that requires surgery in this age group. Because appendicitis is seldom considered, the diagnosis is often missed or delayed. Perforation is therefore more common, and a disproportionately high percentage of deaths due to appendicitis occurs in children younger than 5 years. Poisoning, most common in children ages 1 to 4 years, is another frequent cause of abdominal pain.

In children between 5 and 12 years, the major dilemma involves functional abdominal pain, which is usually of psychosomatic origin, though it may be due to organic disease. Children with functional abdominal pain have a high incidence of behavioral and personality disorders. These patients tend to be high-strung perfectionists and are often apprehensive. Many have histories of colic and feeding problems in infancy and stressful family and school situations. Unexplained episodes of recurrent abdominal pain occur in 10% of school-aged children, but an organic cause is found in less than 10% of these cases.

In female adolescents with abdominal pain, dysmenorrhea, endometriosis, pelvic inflammatory disease (PID), ovarian cysts, corpus luteal cysts, and müllerian abnormalities must be considered. Inflammatory bowel disease frequently begins during adolescence and can be a cause of acute or recurrent abdominal pain, especially when associated with growth failure. Growth failure may also indicate gluten-sensitive enteropathy. Sickle cell crises occur almost exclusively in black patients but occasionally in people of Mediterranean descent. Acute appendicitis is most common in children ages 5 to 15 years, with a peak incidence between 10 and 15 years.

Nature of Pain

The timing of the first occurrence of abdominal pain in children may help identify psychological stress as the cause. For example, abdominal pain that develops at a time of school problems, peer pressure, the birth of a sibling, family discord, moving, or parental disease or disability suggests a psychological cause. Functional abdominal pain is usually central and nonradiating and rarely awakens the patient at night. It is rarely associated with recurrent vomiting or diarrhea but is often associated with vagueness and multiple symptoms, particularly headache and extremity pains. Functional abdominal pain is one of the four functional gastrointestinal disorders described by the Rome III criteria (the others being functional dyspepsia, irritable bowel syndrome, and abdominal migraine).

In addition to observing the severity, duration, and location of abdominal pain, the examiner must note whether the onset is gradual or sudden. A gradual onset of cramping pain often suggests an intestinal cause, such as appendicitis, whereas a sudden onset of constant noncramping pain suggests torsion of a viscus, intussusception, or perforation. The pain of appendicitis classically precedes the development of vomiting and anorexia, begins gradually as a crampy epigastric or periumbilical pain, and progresses to a constant pain in the right lower quadrant (RLQ). In young children this pain may be mild, discontinuous, or both. Because of frequent atypical presentations and a decreased incidence in young children, this diagnosis is often missed.

The pain of mesenteric adenitis often mimics that of appendicitis, although a child with adenitis is not quite as sick and is not necessarily anorexic. Mesenteric adenitis usually occurs after a viral or bacterial infection. The associated pain may be colicky in younger children and severe and episodic in older children. The child has tenderness and guarding when the pain is present and usually shows no guarding when the pain is absent. This pattern is in contrast to that in appendicitis, in which the guarding persists despite the absence of pain. Guarding and abdominal tenderness are the symptoms most frequently associated with a surgical diagnosis.

Diffuse cramping abdominal pain that follows or coincides with the onset of diarrhea, nausea, or vomiting suggests gastroenteritis. Cramping pain occurring primarily after meals, especially if it is relieved by defecation, is often due to constipation. This diagnosis should be accepted only when an enema yields a large amount of feces and relieves pain. Sudden onset of severe, crampy, spasmodic pain that causes an infant to scream and draw up the legs should suggest intussusception. This spasmodic pain often recurs at 15- to 30-minute intervals, and the child may be normal, lethargic, or sleeping between attacks.

When abdominal pain is severe and colicky and radiates to the groin or flank, urolithiasis should be considered. Hematuria may confirm this diagnosis. Hematuria may also be noted when an inflamed retrocecal appendix overlies the ureter. Abdominal pain associated with tenderness on percussion in the region of the costovertebral angle may indicate pyelonephritis.

When the abdominal pain is relatively constant, located in the midepigastrium, and exacerbated by eating, chronic gastritis caused by Helicobacter pylori must be considered. Likewise, H. pylori infections should be considered in children with duodenal ulcers and recurrent abdominal pain.

The abdominal pain of diabetic acidosis is often generalized, and ketosis is usually present. The abdominal pain of a sickle cell crisis is severe and usually associated with ileus. This diagnosis should be considered in all black children with severe abdominal pain. Every black child in whom the diagnosis of appendicitis is considered should undergo a sickle cell test before surgery. When appendicitis is suspected in the patient with a positive sickle cell test result, an appendectomy should not be performed until the patient is clearly not showing response to medical therapy for sickle cell crisis or shows progressive manifestations of sepsis. Recurrent episodes of severe abdominal pain suggest sickle cell disease, inflammatory bowel disease, cystic fibrosis, and constipation.

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Tags: Differential Diagnosis of Common Complaints

Mar 21, 2018 | Posted by admin in BIOCHEMISTRY | Comments Off

Birth to 1 year	Infantile colic Gastroenteritis Constipation Urinary tract infection Intussusception Volvulus Incarcerated hernia Hirschsprung’s disease
2 to 5 years	Gastroenteritis Appendicitis Constipation Urinary tract infection Intussusception Volvulus Trauma Pharyngitis Sickle cell crisis Henoch-Schönlein purpura Mesenteric lymphadenitis
6 to 11 years	Gastroenteritis Appendicitis Constipation Functional pain Urinary tract infection Trauma Pharyngitis Pneumonia Sickle cell crisis Henoch-Schönlein purpura
12 to 18 years	Appendicitis Gastroenteritis Constipation Dysmenorrhea Mittelschmerz Pelvic inflammatory disease Threatened abortion Ectopic pregnancy Ovarian/testicular torsion Mesenteric lymphadenitis

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