Abdominal pain in children - common problem that often poses a diagnostic…
Abdominal pain in children - common problem that often poses a diagnostic dilemma. The vast majority of episodes are benign and self-limiting, but persistent abdominal pain may signify an underlying pathology requiring urgent intervention
Acute- Character- may vary in severity over time, localised, described as sharp and/or stabbing in nature.
Chronic- lasts days, weeks, months
Age of child, pain hx, associated symptoms, Trauma Hx, travel Hx, stool patterns and diet hx, PMHx including birth and development, Drug Hx, FHx, SHx, Sexual Hx
Acute- lasts from hours to days.
Chronic- character-dull, diffuse, and poorly localised, variable
FBC, U&Es, LFTs, amylase and lipase, inflammatory markers ESR/CRP, coagulation profile
For females of reproductive age a urine pregnancy test and/or serum beta-hCG is necessary to exclude miscarriage and ectopic pregnancy.
Urinalysis to exclude infection
Helicobacter pylori breath test or stool antigen test may be helpful.
Polymorphonuclear leukocytes (PMNs) seen on wet mount of vaginal secretions confirms vaginal infection in cases of pelvic inflammatory disease (PID).
STI, hepatitis and HIV screen
BP, Pulse, Temp, Resp, CR, SpO2, hydration and circulation, activity, respiratory,
Comprehensive physical examination
Abdominal examination- Classic abdominal signs of appendicitis are RLQ abdominal tenderness (McBurney's sign) and localised rebound tenderness, if the appendix is anterior. Compressing the left lower quadrant (LLQ) may elicit pain in the RLQ (Rovsing's sign). Patients with appendicitis may lie still and try not to move, particularly in severe cases with significant peritoneal irritation.
Acute mesenteric adenitis often resembles acute appendicitis; however, pain in the abdomen is usually diffuse with tenderness not localised to the RLQ. Guarding may be present but rigidity is usually absent
Abdominal distension and hyperactive bowel sounds are common findings, with diffuse pain without evidence of guarding or rebound tenderness, in patients with gastroenteritis
abdominal distension and tenderness associated with decreased or absent bowel sounds is strongly suggestive of large bowel obstruction. In severe cases of constipation, abdominal distension may be present with a palpable faecal mass per abdomen or rectum.
Flank pain or renal angle tenderness may indicate pyelonephritis or nephrolithiasis
Epigastric pain may indicate peptic ulcer disease or pancreatitis. Patients with pancreatitis may lie with their knees and hips flexed and avoid moving. It is important to note that, in younger patients with pancreatitis (<3 years of age), abdominal tenderness may not be the main finding; these patients may demonstrate increased irritability and abdominal distension. With haemorrhagic pancreatitis, discoloration may be noted around the umbilical area (Cullen's sign) or in the flanks (Grey-Turner's sign) due to blood tracking along defined fascial planes.
Tenderness in the right upper quadrant (RUQ) is a classical sign of gallbladder disease, as is Murphy's sign (cessation of inspiration during concurrent deep RUQ palpation). Patients with biliary dyskinesia usually present in a similar fashion to those with cholelithiasis and cholecystitis and may have RUQ tenderness on palpation.
splenic infarction typically present with left-sided abdominal pain. Pain may also be reported in the left side of the chest or the left shoulder. Those with a splenic cyst are either asymptomatic or present with dull left-sided abdominal pain in the absence of fever
Abdominal trauma should be considered when abdominal pain is out of proportion to physical examination findings. Signs of accidental (e.g., seatbelt mark suggesting a motor vehicle accident) and non-accidental injury (particularly if history is suspicious) should be sought (e.g., cigarette burns, subdural haemorrhages in an infant/young toddler). The presence of seat belt marks increases the likelihood that intra-abdominal injuries are present, particularly in the presence of lumbar fracture or persistent tachycardia
If clinical findings are minimal and the child appears well, a diagnosis of functional abdominal pain should be considered. Diagnostic criteria for functional abdominal pain are symptom based, not physical examination or laboratory based
Absent bowel sounds, bilious vomiting, bloody diarrhoea or occult blood in stool, fever (≥38°C [≥100.4°F]), rebound tenderness, rigidity, and voluntary guarding indicate a possible need for surgery
The presence of an anal fissure and/or haemorrhoids (rare in children; may be mistaken for skin tags from Crohn's disease), imperforate anus, or anal stenosis (particularly in a neonate or infant) may provide further diagnostic clues.
There may be palpable stool in the rectum in constipation
External genital examination
Blood at the urethral meatus, or haematuria, after trauma may suggest urinary tract or kidney injury.
Testicular torsion is likely in any male child with abdominal tenderness plus loss of the cremasteric reflex, diffuse testicular tenderness, elevated testes, and a horizontal rather than vertical position of the testes on exam
Functional abdominal pain
Acute appendicitis resulting in perforation
Ruptured ectopic pregnancy
X-ray- abdo and chest
laparoscopy and endoscopy