Acute Abdominal Pain
The abdominal pain evaluation in children is problematic because the pain is often difficult to localize,and the history in children is often nonspecific.
1. Localization of abdominal pain
: Generalised pain in the epigastrium usually comes from the stomach, duodenum, or the pancreas.
: Periumbilical pain usually originates in small bowel and colon or spleen.
: This is caused by inflammation, is usually well localized.
Referred abdominal pain
: This pain occurs when poorly localized visceral pain is felt at a distant location.
Pancreatitis, cholecystitis, liver abscess, or a splenic hemorrhage cause diaphragmatic irritation, which is referred to the ipsilateral neck and shoulders. Intra abdominal fluid may cause shoulder pain on reclining. Gallbladder pain may be felt in the lower back or infrascapular area. Pancreatic pain often is referred to the posterior flank. Ureterolithiasis often presents as pain radiating toward the ipsilateral groin. Rectal or gynecological pain often is perceived as sacral pain. Right lower lobe pneumonia maybe perceived as right upper quadrant abdominal pain.
2. Clinical evaluation
History should include the quality, timing, and type of abdominal pain.
Pain of sudden onset often denotes colic, perforation or acute ischemia caused by torsion or volvulus.
Slower onset of pain suggests inflammatory conditions, such as appendicitis, pancreatitis, or cholecystitis.
Colic pain is characterized by severe, intermittent cramping, followed by intervals when the pain is less intense. Colic pain usually originates from the biliarytree, pancreatic duct, gastrointestinal tract, urinary system,or uterus and tubes.
Inflammatory pain is caused by peritoneal irritation, and the patient presents quietly without much motion and appears ill. The pain is initially less severe and is exacerbated by movement.
: Abdominal pain will usually precede vomiting. The interval between abdominal pain and vomiting is shorter when associated with colic.
: Mild diarrhea with the onset of abdominal pain suggests acute gastroenteritis or early appendicitis. Delayed onset of diarrhea may indicate a perforated appendicitis, with the inflamed mass causing irritation of the sigmoid colon.
: The abdomen should be observed, and palpated for distention, localized tenderness, masses, and peritonitis. The groin must be examined to exclude an incarcerated hernia or ovary, or torsion of an ovary or testicle.
- Gross blood in the stool suggests ectopic gastric mucosa, Meckelís diverticula, or polyps.
- Blood and mucus (currant jelly stool) suggests inflammatory bowel disease or intussusception.
- Tests for occult blood in the stool should be performed.
Pelvic examinations are mandatory for postmenarchal and/or sexually active female patients. The rectal examination may also be used to evaluate the cervix, uterus, adnexa, and pelvic masses.
- Thoracic disease (eg, pneumonia) may be the cause of abdominal pain associated with fever.
- Costovertebral angle tenderness with fever suggests pyelonephritis or a high retrocecal appendicitis.
Fever, vomiting, irritability, lethargy with right lower quadrant (RLQ) tenderness and guarding are diagnostic of appendicitis in the very young patient until proven otherwise.
A WBC >15,000 supports the diagnosis. An ultrasound of the appendix may be useful.
Children older than 2 years old present with a perforated appendix about 30-60% of the time. This incidence declines as the age of the child increases.
Intussusception is the most common cause of bowel obstruction between 2 months and 5 years of age.
Intussusception is characterized by vomiting, colicky abdominal pain with drawing up of the legs, and currant jelly stools. Fever is common.
The abdomen may be soft and non tender between episodes of pain, but eventually it becomes distended.
: The leading edge ofthe intussusception is usually outlined with air, which will establish the diagnosis. Often there are radiographic signs of bowel obstruction. When the plain abdominal x-rayis normal, intussusception cannot be excluded without a barium enema.
Treatment consists of radiologic reduction, which is effective in 80-90%. Radiographic reduction is contraindicated if there is peritoneal irritation or toxicity.
5. Gallbladder disease
Cholecystitis in children occurs most commonly in the adolescent female, but it may affect infants who are only a few weeks of age. Cholecystitis is suggested by back pain, or epigastric pain, radiating to the right subscapular area, bilious vomiting, and fever. Jaundice is present in 25-55%, usually in association with hemolytic disease.
Ultrasonography delineates gallstones and is the study of choice to screen for gallbladder disease.
Radioisotopic scanning evaluates biliary and gallbladder function.
6. Ectopic pregnancy
Ectopic pregnancy must be considered in any postmenarchal, sexually active adolescent with abdominal pain. It is uncommon and usually seen in late adolescence.
Signs of ectopic pregnancy include abdominal pain in any location, vaginal bleeding, and/or amenorrhea. Nausea and vomiting, other symptoms of pregnancy,and lightheadedness may also be present.
Abdominal, adnexal, and/or cervical tenderness are often found on pelvic examination, but occasionally abdominal tenderness is absent. The cervix may be soft and bluish in color. The examination may reveal adnexal fullness and uterine enlargement.
Evaluation includes a pregnancy test and ultrasound. Treatment consists of removal of the ectopic pregnancy by laparoscopy or exploratory laparotomy.
7. Gonadal pain in males
In males with lower abdominal pain, the scrotum and its contents must be examined. Testicular torsion is a surgical emergency and must be treated within 6 hours of the onset of the pain to save the testicle.
Testicular torsion may present as lower abdominal pain, which may be associated with recent trauma or cold. The gonad is tender and elevated in the scrotum, with a transverse orientation. Although testicular torsion may occur at any age, it usually occurs in adolescent males at puberty or shortly afterwards.
8. Gonadal pain in females
The leading causes of gonadal pain in females are ovarian cysts and torsion of uterine adnexal structures.
Ovarian cysts are responsible for 25% of childhood ovarian tumors, most commonly in adolescents. Bleeding into the cyst or cystic rupture causes pain, which usually subsides within 12-24 hours. Ultrasound may show pelvic fluid and the cyst.
Torsion of uterine adnexal structures.
Torsion is associated with unilateral, sudden, severe pain with nausea and vomiting. The patient may also have subacute or chronic symptoms, with intermittent pain for days. The pain is usually diffuse and periumbilical in younger patients, but in older children and adolescents, the pain may radiate initially to the anterior thigh or ipsilateral groin.
Fever and leucocytosis are usually present. Physical exam may reveal muscle rigidity and fixation of the mass on pelvic examination.
Ultrasound will identify the mass accurately. Surgical exploration may sometimes salvage the ovary. Malignant neoplasms may cause torsion in 35% of cases.