ACUTE ABDOMINAL PAIN IN CHILDREN
Category: Pediatric Surgery
Abstract : Acute abdominal pain in children presents a diagnostic dilemma. Although many
cases of acute abdominal pain are benign, some require rapid diagnosis and
treatment to minimize morbidity. Numerous disorders can cause abdominal pain.
The most common medical cause is gastroenteritis, and the most common surgical
cause is appendicitis. In most instances, abdominal pain can be diagnosed
throug
Acute abdominal pain in children presents a diagnostic dilemma. Although many
cases of acute abdominal pain are benign, some require rapid diagnosis and
treatment to minimize morbidity. Numerous disorders can cause abdominal pain.
The most common medical cause is gastroenteritis, and the most common surgical
cause is appendicitis. In most instances, abdominal pain can be diagnosed
through the history and physical examination.
Age is a key factor in evaluating
the cause; the incidence and symptoms of different conditions vary greatly over
the pediatric age spectrum. In the acute surgical abdomen, pain generally
precedes vomiting, while the reverse is true in medical conditions. Diarrhea
often is associated with gastroenteritis or food poisoning. Appendicitis should
be suspected in any child with pain in the right lower quadrant. Signs that
suggest an acute surgical abdomen include involuntary guarding or rigidity,
marked abdominal distention, marked abdominal tenderness, and rebound abdominal
tenderness. If the diagnosis is not clear after the initial evaluation, repeated
physical examination by the same physician often is useful. Selected imaging
studies also might be helpful. Surgical consultation is necessary if a surgical
cause is suspected or the cause is not obvious after a thorough
evaluation.
Abdominal pain is a common problem in children. Although most
children with acute abdominal pain have self-limited conditions, the pain may
herald a surgical or medical emergency. The most difficult challenge is making a
timely diagnosis so that treatment can be initiated and morbidity prevented.
This article provides a comprehensive clinical guideline for the evaluation of
the child with acute abdominal pain.
Pathophysiology
Clinically,
abdominal pain falls into three categories: visceral (splanchnic) pain, parietal
(somatic) pain, and referred pain.
Visceral pain occurs when noxious
stimuli affect a viscus, such as the stomach or intestines. Tension, stretching,
and ischemia stimulate visceral pain fibers. Tissue congestion and inflammation
tend to sensitize nerve endings and lower the threshold for stimuli. Because
visceral pain fibers are bilateral and unmyelinated and enter the spinal cord at
multiple levels, visceral pain usually is dull, poorly localized, and felt in
the midline. Pain from foregut structures (e.g., lower esophagus, stomach)
generally is felt in the epigastrium. Midgut structures (e.g., small intestine)
cause periumbilical pain, and hindgut structures (e.g., large intestine) cause
lower abdominal pain.
Parietal pain arises from noxious stimulation of
the parietal peritoneum. Pain resulting from ischemia, inflammation, or
stretching of the parietal peritoneum is transmitted through myelinated afferent
fibers to specific dorsal root ganglia on the same side and at the same
dermatomal level as the origin of the pain. Parietal pain usually is sharp,
intense, discrete, and localized, and coughing or movement can aggravate
it.
Referred pain has many of the characteristics of parietal pain but is
felt in remote areas supplied by the same dermatome as the diseased organ. It
results from shared central pathways for afferent neurons from different sites.
A classic example is a patient with pneumonia who presents with abdominal pain
because the T9 dermatome distribution is shared by the lung and the
abdomen.
Etiology
Information on rare entities can be found in a
standard pediatric surgery textbook.
INFANTILE COLIC
Infantile colic
affects 10 to 20 percent of infants during the first three to four weeks of
life. Typically, infants with colic scream, draw their knees up against their
abdomen, and appear to be in severe
pain.
GASTROENTERITIS
Gastroenteritis is the most common cause of
abdominal pain in children. Viruses such as rotavirus, Norwalk virus,
adenovirus, and enterovirus are the most frequent causes. The most common
bacterial agents include Escherichia coli, Yersinia, Campylobacter, Salmonella,
and Shigella.
APPENDICITIS
Appendicitis is the most common surgical
condition in children who present with abdominal pain. Approximately one in 15
persons develop appendicitis. Lymphoid tissue or a fecalith obstructs the
appendiceal lumen, the appendix becomes distended, and ischemia and necrosis may
develop. Patients with appendicitis classically present with visceral, vague,
poorly localized, periumbilical pain.Within six to 48 hours, the pain becomes
parietal as the overlying peritoneum becomes inflamed; the pain then becomes
well localized and constant in the right iliac fossa.
MESENTERIC
LYMPHADENITIS
Mesenteric lymphadenitis often is associated with adenoviral
infection.The condition mimics appendicitis, except the pain is more diffuse,
signs of peritonitis often are absent, and generalized lymphadenopathy may be
present.
CONSTIPATION
Acute constipation usually has an organic cause
(e.g., gastroenteritis, appendicitis), while chronic constipation usually has a
functional cause (e.g., low-residue diet). Abdominal pain resulting from
constipation is most often leftsided or suprapubic.
ABDOMINAL
TRAUMA
Abdominal trauma can be accidental or intentional. Blunt abdominal
trauma is more common than penetrating injury.Abdominal trauma may cause
musculocutaneous injury, bowel perforation, intramural hematoma, laceration or
hematoma of the liver or spleen, and avulsion of intra-abdominal organs or
vascular pedicles.
INTESTINAL OBSTRUCTION
Intestinal obstruction
produces a characteristic cramping. Causes of intestinal obstruction include
volvulus, intussusception, incarcerated hernia, and postoperative
adhesions.
PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease
(PID) usually is caused by Chlamydia trachomatis or Neisseria gonorrhoeae. Risk
factors include multiple sexual partners, use of an intrauterine device (IUD),
and a history of PID.
Clinical Evaluation
In
evaluating children with abdominal pain, a thorough history is required to
identify the most likely cause. An initial evaluation of the history is followed
by a physical examination and a reassessment of certain points of the
history.
HISTORY
Age of Onset. Age is a key factor in the evaluation
of abdominal pain.
Pain History.
Children who do not
verbalizetypically present with late symptoms of disease. Children up to the
teenage years have a poor sense of onset or location of pain. The classic
sequence of shifting pain usually occurs with appendicitis. In children who
cannot verbalize, the initial 24-hour history of vague nausea or periumbilical
pain may be unreported or go unnoticed, so these children more often present at
the second stage of more visceral pain. However, any child with pain that
localizes to the right lower quadrant should be suspected of having
appendicitis. Thus, inquiry into the location, timing of onset, character,
severity, duration, and radiation of pain are all important points but must be
viewed in the context of the child’s age.
Recent Trauma.
A history of
recent trauma may indicate the cause of pain.
Precipitating or Relieving
Factors.
Parietal pain is aggravated by movement.Relief of pain after a bowel
movement suggests a colonic source, and relief after vomiting suggests a source
in the more proximal bowel.
Associated Symptoms.
In the acute surgical
abdomen, pain generally precedes vomiting, and the reverse is true in medical
conditions. Any child presenting with bilious vomiting should be presumed to
have a bowel obstruction. Diarrhea often is associated with gastroenteritis or
food poisoning, but it also can occur with other conditions. Bloody diarrhea is
much more suggestive of inflammatory bowel disease or infectious enterocolitis.
The classic “currant-jelly stool” often is seen in patients with
intussusception. Failure to pass flatus or feces suggests intestinal
obstruction.
Urinary frequency, dysuria, urgency, and malodorous urine
suggest a urinary tract infection. Purulent vaginal discharge suggests
salpingitis. Cough, shortness of breath, and chest pain point to a thoracic
source. Polyuria and polydipsia suggest diabetes mellitus. Joint pain, rash, and
smoke-colored urine suggest Henoch-Schönlein purpura.
Gynecologic
History.
In girls, a thorough gynecologic history, including a menstrual
history and a history of sexual activity and contraception, is essential.
Amenorrhea may indicate pregnancy. A history of multiple sexual partners and the
use of an IUD suggest PID. Use of an IUD and a history of PID or tubal ligation
increase the risk of ectopic pregnancy. Sudden onset of midcycle pain of short
duration suggests mittelschmerz.
Past Health.
All previous
hospitalizations or significant illnesses such as sickle cell anemia and
porphyria should be noted.A history of surgery not only can eliminate certain
diagnoses but also can increase the risk of others, such as intestinal
obstruction from adhesions. A history of similar pain may suggest a recurrent
problem.
Drug Use.
A detailed drug history is important, because
certain drugs may cause abdominal pain.
Family History.
A family
history of sickle cell anemia or cystic fibrosis may indicate the diagnosis. The
patient’s ethnic background is important because sickle cell anemia is most
common in blacks of African origin.
PHYSICAL
EXAMINATION
General Appearance.
In general, children with
visceral pain tend to writhe during waves of peristalsis, while children with
peritonitis remain quite still and resist movement. The hydration status of the
child should be assessed.
Vital Signs.
Fever indicates an underlying
infection or inflammation. High fever with chills is typical of pyelonephritis
and pneumonia. Tachycardia and hypotension suggest hypovolemia. If a
postmenarcheal girl is in shock, ectopic pregnancy should be suspected.
Hypertension may be associated with Henoch-Schönlein purpura or hemolytic uremic
syndrome. Kussmaul’s respiration indicates diabetic
ketoacidosis.
Abdominal Examination.
The breathing pattern should be
observed, and the patient should be asked to distend the abdomen and then
flatten it. After the child is asked to indicate, with one finger, the area of
maximal tenderness, the abdomen should be gently palpated, moving toward (but
not palpating) that area. The physician should examine for Rovsing’s sign (when
pressure on the left lower quadrant distends the column of colonic gas, causing
pain in the right lower quadrant at the site of appendiceal inflammation), then
gently assess muscle rigidity. Gentle percussion best elicits rebound
tenderness. Deeper palpation is necessary to discover masses and
organomegaly.
Rectal and Pelvic Examination.
These examinations should
be used when significant information is sought or expected. A rectal examination
may provide useful information about tenderness, sphincter tone, and presence of
masses, stool, and melena. In boys, examination of the external genitalia may
reveal penile and scrotal abnormalities. In girls, it may reveal vaginal
discharge, vaginal atresia, or imperforate hymen. A bimanual pelvic examination
may provide useful information about uterine or adnexal masses or tenderness.
Purulent cervical discharge, cervical motion tenderness, and adnexal mass are
signs of PID.
Associated Signs.
Jaundice suggests hemolysis or liver
disease. Pallor and jaundice point to sickle cell crisis. A positive iliopsoas
test (passive extension of the right hip and flexion of the right thigh against
resistance) or obturator test (rotation of the right flexed hip) suggests an
inflamed retrocecal appendix, a ruptured appendix, or an iliopsoas abscess. A
positive Murphy’s sign (interruption of deep inspiration by pain when the
physician’s fingers are pressed beneath the right costal margin) suggests acute
cholecystitis. Cullen’s sign (bluish umbilicus) and Grey Turner’s sign
(discoloration in the flank) are unusual signs of internal hemorrhage. Purpura
and arthritis suggest Henoch-Schönlein
purpura.
Investigations
Laboratory studies should be
tailored to the patient’s symptoms and clinical findings. Initial laboratory
studies may include a complete blood cell count and urinalysis. A low hemoglobin
level suggests blood loss or underlying hematologic abnormalities, such as
sickle cell disease. However, a normal hemoglobin level does not exclude an
acute massive hemorrhage for which the body has not yet compensated.
Leukocytosis, especially in the presence of a shift to the left and toxic
granulations in the peripheral smear, indicates an infection. Urinalysis can
help identify urinary tract pathology, such as infection or stones. A pregnancy
test should be considered in postmenarcheal girls.
Plain-film abdominal
radiographs are most useful when intestinal obstruction or perforation of a
viscus in the abdomen is a concern. Chest radiographs may help rule out
pneumonia. The most contentious issue in emergency medicine may be the
usefulness of ultrasonography and computed tomography (CT) in patients with
abdominal pain. CT likely is more accurate than ultrasonography. However, the
experience of the operator and interpreter significantly affect the accuracy of
both modes. In the emergency department, ultrasonography probably is most useful
in diagnosing gynecologic pathology such as ovarian cysts, ovarian torsion, or
advanced periappendiceal inflammation. CT involves radiation exposure and may
require the use of contrast agents. CT may be necessary if excessive bowel gas
precludes ultrasonographic
examination.
Management
Treatment should be directed
at the underlying cause. In many patients, the key to diagnosis is repeated
physical examination by the same physician over an extended time. Traditionally,
the use of analgesics is discouraged in patients with abdominal pain for fear of
interfering with accurate evaluation and diagnosis. However, several
prospective, randomized studies have shown that judicious use of analgesics
actually may enhance diagnostic accuracy by permitting detailed examination of a
more cooperative patient.
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