Abdominal Pain

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Chapter 5 Abdominal Pain

Reza J. Daugherty, MD, Jill C. Posner, MD

1 Why is the evaluation of abdominal pain especially challenging in the pediatric patient?

Infants with abdominal pain may present with nonspecific signs, such as irritability, poor feeding, and lethargy. Toddlers and preschool children may report pain but are unable to provide further details, such as the quality or location of the pain. The physical examination of a child requires time and patience on the part of the examiner. The history and a physical examination of the abdomen may be more difficult to obtain with children. In addition to the more common causes, the differential diagnosis of abdominal pain in children includes a host of disorders unique to the pediatric patient, such as congenital anatomic abnormalities, Henoch-Schönlein purpura, abdominal migraines, or metabolic disorders.

McCollough M, Sharieff GO: Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 21:909–935, 2003.

Pollack ES: Pediatric abdominal surgical emergencies. Pediatr Ann 25:448–457, 1996.

2 How can I organize my approach to the patient?

In the unstable patient, the initial approach should begin with an assessment of the patient’s airway, breathing, and circulation. Following stabilization, obtain a complete history and perform a physical examination. The history and physical examination are the essential components of the evaluation. Elicit the nature of the pain, such as its onset, quality, location, and duration, as well as the presence of any associated symptoms. The differential diagnosis of abdominal pain in children is extensive (Table 5-1). The age of the patient and the most likely diagnoses in that age group can be used in concert with the history and physical examination to narrow the differential and guide further diagnostic testing.

Table 5-1 Causes Of Acute Abdominal Pain

image

image

3 What are the life-threatening causes of abdominal pain?

image Appendicitis

image Intussusception

image Incarcerated hernia

image Trauma (accidental or inflicted injury)

image Tumors

image Sepsis

image Volvulus

image Ectopic pregnancy

image Diabetic ketoacidosis

image Intra-abdominal abscess (pelvic inflammatory disease, inflammatory bowel disease)

image Aortic aneurysm

image Toxic ingestion (iron, lead, aspirin)

4 What are some extraintestinal causes of abdominal pain?

Pain originating at sites distant from the abdomen can be manifest by abdominal pain. In processes such as lower lobe pneumonia, afferent nerves from the parietal pleura share central pathways with those that originate from the abdominal wall. Similarly, scrotal pain may be referred to the abdomen. Other illnesses that are associated with abdominal pain include streptococcal pharyngitis, renal calculi, urinary tract infections, diabetes mellitus, ovarian disease (cyst, torsion, pelvic inflammatory disease), testicular disease, cholecystitis, pancreatitis, sickle cell vaso-occlusive crisis, lead toxicity, and porphyria.

5 How can I maximize the physical examination of the pediatric patient with abdominal pain?

The physical examination of a child requires patience on the part of the examiner, who must take time to establish rapport. Begin with observation, often best accomplished while unseen by the child. Notice the general appearance of the child. Is he lying still on the stretcher, suggesting peritonitis, or writhing with colicky pain? Is she able to climb off or onto the stretcher? Commence further inspection, auscultation, and palpation by examining the least threatening areas first and saving particularly invasive aspects of the examination for last (e.g., otoscopy). Lying the child with his or her knees flexed may facilitate relaxation of the rectus muscles. The child’s “help” can be elicited during the abdominal examination by allowing him to place his hands on top of the examiner’s during palpation. Apply gentle pressure beginning in a location away from the area identified by the child as the most painful. If a surgical consultation is anticipated, the physicians should agree on who will perform the digital r examination, thus minimizing the number of examinations.

McCollough M, Sharieff GO: Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 21:909–935, 2003.

KEY POINTS: ABDOMINAL EMERGENCIES

1 Analgesia should not be withheld from a child with abdominal pain of unknown etiology simply for fear of delaying diagnosis or causing misdiagnosis.

2 Children are at particularly high risk of ruptured appendicitis, with the youngest children possessing the highest risk.

6 Does the use of IV analgesia affect the diagnostic accuracy of the physical examination in children with significant abdominal pain of unknown etiology?

It is imperative that health care practitioners caring for children make every effort to safely and effectively treat pain whenever possible. Multiple studies with adults and one with children have shown that giving IV narcotics at adequate doses to decrease pain does not adversely affect the physical examination or diagnostic accuracy in patients with abdominal pain of unknown etiology. In fact, pain control might facilitate localization of the origin of the pain, thereby improving the diagnostic accuracy of the physical examination. Therefore, avoid delaying administration of proper analgesia simply because the diagnosis is unknown or the child is awaiting examination by a consultant.

Kim MK, Strait RT, Sato TT, et al: A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 9:281–287, 2002.

Thomas SH, Silen W, Cheema F, et al: Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: A prospective, randomized trial. J Am Coll Surg 196:18–31, 2003.

7 Which blood tests may be useful in the evaluation of abdominal pain?

Patients who have experienced unremitting vomiting and appear dehydrated may have electrolyte abnormalities. In young infants, patients who will undergo surgery, or patients who are more severely ill, it may be more important to obtain blood studies to evaluate abdominal pain. The benefit of the complete blood count (CBC) remains controversial. While an elevated white blood cell count is common in appendicitis, this finding is neither sensitive (many patients with appendicitis will have a normal white blood cell count) nor specific (many patients without appendicitis will have an elevated count). Measurement of liver aminotransferase values is useful in patients with scleral icterus or right-upper-quadrant tenderness. An elevation of one or both of serum amylase and lipase in the appropriate clinical context supports the diagnosis of pancreatitis.

8 What other laboratory testing may be helpful in certain patients?

A urinalysis is relatively inexpensive and easy to obtain. It can be helpful in diagnosing urinary tract infections and renal calculi but can be misleading if pyuria is due to cervicitis or bladder/ureteral irritation from an adjacent inflamed appendix. A urine pregnancy test is indicated in most postpubertal females. Additionally, diagnostic testing for gonorrhea and chlamydia should be included when indicated.

9 What are the two most common causes of acute abdominal emergencies in children?

Appendicitis is the most common cause in the United States, followed by intussusception.

Pollack ES: Pediatric abdominal surgical emergencies. Pediatr Ann 25:448–457, 1996.

10 What is the typical presentation of appendicitis in children?

There is no typical presentation of appendicitis; thus, the diagnosis can be difficult to make and easy to miss. Classically, periumbilical abdominal pain precedes the onset of vomiting and is associated with low-grade fever and anorexia. As the inflammation of the appendix advances and touches the adjacent peritoneum, the pain localizes to the right lower quadrant at McBurney’s point. Since the clinical course often does not follow the “textbook” description, the physician must maintain a high index of suspicion.

D’Agostino J: Common abdominal emergencies in children. Pediatric Emerg Med 20:139–153, 2002.

11 What are some of the pitfalls in diagnosing appendicitis?

The presentation of a child with appendicitis may not be “textbook.” The absence of fever or anorexia, pain in an atypical location, the presence of diarrhea, prolonged symptoms, and normal laboratory values can occur in patients with appendicitis. An appendix that is located in the lateral gutter can cause flank pain and lateral abdominal tenderness; an appendix that lies toward the left may produce hypogastric tenderness; and a retrocecal appendix may cause pain elicited only on deep palpation. While vomiting occurs more commonly, diarrhea may result from direct sigmoid irritation from the adjacent low-lying pelvic appendix. Similarly, bladder or ureteral irritation may result in dysuria and pyuria.

12 Discuss the test characteristics (e.g., sensitivity, specificity) of limited computed tomography (CT) with rectal contrast in the evaluation of children with suspected appendicitis.

Delays in the diagnosis of appendicitis may result in increased morbidity and mortality. Limited helical CT with administration of rectal contrast material has gained popularity in recent years. Although ultrasonography has the benefit of not exposing the child to ionizing radiation, it is operator dependent and may have limited use in obese children. CT is less operator dependent than ultrasonography, may provide several alternate diagnoses, and has excellent reported test characteristics in children. The sensitivity has been reported as 97%; specificity, 99%; positive predictive value, 98%; and negative predictive value, 98%.

Mullins M, Kircher M, Ryan D, et al: Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. AJR 176:37–41, 2001.

Pena BM, Taylor GA, Fishman SJ, Mandl KD: Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children. Pediatrics 106:672–676, 2000.

13 Which patients are more likely to develop appendiceal perforation?

Young children, those with atypical presentations, and those who present early in their clinical course are at the highest risk.

14 What is the “Classic Triad” of intussusception? Does it occur in most patients?

Intussusception occurs when a portion of the bowel, usually the distal ileum, telescopes into an adjacent segment of bowel. This effectively leads to intestinal obstruction followed by venous congestion and, finally, arterial insufficiency. The classic triad of pain, currant-jelly stool, and abdominal mass on palpation are present in about 20–25% of children with intussusception.

15 In which patients should the diagnosis of intussusception be considered?

In the classic description of intussusception, a child age 3 months to 3 years presents with the legs intermittently drawn up to the chest while crying, bloody stools, vomiting, and a sausage-shaped abdominal mass. Unfortunately, the classic presentation is not common. Many children present with lethargy or a change in mental status. The goal is to diagnose and treat intussusception prior to the evolution of “currant-jelly stools,” an indicator that significant bowel ischemia has occurred.

Klein EJ, Kapoor D, Shugerman RP: The diagnosis of intussusception. Clin Pediatr 43:343–347, 2004.

Kuppermann N, O’Dea T, Pinckney L, Hoecker C: Predictors of intussusception in young children. Arch Pediatr Adolesc Med 154:250–255, 2000.

16 Are plain radiographs helpful in the diagnosis of intussusception?

Very often, plain radiography is the first imaging study performed in the evaluation of the child with possible intussusception. Early on, plain films are usually normal, but, as the disease progresses, up to 60% will show absence of air in the right upper and lower quadrants and evidence of soft tissue density. Because radiography lacks sensitivity and many false-negative results occur, normal plain films should not exclude the diagnosis of intussusception.

Byrne AT, Goeghegan T, Govender P, et al: The imaging of intussusception. Clin Radiol 60:39–46, 2005.

17 What other imaging modalities are commonly used in children to confirm or rule out intussusception?

image Ultrasonography has the advantage of being relatively fast, noninvasive, and without exposure to ionizing radiation. Although it may be operator dependent, in experienced hands the sensitivity and specificity are high.

image Contrast enema has long been the standard for diagnosis and often treatment of intussusception. Barium or air is introduced under pressure into the bowel via a tube in the rectum during fluoroscopy. Air is safer, cheaper, more effective at reduction, and poses less risk of bowel perforation.

Byrne AT, Goeghegan T, Govender P, et al: The imaging of intussusception. Clin Radiol 60:39–46, 2005.

18 Are plain radiographs indicated in every child with abdominal pain?

No. Many experts would argue against the routine use of abdominal radiographs for patients with abdominal pain. A negative x-ray rarely eliminates the concern for an underlying pathologic process. Radiographic findings, if present, are often nonspecific.

19 What abnormalities may appear on plain radiographs in children with abdominal pain?

The plain film should be assessed for “bones, stones, masses, and gas.” An appendicolith is present in only about 10% of patients with appendicitis. Other findings in appendicitis may include diminished air, thickening of the cecal wall and mucosal folds, indistinct psoas margins with scoliosis toward the right, and obliteration of the properitoneal fat pad. Rarely, a perforated appendix may produce pneumoperitoneum. Some renal calculi can be visualized on plain radiographs of the abdomen. The invaginating bowel of intussusception may be apparent as an intraluminal density, but the more common finding is a paucity of air in the right lower quadrant. Multiple stacked, dilated loops of bowel with air fluid levels and the absence of distal air may signify intestinal obstruction. Abdominal radiographs may show evidence of constipation, previously unsuspected.

20 Are there any other useful radiologic studies for children with abdominal pain?

The benefits of ultrasonography have been clearly established in some disease processes. It has become an integral component of the workup for pyloric stenosis, can be useful in evaluating the postpubertal female with possible ovarian or uterine pathology, or the child with suspected appendicitis. With the advent of spiral CT, CT scanning is gaining in popularity for detecting renal calculi and intra-abdominal infections, including appendicitis. An upper gastrointestinal series with small bowel follow-through is used to detect intestinal malrotation. Failure of the C-loop of the duodenum to cross the midline and an abnormal location of the cecum signify a malrotation diagnosis.

21 What is the most important diagnostic “test” in cases of abdominal pain when the diagnosis is unclear?

Serial abdominal examinations.

22 A 17-year-old sexually-active female presents with right-upper-quadrant abdominal pain and a low-grade fever. She denies vomiting, diarrhea, dysuria, or vaginal discharge. The physical examination is remarkable for mild right-upper-quadrant tenderness without peritoneal signs. She is anicteric. The pelvic examination does not reveal discharge, cervical motion, or adnexal tenderness. What is the most likely diagnosis?

Fitz-Hugh-Curtis syndrome occurs in 5–10% of patients with chlamydial or gonococcal pelvic inflammatory disease. It is theorized that seeding of the peritoneal cavity occurs as the organism ascends the female genital tract. It then tracks along the paracolic gutter, reaches the liver, and causes inflammation of its capsule. There have been several reported cases of perihepatitis in men, thus precipitating the emergence of alternative hypotheses for its pathophysiology: lymphatic or hematogenous spread. In affected women, the pelvic examination may be normal and cervical cultures may not isolate an organism. Hepatic aminotransferase values are normal or transiently mildly elevated. In most cases, the diagnosis is inferred as the symptoms abate with antibiotic therapy. Definitive diagnosis can only be made laparoscopically.

Peter NG, Clark LR, Jaeger JR: Fitz-Hugh-Curtis syndrome: A diagnosis to consider in women with right upper quadrant pain. Cleve Clin J Med 71:233–239, 2004.

23 Describe the management of an acute abdominal emergency.

The immediate management should begin with a careful assessment of the patient’s airway, breathing, and circulation. Intravascular access should be obtained and fluid resuscitation initiated with normal saline or lactated Ringer’s solution (20 mL/kg). Laboratory studies may be sent with blood obtained during the IV placement. Promptly administer broad-spectrum antibiotics, including anaerobic coverage, and obtain surgical consultation as early as possible.

24 What is the most common cause of recurrent abdominal pain?

Although numerous organic causes are possible, 90–95% of patients with recurrent abdominal pain will have functional pain. In the functional abdominal pain syndrome, the pain is generally episodic, is periumbilical, rarely occurs during sleep, and rarely is associated with eating or activities. There are no signs of systemic illness, such as fever, diarrhea, vomiting, rash, or joint pains. The child’s growth and development are normal. The physical examination is usually unremarkable, with the exception of mild midabdominal tenderness without peritoneal signs.

25 How should the diagnosis of functional abdominal pain be addressed in the emergency department (ED)?

The diagnosis of functional abdominal pain is usually evident following the completion of the history and physical examination. Failure to mention this diagnosis early or obtaining unnecessary studies to appease an anxious family may only result in the parents’ feelings that “the right” diagnostic test has yet to be performed. The parents and child should be reassured that stress-related abdominal pain is real pain and not due to the child’s “faking it.” They should be encouraged to continue their normal activities (e.g., school attendance) and seek psychological services. Finally, the emergency physician should provide careful instructions on the symptoms that should prompt an immediate return to the ED and should encourage follow-up with the child’s primary care provider.

26 When should a surgical consultation be obtained?

Request the assistance of surgical colleagues when a surgical process is clearly evident or when the possibility of a surgical diagnosis cannot be ruled out. For appendicitis, consider a surgical consult when findings on two or more of the following are abnormal: history, physical examination, or laboratory studies.

KEY POINTS: PROBLEMS IN DIAGNOSING PEDIATRIC ABDOMINAL PAIN

1 History may be limited; physical examination may be difficult.

2 Children may not have “classic” features of appendicitis.

3 CBC is not specific for appendicitis.

4 Plain films are often not diagnostic.

5 Differential diagnosis is extensive.

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